NATIONAL LIBRARY NLM 00102317 2 'n 3Nioia3w do Aavaan ivnoiivn snioiosw do Aavaan iVNOiivf DICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICIN MOIiVN 3NIDI03W dO AaV89IT IVNOIIVN 3NIDia3W dO AHVHaiT IVNOIIVN 3NIDI03W dO AHVaail TVNOIlVr- 3ICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINI / W" Ay*J AOVam I iv inv./ij. v i"^ jiii^iujh 3«^/ /\uvuaii iv i-«\^ij. v i-« JINIJIU3M 3^ NLM001023172 rv do Aavaan tvnouvn 3nidiq3w do Aavaan tvnouvn X, s7 X o \. 3NiDia3w do Aavaan tvnouvn 3nidiq3w dc M <#Ji%4 S V L LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE / NATIONAL LIBRARY OF MEDICINE NATIONAL LI 3x- w do Aavaan tvnouvn snidiosw do Aavaan tvnouvn c 3NIOIQ3W dO AavaaiT TVNOUVN 3NI3IQ3W d 1 • x.w SsA f ^ ! v if X I \ ^ AL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE 0. \ | %$y NATIONAL LIBRARY OF MEDICINE NATIONAL L -X^ aw do Aavaan tvnouvn 3nidio.3w do Aavaan tvnouvn dNiDiasw do Aavaan tvnouvn snidiqsw dO IAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE 3b. ! ,£i 3w do Aavaan ivnoiivn 3nidio3w do Aavaan tvnouvn X 3nidio3w do Aavaan TVNOUVN 3NIDI03W X x \l LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL L X CYCLOPEDIA OF THE PRACTICE OF MEDICINE Edited by Dr. H. von^JEMSSEN, pnoFESsoa of clinical medicine in musicii. bavaria. VOL. IV. DISEASES OF THE RESPIRATORY ORGANS. By DR. FRAENKEL of Berlin, PROF, von ZIEMSSEN of Munich, PROF. STEINER of Prague, DR. RIEGEL of Cologne, and DR. FRAENTZEL of Berlin. ffiranslatflj ig J. BITRNEY YEO, M.D., of London ; J. SOLIS COHEN, H.D., of Fhiladelphia; A. BRAYTON BALL, 31. D., and GEORGE M. LEFPERTS, M.D., of New York; and EDWARD W. SCHAUFFLER, M.D., of Kansas City. ALBERT II. BUCK, M.D., New York, EDITOR OF AME:fij05 Predisposing causes.................................................. 306 Exciting causes...................................................... 310 Anatomical alterations.................................................... 317 Symptomatology.......................................................... 331 Analysis of individual symptoms...................................... 331 Alterations of breathing.............................................. 331 Cough.............................................................. 335 Condition of the skin................................................ 338 Condition of nutrition................................................ 339 Expectoration........................................................ 340 Thoracic pains—disturbances on the part of the nervous system.......... 344 Disturbances of the digestive organs...................................346 Condition of the urine......................... ..................... 347 Febrile symptoms...................................................347 Nutrition............................................................ 348 Activity of the heart and pulse...................................... 349 Symptoms furnished by physical exploration..........................350 Inspection.......................................................... 350 Spirometry.......................................................... 351 Pneumatometry.........................•........................... 352 Percussion....................................................... 353 Auscultation........................................................ 353 Special forms of tracheitis and bronchitis.................................... 356 1. Acute tracheo-bronchitis; acute catarrh of the trachea and larger bronchi .........................................................356 Pathogenesis and etiology............................................ 357 Symptomatology.................................................... 357 2. Acute catarrh of the medium-sized and minuter bronchi, bronchitis capillaris, acute diffuse bronchial catarrh............................ 364 CONTENTS. XV PAGE Pathogenesis and etiology............................................ 365 Symptomatology.................................................... 367 Course of the acute diffuse form of bronchitis.......................... 375 Capillary bronchitis..................................................378 Diagnosis of capillary bronchitis...................................... 382 3. Chronic forms of bronchitis......................................... 383 Pathogenesis........................................................383 Symptomatology.................................................... 385 Course of chronic bronchial catarrhs.................................. 386 Varieties of chronic bronchitis........................................ 391 Dry catarrh........................................................391 A so-called mild form of chronic bronchitis, with moderate mucous expec- toration ........................................................... 393 Broncho-blennorrhcea................................................ 394 Serous bronchorrhcea................................................. 395 Fetid or putrid bronchitis...................,........................396 Complications and sequel®................................................ 401 Diagnosis of tracheitis and bronchitis....................................... 403 Terminations, prognosis................................................... 405 Treatment............................................................... 407 Prophylaxis........................................................ 407 Therapeutic treatment...............................................411 Inhalations.......................................................... 415 Expectorants.......................................................416 Emetics............................................................417 Derivatives and revulsives............................................ 418 Narcotics...........................................................419 Astringents, balsamic and resinous remedies............................ 420 Antipyretics and antiphlogistics....................................... 421 Stimulants and tonics............................................... 422 Mineral waters, milk, whey, and grape cures........................... 423 The pneumatic cabinet, the employment of condensed and rarefied air---424 Treatment of acute bronchitis.......................... ............. 426 Treatment of chronic forms of bronchitis.............................. 430 Pseudo-membranous, Croupous, or Fibrinous Bronchitis; Bronchial Croup ; Bronchitis, with the Formation of Bronchial Casts.........438 Prefatory remarks......................................................438 Literature.............................................................. 439 Introductory remarks and etiology.........................................442 Forms and course of fibrinous (croupous) bronchitis in general----...........446 Course of the acute form............................................. 446 Results of physical examination....................................... 448 Duration of the acute form........................................... 448 Course of the chronic form........................................... 448 Duration of the chronic form.........................................450 xvi CONTENTS. PAGE Anatomical clianges.....................................................451 Symptomatology.......................................................... 456 Analysis of individual symptoms...................................... 456 Characteristics of the bronchial casts..................................457 Condition of the voice................................................459 Febrile movements...................................................460 Sweating, cyanosis, changes in nutrition..............................400 Subjective symptoms................................................. 460 Physical signs....................................................... 461 Diagnosis of croupous bronchitis........................................... 463 Complications, duration, termination, and prognosis.........................464 Treatment....... ...................................................... 467 Narrowing op the Trachea and Bronchi; Tracheostenosis; Bronchial Stenosis................................................................. 470 Literature.............................................................. 470 Preliminary remarks..................................................... 473 Etiology................................................................. 474 Anatomical alterations.................................................... 481 Symptomatology.........................................................t 485 Alterations in breathing due to stenosis................................486 Condition of the thoracic walls........................................ 488 Respiratory sounds................................................... 489 Condition of the voice............................................... 489 Exploration with the sound and laryngoscopy.......................... 490 Duration, terminations, and prognosis...................................... 498 Treatment..............................................................499 Foreign Bodies in the Trachea and BitoNcni............................ 501 Literature............................................................... 501 Etiology and patliogenesis................................................. 506 Anatomical alterations.................................................... 510 Symptomatology.......................................................... 511 Course.................................................................. 517 Diagnosis................................................................ 519 Prognosis................................................................ 520 Treatment.............................................................. 520 Bronchial Asthma....................................................___523 Literature.............................................................. 523 Introductory remarks....................................................530 Etiology and pathogenesis................................................. 533 Different theories.....,............................................ 541 Theory of Wintrich.................................................. 542 Theory of Bamberger................................................ 542 Theory of Biermer.........,........................................ 543 Theory of Lebert.................................................... 546 Theory of Leyden...................... ............................ 547 CONTENTS. Xvii PAGE Theory of Weber.................................................... 548 Anatomical alterations................................................... 555 Symptomatology and course............................................... 557 Mode of attack...................................................... 557 Analysis of in dividual symptoms................... ...................... 561 Position of the body................................................. 561 Condition of the respiration.......................................... 562 Results of tracheoscopic examination.................................. 563 Results of percussion................................................. 563 Results of auscultation............................................... 564 Condition of the expectoration.......................................565 Temperature of the body............................................. 566 Subjective symptoms ; disorders on the part of the nervous system....... 566 Further course...................................................... 566 Diagnosis.............................................'.................. 568 Prognosis and terminations...............................................573 Treatment............................................................... 575 (Translated by J. Solis Cohen, M.D.) Fraentzel. DISEASES OF THE PLEURA. Pleuritis..... ............................................................ 589 Bibliography........................................................... 589 History................................................................. 592 Etiology................................................................ 593 Primary pleuritis.................................................... 594 Secondary pleuritis.................................................. 595 Pathology............................................................... 600 Various forms and general course of the disease........................ 600 Anatomical changes.................................................. 605 Fibrino-serous exudations........................................ 61C Purulent exudations............................................. 611 Hemorrhagic exudations.......................................... 613 Perforation of the pleura......................................... 618 Formation of false membranes; retraction of the compressed lung... 622 Symptomatology........................................ ................ 624 General aspects of the disease......................................... 624 Fever..........................................................624 The pulse....................................................... 625 Respiration...................................................... 626 Position of the patient...........................................628 Pleuritic pain .................................................. 629 Cough and expectoration......................................... 632 Aspect of the countenance, emaciation, etc......................... 635 xviii CONTENTS. PAGE Special features of the disease......................................... • 639 Nervous system and digestive organs.............................. tt • .... 640 Urinary organs................................................. _ . . . ..... 641 Physical signs.................................................... 1 In the commencement of pleuritis, when there is little or no fluid ff • .... 641 effusion..................................................... 2. When there is fluid effusion, without displacement of adjacent organs or expansion of the thorax............................."™ 3. In fluid effusions leading to displacement of adjacent organs and dilatation of the thorax...................................... 64b 4. When the effusion becomes absorbed, without leaving any de- formity of the chest.......................................... 662 5. In diminution of the effusion, with consequent more or less cir- cumscribed retraction and deformity of the chest............... 666 Complications and sequelae............................................ 669 Diagnosis............................................................... "'4 Duration, results, and prognosis..........................................680 Treatment.............................................................. 684 Antiphlogistic treatment............................................. 686 Symptomatic treatment..............................................689 Operative treatment................................................ 693 Hydrothorax.............................................................. 732 Introductory observations and history...................................... 732 Etiology.................................................................733 Pathology............................................................... 735 Form and general course; anatomical changes.......................... 735 Symptoms.......................................................... 737 Complications and sequela?............................................ 738 uration, prognosis.........................................,........ 738 Treatment.............................................................. 738 H^ematothorax............................................................ 739 Etiology................................................................. 739 Pathology............................................................... 740 Anatomical changes, symptoms, complications and sequelae..............741 Diagnosis, duration, prognosis........................................ 742 Treatment.............................................................. 742 Pneumothorax...................................................... ......744 Introductory remarks.................................................... 744 History................................................................. 745 Etiology................................................................ 745 Form and general course of the disease..................................... 750 Anatomical changes...................................................... 751 Symptoms............................................................... 754 Complications and sequelw................................................ 762 Diagnosis............................ ,................................. 763 CONTENTS. Xix PAGE Duration, results, and prognosis........................................... 765 Treatment............................................................... 767 Tuberculosis op toe Pleura.............................................. 771 Malignant New-Growths in the Pleura................................. 771 Symptoms............................................................... 772 Diagnosis............................................................... 773 Duration, results, prognosis............................................... 774 Treatment.............................................................. 775 (Translated by J. Bumey Yeo, M.D.) I THE GENERAL DIAGNOSIS AND THERAPEUTICS op DISEASES OF THE NOSE, NASOPHARYNGEAL SPACE, PHARYNX, AND LARYNX. FRAENKEL. GENERAL DIAGNOSIS. EXAMINATION BY THE EYE. INSPECTION OF THE PHARYNX. Next to the mouth the pharynx is probably more frequently inspected for diagnostic or therapeutic purposes than any other cavity of the human body, and it is therefore important not only that a systematic method of examination be observed, but that the examiner acquire the necessary dexterity in manipula- tion by sufficient practice. If a patient be placed in a suitable light, with the mouth as widely extended as possible, more or less of the pharynx can be seen, the view embracing in certain cases not only the pars oralis and pars laryngealis pliaryngis, but sometimes even the epiglottis, while in others the velum and uvula can scarcely be distinguished. The field of vision is then limited by the tongue. If this organ can be made to lie on the floor of the mouth, by the patient's own efforts, a view of the deeper por- tions of the pharynx is practicable; while this is prevented if the tongue is naturally very thick, or raises itself in the form of an arch. In these latter cases it is necessary that the tongue should be depressed, and as this procedure will often be alluded to—not only here, but also in future pages, when considering the various other methods of examination—a careful consideration of the proper manner of performing the operation is advisable at this point. For simple inspection of the pharynx, it is of little importance how the tongue is prevented from obstructing the view, but for other purposes—especially for rhinoscopy, and for obtaining a view of the epiglottis without the use of further 4 FRAENKEL.—DISEASES OF NOSE, PHARYNX, AND LARYNX. appliances—a certain position, one inclining downwards and forwards, is necessary. The operator will therefore find it advisable to accustom himself from the commencement of his examinations not to press the tongue either directly downwards or backwards, but rather to draw it fomoards and down- wards, as by so doing the ascending portion of the root of the tongue, together with the epiglottis, will be drawn away from the posterior pharyngeal wall, and the view into the deeper parts of the pharynx be thereby rendered considerably more extensive. In exerting the necessary pressure, it should com- mence at that point where the horizontal portion of the dorsum of the tongue begins to incline downwards, and the direction given should be such that if the line of pressure were carried out it would strike the skin in front of and not behind the hyoid bone. If the tongue is depressed in the manner described, the whole pharynx, as far as it is visible from the mouth—and very often the free edge of the epiglottis also—will be presented to the eye. If retching occur during the procedure, the purpose of the examination will only be facilitated, as during the act the larynx is elevated, while at the same time the tongue is de- pressed upon the floor of the mouth. It is sometimes found desirable purposely to excite retching, in order to increase the extent of the view into the pharynx, and this is easily accom- plished by passing the tongue depressor far back upon the dorsum of the tongue. For the purposes of examination alone, however, it is very seldom necessary to excite the act, and if the tongue has been depressed as described, the operator will be able to see all that can be seen without the aid of other instruments, and without causing the patient to undergo a procedure which can but be very disagreeable to him. Allusion to this method is, however, necessary, as Voltolini, who is entitled to the credit of having first taught that the deeper parts of the pharynx can be seen from the mouth, if the operation be properly conducted, always excites retching for this purpose. His method of exami- nation differs from the one here described, insomuch as he draws the tongue as far as possible out of the mouth, and then causes retching by depressing it strongly and carrying the spatula as INSPECTION OF THE PHARYNX. 5 far backwards as possible.' It cannot be denied that this pro- cedure, disagreeable aj it is to the patient, sometimes permits of a much deeper view into the pharynx than can be obtained when the examination is made with the tongue lying behind the incisor teeth, and therefore deserves a trial when the operator is unable to effect his purpose by other means. In order to depress the tongue, the finger—preferably the left index finger—or any other improvised means may be used, or instruments made especially for the purpose be employed. In either case care must be taken not to interfere with the neces- sary light, and consequently, in introducing the finger or the instrument, we should be careful to keep as close as possible to the incisor teeth. If the operator uses his finger, or an instrument of like dimensions, it should be introduced from the corner of the mouth, or, if spaces exist between the teeth, through these. In order to prevent the finger from being bitten by children or fainting patients, it may be guarded by a broad metal ring, which is prepared for the purpose, or the lower lip of the patient may be carried over the teeth with the finger when introducing it. The patient will then avoid attempts at biting, as by so doing he pinches his own lower lip, which lies between his teeth and the operator's finger. Improvised instntments usually consist either in the handle of a spoon, a pen handle, a pencil, or something of a similar nature, which is found at hand. The instruments prepared especially for the purpose are termed tongue or mouth spatulas —a designation obtained from the original form of the instrument, which subserved the double purpose of depressing the tongue and spreading ointments, and although many of them are less practical than the handle of a spoon for the purpose of examin- ing the pharynx, they are still found in instrument-cases. More recently, however, especiallj- since the introduction of rhinos- copy, many different forms of spatulas have been devised by various authors, all of which are much better adapted to their purpose than the earlier forms, as they permit of the tongue 1 Galvanokaustik. Wien, 1871, S. 72. G FRAEXKEL.—DISEASES OF NOSE, PHARYNX, AND LARYNX. being well depressed upon the floor of the mouth, without caus- ing any interference with the rays of light which enter the latter. Fig. No. 1 represents the various forms of tongue depressors which have been found to be most practical for rhinoscopic pur- poses ; 1, being the original form of spatula, improved by being curved like a bayonet; 2, the form of spatula recommended by Turck;' and 3, that of the author.2 In using the forms of spatula represented in Figs. 2 and 3, it will be found necessary, in order to press the tongue downwards and forwards, to ele- vate the handle of the instru- ment and carry it away from the patient. The instrument must thus, as it were, be rotated about a fixed point, which is to be considered as lying just above the incisor teeth, in order that the portion of the spatula which lies upon the tongue may exert its pressure in the desired direction. The instruments figured as 2 and 3 are so constructed that they may be held by the patient. In order to avoid causing retching when using the spatula, it is necessary to place it firmly, but without much pressure, upon the tongue, to prevent its gliding backwards and forwards, and to keep it away from those points which are liable to initiate reflex acts of retching. These differ in different individuals, but, as a rule, the palate and neighboring parts are especially irritable.3 In the examination of the pharynx it is also necessary to pay especial attention to the method of illumination. The rays of Fig. 1 Tongue spatulas. 1. Bent in bayonet form 3. According to B. Fraenkel 2. According to Turck. 1 Klinik der Krankheiten des Kehlkopfes. Wien, 18G6, S. 104. 2 Demonstrated in the Berlin Med. Society, the 27th of Feb., 1870. Berl. klin. Wochenschrift, 1870, S. 221. 3 It is self-evident that in all cases in which the same instrument is used upon several patients, it should be carefully cleaned, to avoid the danger of conveying contagious secretions. Instruments of metal may be readily disinfected by immersing them in boiling-water. INSPECTION OF TIIE PHARYNX. 7 light should have the same direction as the open mouth of the patient, and, when this is impracticable, the operator will be obliged to use a reflector, for the purpose of producing a suit- able illumination of that cavity. We cannot refrain, in this connection, from specially urging the importance of the use of the reflector for purposes of illumi- nation. The writer himself regards this simple instrument as so useful that he always carries it with him in practice, and is thus never obliged to do without favorable illumination. The pharynx, and especially its deeper parts, can be better viewed with the aid of a reflector than without, and its use is accompanied with the further advantage that the position of the patient need not be accommodated to the light, but that he can be examined in any position. By daylight, for instance, there is no need to set a patient up, or to turn him round, even if he is lying with his head against the window. With artificial light, the value of the reflector is even more striking, and in fact one can hardly do without it. In its absence the lamp must be held between the examiner and the patient. In that case it is well to protect the eye of the examiner against the light, by some opaque shield, as in Helm- holtz's simplest form of ophthalmoscope, which shield maybe of pasteboard, or consist of the bowl of a spoon, the examiner look- ing past the light into the pharynx. By this method, then, that part of the pharynx which serves the double purpose of a passage for food and air is rendered visible, and the examiner will find that, in accordance with this double purpose, its configuration, dependent upon the degree of contraction of the muscles situated within its walls, is very variable, and that the position of the velum, with its widely spreading arches, exercises an important influence in determining its general form. The latter, when in a state of rest, forms a dividing partition, or curtain, between the cavities of the mouth and pharynx, and represents a continuation of the bony palate which separates the nose from the mouth. In the median line, which may be recognized by a pale, shal- low depression, the velum terminates in the conical uvula, about eight-tenths of an inch in length, while laterally it divides into 8 FRAENKEL.—DISEASES OF NOSE, PHARYNX, AND LARYNX. two arched continuations. The anterior of these, the arcus glos- so-palatinus, recedes laterally, and towards the tongue appears as a sharp fold of mucous membrane, while above, towards the uvula, it loses itself. The posterior, the arcus pharyngo-palati- nus, reaches further towards the median line, and appears supe- riorly as a sharply marked ridge, while inferiorly it merges into the lateral wall of the pharynx. In this arch are located mus- cles of the same name, the contraction of which affords a divid- ing line between the mouth and the pharynx (isthmus pharyngo- oralis), or between the pharynx and the nose (isthmus pharyngo- nasalis). Between the arches extends on either side the inter- stitium arcuarium, an irregular triangular space, increasing in size from above downwards and from before backwards, and containing, imbedded in its loose mucous membrane, the oval tonsilla palatina, which is made up of an aggregation of folli- cular glands. The tonsil may either lie on a level with that of the mucous membrane, rise above it, or be deeply imbedded in it, and always presents an irregular and fissured surface, together with numerous small openings, leading into those cavity-like depressions of the mucous "membrane around which the follicles are aggregated. The number of these openings is usually in inverse ratio to their size. Looking through the arches of the velum the posterior wall of the pharynx may be seen, with its loosely stretched mucous membrane thrown into small folds, and closely following the curve of the vertebral column. The position of the velum will determine the limit of inspection upwards, while upon the degree of depression given to the tongue will depend the extent of the view obtained downwards—the latter in favorable cases including the free edge of the epiglottis, and occasionally the tips of the arytenoid cartilages. The smooth surface of the mucous mem- brane is here broken only by the plica pharyngo-epiglottica, which runs obliquely from below upwards at an acute angle towards the arcus pharyngo-palatinus, and in which is found that portion of the stylo-pharyngeus muscle which goes to the epiglottis. The mucous membrane of the parts, provided with more or less well-developed papillse, and covered by pavement epithe- INSPECTION OF THE PHARYNX. 9 lium, appears uniformly red. At certain points, especially on the posterior pharyngeal wall, ramifications of small vessels are dis- tinctly seen, and parts—notably the arcus glosso-palatini and the uvula—are normally of a deeper red color than that of the surrounding membrane. Slight irregularities in the surface of the membrane are seen in all the parts which have been de- scribed, but occur especially in those near the arcus pharyngo- palatini and over the posterior pharyngeal wall. These little nodules, which vary much in form and number, are of the size of a millet seed, and are caused by the presence of follicular glands, either single or in clusters. The mucous membrane is always moist. The surgeon is only able by means of frequent inspections and careful observation to determine the normal appearances of the region described, not only as regards its gen- eral configuration, but also in respect to its color, its glands, and the amount of its moisture. Inspection should inform us whether deviations are observ- able in the color, in the blood-supply, or in the degree of mois- ture. We may satisfy ourselves whether there are abnormal secretions, swellings, deposits, foreign bodies, ulcers, cicatrices, closures, etc. We should especially notice the lustre of the mucous membrane, the absence of which sometimes calls our attention to erosions; and, finally, we should test the mobility of the velum, in order to do which we may cause the patient to phonate the vowel "a" [eh], for instance. It not unfrequently happens that either the projecting arcus glosso-palatini or hypertrophied tonsils hide from view the pos- terior portions of the lateral walls of the pharynx, a locality in which syphilitic ulcerations in particular are frequently found. In such cases it is necessary either to press the arch of the palate outwards, during which procedure we are frequently aided by the retching of the patient, or to introduce a laryngeal mirror in such a manner that the hidden parts are reflected in it, an operative procedure which is so simple that it demands no further attention here. The other difficulties which stand in the way of an examina- tion of the pharynx are usually easily overcome. If the patient will not open his mouth willingly—not an unusual occurrence 10 FRAENKEL.—DISEASES OF NOSE, PHARYNX, AND LARYNX. with children—the head, with the mouth directed towards a suit- able light, must be held by an assistant; the arms fastened, and the nose held closed by the fingers until the necessary effort at inspiration causes the mouth to be opened. The spatula, which has been held in readiness, should then be quickly introduced, and when once it is behind the incisor teeth the physician is master of the situation, and may readily cause the patient to open the mouth widely by provoking retching. If during this act the contents of the stomach rise up into the mouth, or a profuse secretion of mucus collected in the pharynx obstruct the view, and interfere with the examination, the obstruction may either be removed by a sponge which has been made ready for the purpose, or the examiner must wait until the matters have been swallowed. By experience, together with perseverance, the surgeon will soon learn to embrace the right moment in which he may accomplish his purpose, and succeed in making as frequent examinations as are necessary, even in young children, and he will find that among the latter it will be only those of an unusually stubborn disposition who will continue to struggle against a procedure the unpleasantness of which they have already learned by experience. Sachs1 has proposed another method of dealing with these cases. He causes retching by passing a feather, sound, or some similar instrument backward between the mucous membrane of the cheek and the teeth, then in through the opening existing behind the molar teeth, thereby irritating the arches of the palate. Considering the energy with which many children and some insane adults resist the physician's efforts, as well as the unreasonable manner in which those belonging to them often act, this procedure, which rapidly attains its result, deserves consideration. A further impediment to an examination of the pharynx lies in the idea of some patients that they cannot submit to the oper- ation of depressing the tongue. Undoubtedly in some cases the pharynx is so irritable as to render the operation very unpleas- ant, in which case the patient should be told that efforts at retch- 1 Berliner klin. Wochenschrift, 1871, S. 603. INSPECTION OF THE LARYNX. 11 ing will rather assist than embarrass the surgeon.; in most cases, however, the objection is only imaginary, and consists simply in an unwillingness to submit to the examination. A quiet expla- nation on the part of the examiner, and especially a rapid and well-conducted examination, will usually serve to relieve such a patient's fears. Occasionally a distaste for the instrument which the operator proposes to use, and the fear that disease may be communicated by means of it, are the reasons for the patient's objection. In such cases the patient's handkerchief may be placed between the spatula and the tongue, as I saw done by Lewin. Again, cases occasionally occur, especially among females, where an examination is not permitted for fear of revealing artificial teeth to the profane eye of the surgeon, and where this is the case diplomacy must support dexterity. Finally, some caution must be observed in making a phar- yngeal examination ; physicians have been infected by the mat- ters which are spit or coughed out of the mouth by the patient during the examination, and the examiner will therefore do well to keep his head as far as possible on one side, and out of range of the projected matters. LARYNGOSCOPY. Czermak, Der Kehlkopfspiegel und seine Verwerthung fur Physiologie unci Medicin, 2. Auflage. Leipzig, 1863.—Turck, Klinik der Krankheiten des Kehlkopfs. Wien, 1860.—Semeleder, Laryngoskopie. Wien, 1863,—Tobold, Laryngoskopie, 3. Auflage. Berlin, 1874.—StbrcJc, Zur Laryngoskopie. Wien, 1859.—The same, Samrnlung klinischer Vortrage, No. 36.—v. Bruns, Die Laryngoskopie. Tubingen, 1865.— Voltolini, Galvanokaustik, 2. Auflage. Wien, 1871.—Morell Mackenzie, Use of the Laryngoscope, 3d Ed. London, 1871.—The same, British Med. Journal, 1872, II., pp. 233, 259, 317.—Gibb, Diseases of the Throat and Windpipe. London, 1864.—Prosper James, Lessons of Laryngoscopy. Lon- don, 1873.—Moura-Bourouillon, Cours complet de laryngoscopie. Paris, 1861. —Fauvcl, Du Laryngoscope au point de vue pratique. Paris, 1861.—Fournie, Etude pratique sur le laryngoscope. Paris, 1863.— Habertsma, De Keelspiegel. Leyden, 1864.—Compare Merkel, Die Leistungen auf dem Gebiete der Laryngo- skopie; Schmidt's Jahrbucher, No. 108, p. 81 ; No. 113, p. 217; No. 119, p. 312; No. 122, p. 89; No. 133, p. 317; No. 134, p. 99. By the term laryngoscopy is understood the art of viewing the interior of the larynx in the living human subject, and to 12 FRAENKEL.—DISEASES OF NOSE, PHARYNX, AND LARYNX. accomplish this, it is necessary, 1st, to illuminate the laryngeal cavity; 2d, to convey the picture of the parts obtained to the eye; and 3d, so to conduct the necessary manipulations as that they can be tolerated by the patient. It was only after all these conditions had been fulfilled that laryngoscopy could claim to rank as a method of examination suitable for general use. According to this view of the subject, Prof. Czermak, lately deceased at Leipzig, may undoubtedly be regarded as the discoverer of the art, for although many of his predecessors had endeavored to obtain a view of the interior of the larynx, and appear to have nearly attained their object, all failed of com- plete success because they were unable to fulfil, at least to a sufficient degree, one of the necessary conditions mentioned above. Czermak, however, not only overcame the difficulties which, up to his time, had been in the way of laryngoscopy, but also appears to have had a clear appreciation of its impor- tance for diagnostic and therapeutic purposes, saying in the "Wiener medicinische Wochenschrift," No. 13, of the 27th of March, 1858, that he recommended this method of examina- tion '' most strongly to physicians, as suitable for the most gen- eral and widespread use." Czermak's claim to priority has, however, been disputed; French authors in particular, even those who wrote prior to 1870, advance the assertion that the art of laryngoscopy was discov- ered before him. There is no question but that the discovery had been nearly reached before him. Certain investigators had already attempted to illuminate the cavities of the human body by means of artificial light, notably Bozzini,1 at the beginning of the present century; Bennati, in 1832, experimenting with an instrument constructed for him by a mechanician, Selligue, who was himself a sufferer from laryngeal phthisis; and finally, in 1844, Avery,* of London. All these observers made use of tubes for the purpose of conducting the artificial light, and it can be readily seen, that aside from the difficulty and awkwardness of introducing such tubes, the tongue and epiglottis, being 1 Der Lichtleiter. Weimar, 1807, und Hufeland's Archiv der Heilkunde, Neue Folge, 17. Band. 2 Diagram of the instrument in Mackenzie. INSPECTION OF THE LARYNX. 13 pushed backwards during the examination, must have presented an insurmountable obstacle to the success of the operation. Trousseau and Belloc, from whose writings the experiments of Bennati and Selligue became better known, also experimented with a similar instrument, and they not only doubt whether Bennati ever saw the larynx, but take pains to prove that it is im- possible to see anything of the larynx excepting the epiglottis.' i Other predecessors of Czermak, among whom may be men- tioned Levret, of Paris, in 1743; Senn, of Geneva, in 1827; Bab- 'ington, of London, in 1829; Baumes, of Lyons, in 1838; and Liston, of London, in 1840, all of whom employed a small mir- ror fastened to a long handle, instead of the tube used by the other authors alluded to, also met with many difficulties in the practical application of the art, and their results were unsatis- factory. Some of the mirrors described by these last-mentioned authors resemble very nearly those in present use, especially that of Babington, a drawing of which is given by Mackenzie, in his work above cited. But the inventors did not understand, on the one hand, how to overcome the difficulty of obtaining an efficient illumination, and, on the other hand, their method of examination was so incomplete that they did not pass much beyond the epiglottis, and consequently only saw, at most, the upper and posterior parts of the larynx. The same facts are true regarding the experiments of War- den, of Edinburgh (1844), who attempted to explore the laryngeal cavity by means of two prisms instead of a mirror. The first experimenter who in reality fully explored the larynx in the living subject was a teacher of singing in London, named Garcia. During a vacation spent in Paris, in September, 1854, he discovered the art of auto-laryngoscopy, and the fol- lowing year communicated the results of his experiments and observations to the Royal Society of London, in a paper entitled "Physiological Observations on the Human Voice." He used, for the purpose of examination, a small mirror fastened to a long handle, and illuminated the parts by means of either direct or 1 Phthisie laryngee. Paris, 1837, p.177. 14 FRAENKEL.—DISEASES OF NOSE, PHARYNX, AND LARYNX. reflected sunlight. Notwithstanding the fact that Garcia demon- strated his method, not only upon himself, but also upon others, it found no general acceptation, chiefly because it was believed that an especial skilfulness and unusual insensibility of the phar- ynx were demanded upon the part of the patient, to permit of the introduction of the mirror—a fact which is readily explain- able when it is stated that Garcia examined the larynx with the tongue lying upon the floor of the mouth, and during a deep inspiration, a position of the parts thereby resulting which prevented even his seeing the anterior portions of the vocal cords. From what has already been stated it appears that, all other investigators having failed in effecting their purpose, the claims of Czermak to priority in the matter of the discovery of laryngo- scopy cannot be controverted. Turck has, however, preferred his claim, with a much greater semblance of right. While phy- sician-in-chief to the General Hospital in Vienna, during the summer of 1857, Turck examined, laryngoscopically, many patients in his wards, using for this purpose the direct rays of the sun, and a mirror of the same form as that which is in use at the present day. He also originated the method of examination which is now generally employed, viz., with a protruded tongue and uninterrupted respiration, and was undoubtedly the first observer who obtained a complete view of the interior of the larynx. He, however, appears either to have had no conception of the importance of his discoveries, or was unable to overcome the difficulties caused by a want of proper illumination ; other- wise, it is unexplainable why he, when so near success, should have allowed the renown of the discovery to pass to another. He states, to use his own words, that he discontinued his examina- tions during the winter of 1857-58, " on account of a scarcity of sunlight," and lent his mirrors to Czermak, professor of physi- ology at Pesth, who was at the time in Vienna, and had heard of Turck's experiments, now given up. As has already been stated, Czermak at once perceived the importance of the subject, and its practicability in nearly all cases, and did all that was possible by lecturing, writing, and demonstrations, to spread the knowledge of the art. INSPECTION OF THE LARYNX. 15 The dispute, therefore, as to the priority of the discovery begun by Tiirck, and the documentary proofs of which, sustain- ing their rival claims, are given in the works of both authors cited above, must be decided in favor of Czermak, whose name will be held in grateful remembrance by posterity, as it is by most of his contemporaries, as the discoverer of laryngoscopy. This controversy over the priority of the discovery begun by Tiirck, together with Czermak's labors, served to spread the fame of the art with astonishing celerity over the whole world. The long list of authors heading this chapter, which could easily be augmented, affords a striking illustration of this fact. Many others, also, have done much to develop and perfect the method of examination. Among these stand Schrotter and Schnitzler, in Vienna ; Gerhardt, in Wurtzburg ; Ziemssen, in Erlangen [now in Munich] ; Lewin, Traube, and Waldenburg, in Berlin; and Rauchfuss, in Petersburg. Fig. 2. 1. Laryngoscopy mivror. a. Handle; b, stem; c, mirror. 2. Sizes of the round mirrors in ordinary use. 3. Other forms of mirrors: a, quadrilateral, with rounded corners (Czermak); 6, oval; c, according to Bruns. The means requisite for the performance of laryngoscopy, are : 1, a laryngeal mirror, and 2, suitable illumination. 16 FRAENKEL.— DISEASES OF NOSE, PHARYNX, AND LARYNX. The mirror is preferably round, from four-tenths of an inch to one and a quarter inch in diameter, and should be made of good white glass, thoroughly polished and well silvered. This is strongly fastened to a rod at an angle of about 120°, the rod terminating in a suitable handle. Instead of this round form of mirror, others have been devised, the forms of which, being shown in Fig. 2, will need no description. The costly steel mir- rors formerly employed are no longer used since the introduction of good glass ones. The intermediate sizes of the latter, Nos. 2 and 3, will be found most convenient for general use. The mirror represented at 3 c, has this disadvantage, that it must be used either by the right hand, as in the cut, or by the left, owing to the rods being fixed at the side of the glass, and a change of hands requires, therefore, a change of mirrors. In purchasing a mirror the following points demand attention: 1. The glass should be white, so that when held over a piece of white paper, the latter shall be mirrored as white, and not blue or green. 2. The metal fastening, made of the best German silver, should not encroach upon its reflecting surface more than 1 mm. 3. The thickness of the mirror should be the least possible, for the thinner the mirror the less space it will occupy, and so much less will the soft palate have to be pressed backwards during the examination. 4. The rod must be of sufficient strength not to bend during use, but, at the same time, should be sufficiently flexible to allow of slight modifications in its form without breaking, and it must be firmly fastened to the mirror, so that there may be no danger of the latter becoming loosened and falling into the larynx during the examination. 5. The handle should be adapted to the hand of the operator who uses it. 6. The rod or stem should be at least three and a quarter inches long ; the handle and rod together, seven or eight inches. It is a matter of indifference whether the rod be fastened on the handle permanently, or temporarily by means of a screw, so that it may be removed. The latter arrange- ment is preferable when it is desired to have several mirrors fit into one handle, viz., in a transportable instrument-case. In speaking of the subject of laryngoscopic illumination,* it will be desirable first to establish the physical conditions which regulate its successful performance. A plain laryngeal mirror (Fig. 3) placed in the pharynx reflects the rays of light which enter into the mouth of the patient in such a manner that they 1 Compare Weil, Gewinnung vergrosserter Kehlkopfspiegelbilder. Heidelberg, 1872 ; B. Frdnkel and J. Ilirschberg, Deutsches Archiv f lir klinische Medicin, XII. Band. INSPECTION OF THE LARYNX. 17 are thrown into the larynx, and the examiner sees the latter, in all its parts, reflected back to his eye in the same manner and along the same path by which the light entered. From this fact, therefore, we derive the following conditions for the illumination of the laryngeal parts : 1. When we desire to view the most brilliantly illuminated part of the larynx in the mirror, it is necessary to place the eye as near as possible in the centre of the cone of light which enters the mouth of the patient. 2. It is necessary to use an intense light, on account of the great loss that the light suffers from absorption and refraction during its course, and because, owing to the relatively narrow opening which the mouth of the patient presents, only a small part of the light which enters it is thrown upon the larynx and thus utilized. The less intense the illumination, therefore, the larger must be the laryngeal mirror, in order to obtain a distinct picture of the larynx. 3. In using the various forms of illuminating apparatus, which do not produce a uniform clearness or brilliancy of illu- mination at all distances, because they do not throw parallel rays of light, it is of great importance to cause their radiant point to fall upon that part which the examiner wishes especially to illuminate and observe, and for the larynx this point may be considered as lying upon a level with the glottis. In adults, therefore, of medium size, it will be three inches below the laryn- geal mirror which is held in position in the pharynx, and as this latter lies three inches within the mouth of the patient, it will be necessary in such cases to throw the radiant point six inches within the mouth of the patient. In women the distance which the rays of light will have to travel to reach the glottis from the opening of the mouth will be from four to five inches, and in children from three to four inches. It will be readily understood that these rules cannot be observed with mathematical accuracy, nor be closely carried out in all cases. All illuminating apparatuses afford circles of dis- persion sufficiently distinct for our purposes in the vicinity of their radiant point, perhaps one inch above or below it, and the plane of the glottis may, therefore, be considered as the correct VOL. IV.—2 18 FRAENKEL.—DISEASES OF NOSE, PHARYNX, AND LARYNX. one for the whole larynx ; slight variations from the above rule being dismissed as unimportant. The only point, then, which demands careful attention is, that the part which is to be examined shall be more brightly illuminated, and if the bifurcation of the trachea, for instance, is to be inspected, it is necessary to remember that the trachea is five or six inches long, and that the light must be adapted accordingly, otherwise the success of the examination will be materially interfered with. It is not desirable during the examination to place the eye nearer than five inches to the mouth of the patient, for apart from other inconveniences this amount of intermediate space between patient and physician is necessary in order to afford room for the hands of the operator to carry on the manipulations with the laryngeal mirror and other instruments. The larynx lies eleven inches, the bifurcation from sixteen to seventeen inches, from the examiner's eye. To emmetropic per- sons these distances admit of the most distinct views, but hyper- metropic and presbyopic subjects will have to make use of com- pensating convex glasses in order to make these same distances suit, or they may bring the glottis within their range of vision by increasing the distance of their eye from the patient's mouth. Myopia of less than one-tenth requires the aid of negative glasses, while that of from one-tenth to one-seventeenth does not need them, except to view the bifurcation and the trachea. Thus all that laryngoscopy requires of the science of optics may be stated in the following proposition: It is necessary to produce as intense an illumination of the throat as possible, which in the adult shall be brightest at a distance of six inches from and within the patient'' s mouth, and which will at the same time permit of the observer's eye taking, as nearly as pos- sible, a central position in the entering cone of light, at a point about five inches from the mouth. The different methods of illumination may now be considered in the following order : A. ARTIFICIAL ILLUMINATION. This is indispensable, for by means of it the operator is ren- METHODS OF ILLUMINATION. 19 dered entirely independent of both weather and time of day. Those methods will first be described which may be employed with every artificial source of light. It is possible to examine the larynx by means of a simple flame, covered towards the observer's eye, and placed as near the patient's mouth as possible without obstructing the view; but this method, which is the simplest form of illumination, presents so many disadvantages that it is seldom employed except in cases of necessity. Con- sequently other optic aids are generally resorted to. Among these the first to demand attention is I. Illumination by Means of Concave Mirrors, And first, attention is called to the following formula : 1st. — = _ + _ F A A' in which F denotes the focal distance of the mirror (half the radius of the curve), A the distance of the flame from the mirror, and A' the distance of the image from the mirror. 2d. g : g' = e : e' in which g = the size of the object (in this case of the flame), g' = the size of the image, e = the distance of the flame, and e' = the distance of the image from the mirror. In order to fulfil the above requirements which laryngoscopy makes upon the science of optics, concave mirrors, perforated or transparent in the centre, with a diameter of from three to four inches, and a focal distance of from six to seven inches, are the best. They are perforated or transparent in the centre, in order that the eye, when looking through them, may be brought within the axis of the cone of light which is thrown into the patient's mouth. If the silver foil alone has been removed, it is true that the observer's eye will be sufficiently protected ; but care will then be necessary, lest a coating of dust should render the instrument useless for purposes of accurate observation. If the perforation be made directly through the glass, it should be either round or oval, and its diameter should not exceed about a quarter of an inch ; this will render it sufficiently large for the eye, and will not unnecessarily diminish the reflecting surface of the mirror. 20 FRAENKEL.—DISEASES OF NOSE, PHARYNX, AND LARYNX. The concave mirror is used in laryngoscopy for the purpose of throwing an image of the flame—that is, the optic expression of the union of all the rays of light which it reflects—into the patient's larynx. The observer's eye being placed close behind the mirror, the image of the flame, according to the above calcu- lation, would be found at a distance of eleven inches from the mirror (five inches before the mouth, and six inches within it). In women and children a deviation from this measurement will be caused by the lesser distance of the glottis from the opening of the mouth ; this is, however, easily corrected by removing the eye and mirror the given distance from the mouth. The intensity of the illumination may be increased by avail- ing ourselves of the conjugate focus, and as this lies on the other side of the principal focus, but within double the focal distance, mirrors of from five and a half to ten inches focus may be used, as deemed desirable. Those of a focal distance of from six to seven inches will, however, be found preferable, as they give the greatest intensity, at the same time relatively diminish- ing the size of the image least; on the other hand, to examine the bifurcation, a mirror with a focal distance of about nine inches would, for the same reasons, be needed. After what has been said, it will be readily seen that far- sighted persons, not desiring to use correcting glasses, may readily select a mirror corresponding to their sight. The focal distance of a concave mirror is measured: 1, Directly, by ascertaining the distance of the solar focus ; 2, Approximatively, by diffused daylight, by ascertaining the distance of the image of a remote object; and 3, With artificial illumination, by measuring the distance of the flame (A) and of its image A', and inserting their values in the above-mentioned equation, of which the, focal distance, F, will then be the unknown quantity. In all cases the measurements must be taken from the centre of the mirror, and at right angles to its tangent. The importance of thus ascertaining the exact focal distance of a mirror, as regards its illuminating power, renders it advisable that the surgeon should make the above measurements himself, and not rely upon the instrument-maker. For laryngoscopic examination, it is not necessary that the mirror be made of metal; a good mirror of glass, covered with Liebig1s silver foil, answering all pur- poses. The larger the diameter of the mirror the greater will be the intensity of the image ; but this diameter cannot be increased to METHODS OF ILLUMINATION. 21 above four inches, for apart from the increased cost of such a large mirror, the surgeon is placed at the disadvantage of not being able to use both eyes in his examination; the diameter of the mirror must, therefore, necessarily be less than double the distance between the observer's eyes. To render this mirror a convenient apparatus for laryngo- scopic illumination, it is framed and attached to a stem by means of a joint which is movable in all directions—preferably a single or double ball-and-socket joint. Upon these points all laryngoscopists are agreed, but great differences of opinion exist as to what the stem should be attached to. All sorts of methods have been recommended. It does not do to hold the handle in one's hand, because in the majority of examinations both hands are otherwise employed, and it will therefore probably be found best to attach it to the observer's head. This may be done by means of the Semeleder spectacle-frame, or the recently improved forehead-band known as Cramer's (Fig. 3). In the former apparatus care must be taken that the handle which joins the mirror to the spectacle- frame is large enough to permit of the mirror's passing freely in front of the observer's nose ; in .-,-,,, , . n a, Semeleder's spectacle-frame; 6, Cramer's forehead-band. the latter apparatus those forms of attachment will be found preferable which admit of a second point of support for the mirror being taken upon the bridge of the nose. Czermak's original mirror was attached to a mouth-piece made of orris root, which was held between the teeth ; but this method has now been entirely laid aside, although, perhaps, not deservedly so, inasmuch as to physicians with good teeth it presents the advantage of causing no dis- arrangement of the coiffure. Whether the mirror should be placed before the right or the left eye, upon the forehead, or over the nose, depends entirely upon the habit of the observer. It is generally, however, worn before the left eye, for the reason that the right hand is the one 22 FRAENKEL.—DISEASES OF NOSE, PHARYNX, AND LARYNX. usually employed for instrumental manipulations, and no light is therefore cut off by it from the mirror over the eye upon the opposite side. Instead of being fastened to the observer's head, the mirror may also be attached, by means of movable arms, to lamps or to certain fixed apparatuses. These latter, in turn, are fastened either to the case in which they are kept (Czermak), or, by means of an arrangement similar to the sewing-bird (Waldenburg, Bose), are screwed fast to tables, chairs, or beds, or they may be supported by a heavy base made especially for this purpose. Arrangements of these latter kinds are more convenient, per- mitting of freer movements of the head, and requiring less practice for their successful use than the former. But away from the consulting-room, and when attempting to examine bed-ridden patients, the physician will often meet with unex- pected difficulties if he be accustomed to their use alone ; while if he use the former, he will find them available everywhere and in all positions which the patient may assume. I have actually found myself in a house, furnished most luxuriously, where there was no piece of furniture upon which the screw apparatus mentioned above could be fastened. For these reasons, then, forehead-bands, mouth-pieces, and spectacle-frames are to be preferred to other means of attachment, when used outside of the consulting-room, and in any case, every form of fixed appa- ratus, to be practicable, must be so arranged as to allow of sufficient room for the free exercise of the operator's hands. By whatever method, however, the mirror may be placed before the eye, it is always necessary that the illuminating flame should have a fixed and exact position. Its proper distance from the concave mirror (A) can easily be determined by means of the above-mentioned formula, the distance of the image of the flame equalling eleven inches, and the focal distance of the mirror being known. The calculation affords the following results: The focal distance of the mirror (F) being The distance of the flame (A) will be 5.5 inches................... 11 inches 1 6. " .................. 13.2 " 6.5 " .................. 15.9 " j. A' = 11. 7. " .................. 19.2 " 8. " .................. 29.3 " METHODS OF ILLUMINATION. 23 Fig. 4. Illustrating the course taken by the rays of light projected by means of a concave mirror. a, Flame; b, concave mirror; r r i •/ ancl pharynx. do not, the patient may be requested to draw up his nose, in order to call to his assistance the levator labii superior is alceque nasi muscle, A moustache, if it be present, must be 38 FRAENKEL.—DISEASES OF NOSE, PHARYNX, AND LARYNX. pushed back ; and artificial teeth, unless firmly fixed, be re- moved, or held firmly in their place. The patient then stretches out his tongue as far as possible, and, after covering it with a single thickness of his handkerchief, holds it fast with the right hand, the thumb being below, and the first finger above. If the patient be too awkward, the physician himself, or an assistant, will be obliged to perform this simple operation for him—a pro- cedure seldom necessary except in children. The tongue should be protruded by the patient, and not drawn out, for by being stretched out voluntarily the hyoid bone and the larynx are raised, and the ascending portion of the base of the tongue is carried away from the posterior wall of the pharynx. Moreover, the muscular fibres which pass from the genio-glossus muscle to the epiglottis are put upon the stretch, and aid in drawing the latter forwards.1 All these circum- stances, therefore, tend to render the performance of laryngos- copy easier, and to bring into view, for the first time, the ante- rior portions of the larynx. Attention being directed first, then, to the mouth and the pharynx—an examination of which should always precede that of the larynx, the patient must be taught that as often as the examiner says, "eh," he is to utter this vowel with a somewhat nasal tone, breathing at all other times calmly and uninter- ruptedly. The sound "eh" or "heh" being phonated by the patient, the pharynx and the larynx are brought into a suitable position for examination ; the latter rises, and the velum and uvula are lifted, while at the same time the tongue is depressed upon the floor of the mouth. The necessity of carrying on the respiration in an uninterrupted manner will be apparent with- out further explanation. It is only after the patient is sufficiently well trained, as regards the holding of his head, the stretching out of the tongue,the breathing, and the phonation of the vowel "a" [eh], that the physician will be able to begin with the introduction of the laryngeal mirror. This latter mast always be warmed to a blood-heat before being used, lest the moisture of the expired 1 Compare Luschka, Kehlkopf. Tubingen, 1871, p. 109. THE USE OF THE LARYNGOSCOPE. 39 breath condense upon its reflecting surface. This warming may readily be done by passing the polished surface of the glass to and fro over the flame of the illuminating apparatus, or holding it in a spirit flame kept in readiness for this purpose. The polished surface of the mirror alone is to be exposed to the heat, as it is the side upon which the moisture of the breath condenses, and if the back were to be heated, it might be found too hot for the patient to tolerate. It is even advisable, after warming the face of the glass, to take the precaution of testing the degree of heat of the back of the mirror by applying it to the hand, and thereby avoid any danger of introducing it too hot into the patient's mouth. Ziemssen uses a mirror furnished with a wooden back, instead of the ordinary one of German silver, in order that the mirror may retain the necessary amount of heat for a longer time. The warming of the mirrors in warm water, as is recommended by Liston, Tiirck, Bruns, and others, is less advantageous, because it is necessary to wipe them dry each time previous to their introduction into the mouth, and a loss of time is thereby occasioned, if the mirror be clean in other respects. For although a mirror should never be used upon more than one patient, without a thorough previous cleansing, it may often, upon the same one, be removed and reintroduced many times during the examination without becoming soiled and needing washing. The laryngeal mirror is held in the same manner as a pen, by the thumb, forefinger, and middle finger, usually, of the right hand (compare Fig. 4). The examiner should, however, accus- tom himself, from the beginning of his examinations, to the use of the left hand also, as the employment of the latter is neces- sary in all local therapeutic and operative procedures, the right hand then being used for introducing the various instruments. As the patient phonates "eh," the mirror should be rapidly and unhesitatingly introduced from the corner of the mouth—its polished side being turned downwards towards the tongue, until the wntla of tlte patient rests upon the back of the mirror, while at the same time the handle of tlte instrument remains in the corner of the mouth (compare Fig. 4). During this proceeding the examiner should watch the mirror carefully with both eyes, 40 FRAENKEL.—DISEASES OF NOSE, PHARYNX, AND LARYNX. and avoid touching with it either the mucous membrane of the mouth or the tongue ; for if the latter be touched, the reflecting surface of the mirror will be tarnished, and if the palate or its arches, retching is likely to be produced. The hand holding the mirror must remain at the side of the mouth, and, after the mirror has been passed into its position, may find a point of support by resting the little finger upon the lower jaw of the patient. At the same time the other hand, which has been left free, corrects, if necessary, the position of the illuminating appa- ratus, and then is also placed upon the jaw of the patient—its thumb serving to steady the patient's hand holding his tongue, while the remaining fingers serve to keep his head in a suitable position. The matter of greatest difficulty to the beginner is to intro- duce the mirror properly into the pharynx, and the following points, therefore, deserve attention. It should be passed into the mouth until its lower edge lies close to the posterior pha- ryngeal wall, and if the patient will tolerate the pressure, may even find a point of support by resting lightly upon it. By means of the back of the mirror, the uvula and velum are raised gently, and are retained in an elevated position, after being pushed upwards and backwards, as far as possible, towards the pars nasalis pharyngis. The angle at which the mirror is held, with reference to the axis of the body, is also of great impor- tance. The angles of incidence and reflection being equal, a per- pendicular erected upon the plane of the laryngeal mirror, at its centre, must form with the axis of the examiner's vision— this latter being identical with the principal axis of the entering light and the longitudinal axis of the patient's mouth—an angle equal to the one which it forms with a line drawn from the centre of the mirror to the point to be examined (compare Fig. 4.) For instance, if the examiner's axis of vision be made horizontal, and a perpendicular erected upon the centre of a plane passing through the glottis be supposed to intersect the horizontal line in the centre of the mirror, so as to form a right angle, the angle of inclination formed by the mirror and the horizontal line should equal forty-five degrees, in order that the examiner be able to illuminate the centre of the glottis and to THE USE OF THE LARYNGOSCOPE. 41 observe it in the image produced in the mirror. This point, then, is the one which requires much practice before the necessary freedom of movement is attained by the examiner in his use of the laryngeal mirror, and he will only be sufficiently expert when he is not only able to obtain a laryngoscopic picture, but can introduce his mirror with the same ease with which he directs his eyes or places his limbs, so as to illuminate instantly any one special part of the larynx which he wishes to examine, and to produce a correct and clear image thereof in the mirror. To examine the posterior parts of the larynx, it will be neces sary to hold the mirror at a more acute angle to the horizontal plane, while to examine the anterior parts the said angle must approach nearer a right angle. It has thus far been taken for granted that the mirror is held straight in the pharynx, and not inclined to either side, that is, is not turned upon its longitudinal axis. If it be thus turned, the image of the larynx will be changed. If the side of the mirror on the examiner's right hand be raised, the left side of the patient's larynx will be seen in the mirror, and, vice versa, the right side when the left edge of the mirror is the highest. This turning of the mirror from side to side is also employed when searching for the individual parts of the larynx we wish to examine. Practice must teach the laryngoscopist the practical application of the principles here alluded to, space forbidding- more than a mere mention of them at this time. In the practical performance of laryngoscopy special obsta- cles are often encountered, which militate against the success of the operation. For instance, individuals are met with in whom the frmnum Ungual is so short that the tongue cannot be drawn sufficiently far forwards over the incisor teeth, and to examine them it is necessary that the tongue should be kept behind the teeth and upon the floor of the mouth, being usually pressed down by the disengaged hand of the operator, as has been de- scribed above when speaking of the inspection of the pharynx (page 4). Again, the tongue may rise up in the mouth, even while the patient phonates the vowel "a" [eh], in which case it will also need to be depressed by the finger, as just described. A still greater obstacle will be caused by the irritability of 42 FRAENKEL.—DISEASES OF NOSE, PHARYNX, AND LARYNX. the pharynx. The reflex movements of retching, which some- times render an inspection of the pharynx easier, are to be care- fully avoided during an examination of the larynx, and the mirror should be immediately removed as soon as the examiner sees, by the preparatory movements of the soft palate, that retch- ing is about to occur; for if once caused, it will readily recur, and will prevent not only any further attempts at examination, but will cause a hyperemia of the larynx which will last for some time. The contractions of the pharynx will, moreover, cover the mirror with the secretion of the parts, and render it unfitted for use until cleaned. All these circumstances, there fore, render it a matter of considerable importance that the patient should be prevented, if possible, from retching during a laryngoscopic examination. Before the various means for overcoming this irritability of the pharynx are spoken of, mention should be made of a form of irritability of the pharynx which is more mental than physi- cal, and which has already been alluded to on page 10. Such a form of sensibility may usually be overcome by performing a firm and rapid examination, even though it be incomplete, in order to acquire the confidence of the patient. On the other hand, apparent sensitiveness may be caused by an awkward examination, and beginners in the art should, therefore, care- fully avoid touching with their mirror those parts of the pharynx which are so irritable as to produce retching if inter- fered with. These parts, as has been previously stated, are the palate and the parts in its immediate neighborhood. Besides these forms of sensitiveness, there exists also a true hyperesthesia of the pharynx, and there are many individuals, especially among drinkers, smokers, and those with tubercular disease, in whom the mere stretching out of the tongue will pro- voke efforts at retching. In such cases where the reflex excita- bility is marked, many means have been recommended to lessen the sensitiveness of the pharynx, in order to permit of an exami- nation at the first sitting. Among these the use of cold, either in the form of ice or by means of an atomizing apparatus (see below), and the swallowing of a spoonful of cognac, or other spirituous fluid, after a previous gargling with it, have served THE USE OF THE LARYNGOSCOPE. 43 me best. In order to overcome this irritability of the pharynx for future examinations, we may advise the internal use of the bromide of potassium, and the topical application of medicated solutions suited to the pathological condition of the pharynx or larynx (pencilling with astringents, etc.). The patient may also be requested to practise at his home, and under his own control, the protrusion and fixing of the tongue, and, with the aid of a mirror, in which he must at least see his uvula, the phonation of the vowel "a" [eh], and to continue these exercises until the movements named are made easy for him, and no longer cause retelling. Other obstacles to the performance of laryngoscopy may be presented by the pharynx, in the form of hypertrophied tonsils, or a long pendulous velum and uvula. In the first case, oval mirrors must be used ; and in the second, either as large a laryn- geal mirror as possible, or the instrument prepared by Voltolini, called the uvula-holder (Fig. 11). Much more difficult to overcome than the preceding are the obstacles to a complete examination of the larynx presented by the epiglottis. The elevation of this cartilage not being due to any muscular apparatus of its own, it sometimes happens that, although the tongue is well protruded, and the patient phonates the vowel "a" most vigorously, the epiglottis is not raised, but hangs over towards the posterior wall of the pharynx, and most effectually prevents any view into the interior of the laryngeal cavity. Occasionally in such cases the epiglottis may be raised under our very eyes, by causing the patient to phonate a high "e." The tongue, however, usually rises at the same time, but may easily be prevented from obstructing the view by depressing it with a spatula. If these means prove unsuccessful, the epiglottis must be raised by means of a suitable laryngeal sound (Fig. 12), and, once having been elevated, by means of such an instrument, it will fall backwards into its original position so slowly that the physician will usually succeed, even after removing the sound, in obtaining a view of the interior of the larynx. The elevation of the epiglottis by means of various kinds of forceps, and by threads which are passed through it, are procedures which ought only to be undertaken as preparatory 44 FRAENKEL.—DISEASES OF NOSE, PHARYNX, AND LARYNX. to intra-laryngeal operations, and are not necessary or advisable for the mere performance of an examination, on account of the danger which attends them. The same measures may be undertaken by the physician to effect an examination, if the form of the epiglottis itself, espec- ially the so-called " Jew's- harp form," render the inspection difficult. Much will depend, in these cases, upon the accurate intro- duction of the mirror, in order that a picture of the interior of the larynx may be obtained through the narrow isthmus, which alone is left free between the inverted edges of the epiglottis. In order to effect this, the mirror will have to be placed lower and further back in the pharynx, or more nearly parallel to the axis of the body, than is usually done. Fig. 11. Laryngeal mirror, with uvula-holder, after Voltolini. a. Laryngeal mirror ; 6, metal plate which prevents the fall- ing of the uvula. (In its place a piece of stiff paper may be attached to the handle.) Fig. 12. Laryngeal sounds. 1. Schrtitter's sound, consisting of a flexible copper wire, covered by an elastic English bougie. 2. Flexible silver wire, with handle. In the foregoing descriptions of the laryngoscopic process of examination, it has been presupposed that the patient affords willing aid to the efforts of the examiner. Should this, however, not be the case, the laryngoscopic examination will be rendered much more difficult. In young children, who even if they do not assist, at least do not intentionally oppose the operator's efforts, no special difficulty is encountered, as they may be examined even while screaming loudly. If, however, obstacles are inten- tionally thrown into the examiner's way, as is often the case with THE USE OF THE LARYNGOSCOPE. 45 children from two to eight years old, and with insane adults, and if all efforts at persuasion fail, he can only accomplish his pur- pose by force. The patient should then be held by assistants, and a gag introduced between the teeth ; after which the tongue should be drawn out with forceps (which, however, will only be needed in case of refractory or unconscious subjects), or, being held behind the incisior teeth, it may be depressed by means of a spatula. In making an examination under these circum- stances, advantage must be taken of the moment in which the secretions collected in the pharynx are swallowed, and the ex- amination then made as rapidly as possible. If the physician follow the foregoing instructions carefully, he will succeed without difficulty in attaining his aim, that is, in making a complete laryngoscopic diagnosis at the first exam- ination of the patient. Beginners very frequently charge their own want of skilfulness to the patient, and commit the great mistake of becoming impatient, or even angry. But it must be remembered that even an awkward and obstinate patient may, by patience and persistent instruction, be made to conform to the operator's desires as regards position, movements, etc., and Fig. 13. The laryngoscopic picture, double size, during quiet respiration.—Heitzmann. that if success does not attend the first introduction of the mirror, a second may be tried. The laryngoscopist must there- fore always appear to have an abundance of time, for he loses it by being hasty, and gains it only by being deliberate. 46 FRAENKEL.—DISEASES OF NOSE, PHARYNX, AND LARYNX. The length of time during which the mirror remains in posi- tion in the pharynx should be short; and the physician will attain his purpose much more satisfactorily if he makes numer- ous short examinations, adding together, as it were, the images obtained in this way, than if he endeavors, in an untrained patient, to obtain a perfect picture of the whole larynx, in all its details, by means of one prolonged examination. The proof, then, of the laryngoscopist's skilfulness will consist in his ability to arrive at a correct diagnosis in all cases at the first exami- nation. The exceptions, where this is not the case, must be so rare that the general rule as regards success will only be con- firmed by them. In examining the picture of the larynx and adjacent parts, as seen in the mirror1 (Figs. 13 and 14), the first object which attracts attention is the base of the tongue, covered with glands but free from papillae, and through the red mucous membrane of which a few veins can generally be distinctly seen. The epiglottis will next be presented to view, its suprahyoid portion rising about one centimetre (four-tenths Of an inch) above the floor of the mouth. Its appearance is very variable, its lingual or anterior surface sometimes being more distinctly seen, as in the cut, at others its posterior or laryngeal surface. The free portion of the epiglot- tis is also subject to marked changes in its configuration. As a general rule, the two surfaces of the cartilage may be termed "saddle-shaped," the arrangement being the reverse on one side from what it is on the other. Thus the posterior surface is concave from right to left, and convex from above downwards, while the anterior sur- fig. 14. face is concave from above down- The laryngoscopic image in phonation. ^^ and conyex f rQm right {q lef t But it sometimes happens in adults, and commonly in children, that the pars suprahyoidea of the epiglottis appears simply i as a channel or longitudinal trough opening posteriorly. In rare instances its sides are inverted posteriorly, and so nearly 1 In this description we avail ourselves of the admirable anatomy of the larynx of von Luschka in his Kehlkopf des Menschen. Tubingen, 1871. THE USE OF THE LARYNGOSCOPE. 47 approach one another that they almost touch, and only a small longitudinal crevice is left between them (the Jew's-harp or omega form of epiglottis). As a rule, the upper free edge is slightly hollowed out in the middle, so that more or less of a median groove is apparent lying between two rounded corners, while occasionally this portion is pointed. This free edge is moreover sharp and thin, and turned over upon itself towards the base of the tongue. The upper edge of the epiglottis never touches the posterior wall of the pharynx when it is laid back- ward, a position which it assumes during each act of degluti- tion, not, however, by the force of any muscles of its own, but in a purely mechanical way, through the descent of the base of the tongue and the elevation of the larynx. In consequence of the transparency of its cartilage the color of the epiglottis appears to be brighter and more of a yellowish red than that of the surrounding parts. Upon its lingual sur- face ramifications of vessels may ordinarily be distinctly seen in the mucous membrane, which is here much niore loosely attached than upon the laryngeal surface. This latter surface, which in the drawing is all that can be seen of the epiglottis, decreases sharply in width from above downward, and constitutes, together with the ligamentum thyreo-epiglotticum, the anterior wall of the superior section of the larynx ; in the middle of this wall appears a protuberance, the tuberculum epiglottidis, formed by a collection of acinous glands. From the epiglottis a fold of mucous membrane, called the ■plica glosso-epiglottica media, and containing a ligament of the same name, passes forward in the median line to be inserted at the base of the tongue. On either side of this fold shallow depressions, the vallecula, may be seen, beneath which the body of the hyoid bone lies superficially, and may often be distin- guished as a yellowish protuberance. On their outer sides these depressions are usually sharply bounded by the plica glosso-epi- glottico3 laterales. The fold of mucous membrane which passes backwards from the free edge of the epiglottis, that is, the plica pharyngo-epi- glottica, has already been described (page 8, also Fig. 4). More important than this, forming a right angle with it, and sloping 48 FRAENKEL.—DISEASES OF NOSE, PHARYNX, AND LARYNX. gradually backwards, downwards, and inwards, towards the tip of the arytenoid cartilage, is the plica ary-epiglottica, the superior sharp edge of which forms the boundary line between the pharynx and the larynx, and limits the vestibulum laryngis on its outer side. At the junction of the posterior and middle thirds of this fold a small elevation is usually apparent, which marks the site of the cartilage of Wrisberg, and at its posterior extremity a similar elevation corresponds to the location of the cartilage of Santorini. Continuing the examination of the superior boundaries of the laryngeal cavity further posteriorly, while it is in a state of rest, the examiner will next observe the rimula sive incisura interaryt&noidea, lying over the median border of the arytenoid cartilages, a point at which, in passing over the musculus arytosnoideus transversus, the pharyngeal mucous membrane merges into the laryngeal. On the outer side of each plica ary-epiglottica lies the recessus pharyngo-laryn- geus, or the sinus pyriformis—recesses of the pharynx, which unite with each other posteriorly behind the arytenoid cartilages, and lead down into the oesophagus. They are usually observed in the laryngoscopic picture as either filled with foamy secretion, or in the act of filling during the examination. In this manner the free edge of the epiglottis, together with the ary-epiglottic folds, etc., form the upper limits of the ostium pharyngeum laryngis, which may be dilated or contracted through the action of its own muscles. The plica ary-epiglottica, which stretches out over the mem- brana quadrangular is of the elastic membrane of the larynx, terminates below in the false vocal cord, or ligamentum vocale spurium. On the lateral wall of the upper laryngeal cavity, represented by the plica ary-epiglottica, and resembling in form an irregular quadrilateral, two small prominences or ridges are observed posteriorly, which run parallel to each other from above and behind, downwards and forwards; the posterior one of the two corresponding to the anterior portion of the arytenoid carti- lage, and the anterior one, which loses itself above in the cartilage of Wrisberg, being caused by an aggregation of glands. Together they form the upright bar of an L, the horizontal bar being repre- sented by the glandular mass, which, together with elastic tissue, TIIE USE OF TIIE LARY'NGOSCOPE. 49 forms the groundwork of the false vocal cord {glandular aggre- gate later ales.) Between these two prominences lies a channel or groove, to which Merkel has given the name fillrum laryngis. Each false vocal cord extends from the angle of the thyroid cartilage to the fovea triangularis of the arytenoid cartilage, the two converging anteriorly so as to form an acute angle, and diverging posteriorly, leaving between them a space called the false glottis. Their course is not direct, but describes the seg- ment of an ellipse. They may, under the influence of their own muscles, be shortened in an antero-posterior direction, as well as separated from one another, or brought together until they meet. During adduction of these cords the upper laryngeal space is shut off from the general cavity of the larynx, and assumes a wedge-shaped form, with a closed bottom. This approximation of the false cords always takes place during the act of degluti- tion, or when anything touches the interior of the larynx above. It also occurs when the false cords vicariously assume the func- tion of sound-producing organs, an office which they never fill normally, but only under pathological conditions. A normal laryngoscopic view shows the entrance only of the middle laryngeal space, which spreads out below the false cords, embracing, in reality, only the ventricle of Morgagni, but consti- tuting a region of great pathological importance. The entrance thereto may be of very variable size. A much more distinct view is obtained of the lower laryngeal cavity, the region of greatest functional importance. The supe- rior surfaces of the true vocal cords, the ligamenta vocalia vera sive inferior a, are readily recognizable by their white ligament- ous color, and are seen, in so far as they are not covered by the false cords, in their entire extent, from the angle of the thy- roid cartilage to the processus vocalis of the arytenoid carti- lage. Their white color depends essentially upon the fact that the capillary network of the vocal cords is by far less dense than that which is found in the remaining mucous mem- brane of the larynx. Occasionally small vessels, running in a longitudinal direction, are seen upon their superior surfaces. The vocal cords are anatomically distinguished from the gen- eral laryngeal mucous membrane by their covering of pave- VOL. IV.—4 50 FRAENKEL.—DISEASES OF NOSE, PHARYNX, AND LARYNX. ment epithelium. The rest of the mucous membrane is every- where covered with ciliated epithelium except at one spot, where the pavement variety occurs in the form of a narrow strip lining the pharyngeal orifice of the larynx, and turned in, as it were, from the pharynx. Towards the rima the pavement epithelium of the vocal cords becomes continuous with that of this strip. The basis of the true vocal cords, which upon vertical sec- tion present a prismatic form, is made up of the musculus thyreo-arytosnoideus internus, and the membrana laryngis elastica, which latter, towards the free and sharp edge of the vocal cords, develops into a true elastic cord. The fibro-cartilage of the processus vocalis is usually easily distinguished at the posterior extremity of the vocal cord, as a yellowish spot, and a similar spot is occasionally seen at the anterior extremity, dependent upon the presence of a small car- tilaginous nodule. Immediately below, accompanying and parallel to the free edge of the cord, runs a narrow, sharp fold of mucous mem- brane, sometimes visible in the laryngoscopic image. In the anterior commissure of the cords, a small fold, wrinkled trans- versely, slanting posteriorly, and presenting a bevelled posterior margin, may sometimes be seen. The true vocal cords constitute the limit of the anterior and greater part of the rima glottidis. Posteriorly they are continu- ous with the median, triangular surface of the vocal process of each arytenoid cartilage, the latter being covered only by a mu- cous membrane, which is closely adherent to the perichondrium. The rima glottidis may, therefore, be divided into an anterior or ligamentous, and a posterior or cartilaginous, portion, this divi- sion corresponding with the now antiquated one of a glottis vocalis, and a glottis respiratoria. This chink of the glottis— which in the cadaver constitutes an isosceles triangle, the base of which measures about one-fourth or one-fifth of the length of one of the sides, which in the male are about one inch, and in the female three-fifths of an inch long—is, apart from the differ-. ences caused by age and sex, subject to the most marked changes in form, in the same individual, these changes being dependent upon the various phases of respiration and phonation. During THE USE OF TIIE LARYNGOSCOPE. 51 each inspiratory act, for instance, the glottis opens widely, and if the inspiration be unusually deep, the median prominence upon the lateral wall of the larynx may disappear, so that the latter will present the appearance of a tube of uniform calibre throughout. During phonation, on the contrary, the vocal cords approach one another, the vocal processes touch, and a narrow slit alone remains open between the cords, the shape of which, as regards form, length, and breadth, will depend upon the register as well as upon the height and strength of the note pro- duced.1 The vibrations of the cords producing this note can in many cases be distinctly seen. If the glottis stand open, the posterior wall of the larynx is seen in its most favorable position for study. It forms the back- ground of the larynx, containing the glandule aggregate pos- teriores, and its lax mucous membrane, even when completely stretched, will still show longitudinal foldings. The true vocal cords serve the purpose, so to speak, of land- marks in the laryngoscopic image. They are very distinctly marked by their white color, and the examiner will have no diffi- culty, after having once identified them, in locating the sur- rounding parts. The law in physics, that the image seen in a mirror appears to be as far behind the mirror as the reflected object stands in front of it, also holds true, of course, in laryngoscopy, and in conse- quence an apparent displacement of the parts occurs, which is worthy of our attention. A plane passing through the larynx on a level with the glottis will be nearly horizontal, and will, there- fore, form with the laryngeal mirror, an angle of forty-five degrees, and the image of this plane will appear in the mirror as almost perpendicular, that is, the parts which in reality lie ante- riorly will appear above in the mirror. This deviation would be much more apparent were it not compensated for in some degree by the direction of the laryngeal orifice, which, as has been already stated, slopes downwards and backwards from the free edge of the epiglottis to the tips of the arytenoid cartilages. The practical importance of this matter will be fully apparent to the 1 Compare Karl Ludw. Merkel, Anatomie u. Physiologie des menschlichen Stimm- und Sprachorgans. Leipzig. 52 FRAENKEL.—DISEASES OF NOSE, PHARYNX, AND LARYNX. examiner when he is about to introduce an instrument into the larynx, and is necessarily obliged to compensate, by the direction of his movements, for the amount of deviation caused by the refraction of the mirror. There is no other deviation but this caused by the position of the mirror ; that which appears on the right lies on the right, but it is self-evident that that which corresponds to the examiner's right, must be on the left of the patient, who sits opposite him, and vice versa. A laryngoscopic examination should only be considered as complete when the whole larynx has been carefully inspected. In an examination, as the mirror is passed deeper into the pharynx, the posterior parts of the larynx usually appear, in the laryngeal picture, immediately after the base of the tongue and the epiglottis, and therefore the point most difficult to accomplish is to obtain a good view of the anterior commissure of the vocal cords. The larynx should be examined both when the glottis is opened and when it is closed. If we wish' to observe the latter condition, the patient may be directed to phonate, in which case the vocal cords will be visible through- out their entire extent; and, if we wish to have the glottis open, he may inspire deeply, when we shall be able, if the mirror is at the correct angle and the illumination sufficient, to look down into the trachea, and even to see its bifurcation. During the latter act, also, the posterior wall of the larynx—a locality most important on diagnostic grounds—is placed under the most favorable conditions for examination, and the incisura interary- tsenoidea may be thoroughly inspected. The examiner must necessarily be content with observing the parts as they are presented to his eye by the laryngeal mirror, and although, by changing the position of the latter, he is some- times able to obtain a better view, a complete one of all the parts is impossible. As a general rule, the statement holds good that in laryngoscopy we cannot, as in the open larynx of the dead subject, obtain a front view of those parts which appear in profile, or a profile view of those which are seen from in front. This fact is especially true in regard to the examination of the posterior laryngeal wall, which appears in the mirror, in trans- verse section, almost reduced to the width of a line. THE USE OF TIIE LARYNGOSCOPE. 53 To obviate this difficulty, Lori has, in a recently published communication,1 recommended the use of two mirrors besides the one ordinarily employed. According to his method the latter merely serves for the purpose of illumination, while one of the former—a small laryngeal mirror simply reversed so that its reflecting surface looks backwards—is introduced further towards the front, so as to obtain as nearly as possible a direct picture of the posterior wall of the larynx, similar to that which the eye would see if looking directly over the epiglottis. This picture it reflects to the third mirror, which is attached to the first or illuminating mirror at an angle of 125°, whence the image is conveyed to the eye of the observer. The same effect may be produced, according to this author, by the use of a prism instead of the three mirrors. In making a laryngoscopical examination, the color of the parts should first receive attention ; and here the examiner must be careful not to be misled by the deviations from the normal color which are caused by the use of artificial light, and to remember specially, that although the vocal cords are usually seen to be of a white color, or even glistening like mother-of- pearl, they may, in perfectly normal cases, be of a pale rose color. Their flexibility, and the absence of all swelling, will serve to differentiate such a case from one of hyperemia. It may be said, in general terms, that hyperemia and ansemia, as well as all other changes of color, look just the same in a mirror as out of a mirror. In regard to form, the examiner must ascertain whether swelling, defects, new-formations, or other anomalies are present, and pay particular attention during his inspection to those parts of the larynx which are only seen in profile. A loss of sub- stance is, for instance, difficult of detection if situated on the posterior wall of the larynx, while if upon the free edge of the vocal cord, even though very small, it is readily distinguished. In like manner, but a small excavation may often be seen during life in the neighborhood of the processus vocalis, which, when seen after death and viewed from in front, is recognized as the entrance to a large and deep ulceration. 1 Pesther med-chirurg. Presse, 1874, No. 25. 54 FRAENKEL.—DISEASES OF NOSE, PHARYNX, AND LARYNX. In regard to swelling, the region in the immediate vicinity of the processus vocalis—especially those parts covered with glands—demands careful observation. A swelling at the base of the tongue causes the epiglottis to appear shortened, and may lead to the diagnosis of a deficiency of that part. The calibre of the larynx must also be carefully examined, to ascertain whether there be any enlargement or contraction of the cavity, whether foreign bodies or secretions are present, and the character of the secretion, if any. The latter may be mistaken, in certain cases, for swellings; but a differential diagnosis is easily made, as the former may be coughed out, or removed mechanically if necessary. Finally, notice must be taken of the general movements of the larynx; whether the action of the arytenoid cartilages during inspiration, expiration, and phonation, are otherwise than normal; and whether the configuration of the opening of the glottis, the tension of the vocal cords and their vibrations, are all as experience has taught us they should be in a perfectly healthy larynx. The further discussion of the points just mentioned must be left for the special parts of this work—but enough has already been said, in this short review, to indicate the important results, from a diagnostic point of view, which may be obtained by means of the laryngoscope. This method of examination will be still more highly prized when we remember that its revela- tions are made through the most accurate of our organs of special sense—the eye. The surgeon may readily succeed in demonstrating the laryn- geal picture to bystanders. The demonstration of a laryngo- scopic image may be conducted either in such manner that, the mirror being fixed within the throat, several persons may observe it in turn, or in such a way that others may look into the larynx at the same time with the operator. For the purpose of fixing the mirror in position, special apparatuses attached to the patient's head, or to stands especially prepared for the purpose, have been employed; but the examiner will find it much easier to introduce the laryngeal mirror in the usual way, and, after fixing it firmly with his hand, to move his head to one THE USE OF THE LARYNGOSCOPE. 55 side, in order that a second person may occupy its position. If we wish to employ this second method of demonstration, a still better plan is for the student or person to whom the surgeon wishes to demonstrate the larynx, and whom we will call our associate, to bring his eye as near as possible into the axis of vision of the operator, preferably upon his right side, without interfering with the course of the reflected light, and to look with him into the patient's mouth, and upon the laryngeal mirror. This method, however, though the simplest for laryngoscopic demonstration, presents some inconveniences to all concerned, and it will be found preferable in practice to place a prismx near the axis of vision of the surgeon—at the point where before the head of the associate was placed—which will make it possible for the latter to look at the same time, and in the same direc- tion, with the surgeon. Or, instead of the prism, a small plane mirror may be used, which, being movable, the associate may arrange in such a manner that he will see the picture of the larynx in it. Such mirrors are attached to the illuminating apparatuses shown in Figs. 5, 7, 8, and are called supplemen- tary mirrors. Siegle has recently described such a form of apparatus which may be attached to every reflector.3 If the prism or the mirror is placed in the right position, the associate will see exactly the same picture as that which is con- veyed to the eye of the surgeon, and the only point to which it will then be necessary to give attention is, that the former will be obliged to accommodate his eye to the distance of eleven inches, plus the additional distance which lies between it and the mirror or prism. Auto-laryngoscopy is performed in a similar way to that of the demonstration just described. A second or counter-mirror is employed, as recommended by Garcia, and the laryngeal mirror is introduced into the examiner's own throat, in precisely the same way as is done in examining others. Auto-laryngoscopy offers, therefore, an excellent method for attaining dexterity in the introduction of the laryngeal mirror, as any faults in 1 Bose, Deutsche Klinik, 1866, No. 15. a Berl. klin. Wochenschrift, 1874, No. 23. 56 FRAENKEL.—DISEASES OF NOSE, PHARYNX, AND LARYNX. the manipulation will be experienced at once by the operator in his own person. The picture obtained of the larynx will lie at a considerable distance from the eye of the observer, the distance being made up of the distance of the counter-mirror from the eye, the distance of the counter-mirror from the mouth, and the distance from the mouth to the glottis, in most cases amounting altogether to some seventeen or eighteen inches. For this reason, therefore, even slightly myopic per- sons will need to wear spectacles during the performance of auto-laryngoscopy. In my courses of instruction I have some- times discovered that some of my pupils were myopic, who had never been aware of it, through the circumstance that they were unable to recognize the auto-laryngoscopic image. In view of the importance of laryngoscopic examinations, the attempt was early made to magnify the laryngoscopic image. For this purpose Tiirck applied a telescopic appara- tus behind the perforation in the concave or reflecting mirror. Wertheim devised concave laryngeal mirrors, which I use at the present time in preference to other methods, on account of their simplicity and correctness. Weil (1. C.) employs lenses, which are placed between the reflector and the laryngeal mirror. In the practical application, however, of both concave laryngeal mirrors and lenses, a difficulty is presented by the optical law which regulates the magnifying process ; according to this, magnified pictures can only be produced when the object to be magnified lies within the focal distance of the mirror or lens, and, the distance of the eye and of the object remaining the same, the magnifying power becomes greater the shorter the focal distance of the mirror or lens. As the concave mirrors we can use must necessarily have a focal distance of more than three inches, and one of at least seven or eight inches, if the pic- ture to be produced is not to be distorted, it will readily be seen that they will magnify only to a very small extent. But in using lenses, those with a focal distance of seven inches may be placed close to the mouth of the patient, while those with a greater curve, and a focal distance of but four inches, may (if attached to a handle) be introduced within the mouth. In either case the lens must not be held at right angles to the axis of INSPECTION OF THE NOSE. 57 vision of the observer, lest disturbing reflections impair the cor- rectness of the image obtained ; and it must also be warmed to a blood-heat, lest the moisture of the breath collect upon it. The magnifying power obtained by these means is stronger than that of concave mirrors; but the application of the lens is much more troublesome than that of the mirror, and requires the use of both of the examiner's hands. In the use of either, the course of the rays of light will be so changed that the image of the ilame will be brought nearer to the reflector; the change, how- ever, will not be so great as to necessitate any change or correc- tion in the illuminating apparatuses previously described. If a tracheotomy wound exist, the examiner may attempt to obtain a view of the larynx by means of a small mirror, intro- duced into the trachea, with its reflecting surface looking upwards. If the canula be retained during this examination, it must be provided with a suitable opening upon its upper surface. INSPECTION OF TIIE NOSE FROM TIIE FRONT. To view the cavity of the nose from the front, the nostrils of the patient need to be dilated as widely as possible, and to effect this, instead of the instruments formerly used, resembling ear specula, I have devised the nares speculum re- presented in Fig. 15. The branches, a, are made of strong (aluminium) wire. Instead of the fenestrated blades shown in the cut, Troltsch employs solid blades, of about an inch in length, which stand at almost right angles to the branches.1 The blades are introduced at the same time into both nostrils as far posteriorly as the cartilages of the alee, leaving the septum free between them. They are then separ- -1 B. Fraenkel's Spec- ated as far as possible, by means of a screw at- uiumnarium. tached to the extremity of the instrument, b. The instrument, thus introduced, will remain in position without support, pro- vided it is of sufficient strength to resist the muscular move- ments of the patient's nostrils which tend to approximate the 1 Ohrenheilkunde. Leipzig, 1873, p. 297. 58 FRAENKEL.—DISEASES OF NOSE, PHARYNX, AND LARYNX. blades. Both blades may also be introduced into one nostril, the branches resting, one against the septum, the other against the ala; but this method will be much less agreeable to the patient than the former, owing to the greater susceptibility of the septum. The speculum then having been correctly introduced as described, the nostrils are dilated as widely as possible and can be freely looked into. The point of the nose may also be held up by way of assistance, and any hairs which interfere with the view removed with the scissors. The nose being thus prepared, everything can be seen which is accessible to the eye in this region, and no further aids to an examination are required, with the exception of suitable illumi- nation. Whoever wishes to satisfy himself of the eminent advan- tages offered by the use of reflecting mirrors in examining the cavities of the body, will find a fitting subject for experiment in the nose. With reference to the method of illumination, that is, to the production of the flame-image with a concave mirror, we refer to the explanations of this given above. In the absence of sunlight the employment of this method of illumination cannot be too strongly recommended. The distance of the flame-image from the mirror may here be regulated by the seeing distance of the observer as well by the reflector that may happen to be at hand for other purposes, ophthalmoscopy for instance; only it is well to produce a small flame-image, as brilliant as possible, and to throw this in accurately. If the method of examination which has just been described be followed, the only limit to the surgeon's field of inspection will be that which depends upon the natural configuration of the parts. I have found that what it is impossible for me to see by this means will also remain invisible to me, even though I have recourse to any of the many expedients which have been advised. Among these may be mentioned Wertheim's "Con- choscope," ' with which I can see scarcely anything, Voltolini's method of introducing a polished bar of metal for the purposes of illumination, and finally, the many forms of tubes and mir- rors, intended to be introduced into the anterior nares, for the purpose of displaying parts otherwise concealed, such as the 1 Wiener Medicinische Presse, 1869, No. 18. RHINOSCOPY. 59 upper part of the middle fossa ; all of which have also, thus far, failed to reveal anything new to me. The parts which can be seen in making such an examination will be, 1, the entire anterior portion of the nasal cavity, from the superior turbinated bone to the floor ; 2, the anterior portion of the middle turbinated bone ; 3, the anterior and inferior surface of the inferior turbinated bone; 4, the surface of the septum; and lastly, in the majority of cases, the greater part of the inferior meatus of the nose. If the meatus be large and wide, the exam- iner will be enabled to look directly through it at the posterior wall of the pharynx, and may observe the movements of the muscles which take their origin at the pharyngeal orifice of the Eustachian tube. The nasal passages are seldom of equal size, and a deflection of the septum, usually towards the left, is very commonly observed. The turbinated bones appear in a normal state as pale, red protuberances, usually covered by a mucous secretion, the amount as well as the color of which varies much within normal limits, and the limits of the latter can only be learned by the experience gained through frequent examinations. If the amount of secretion be so great as to interfere with the examination, it may be washed out by means of a syringe. In an anterior rhinoscopic examination, too, careful attention is to be paid to any alterations from the normal color, to swellings or hypertrophies, as well as to changes in configuration, amount of secretion, the presence of ulcerations, etc., etc. These matters cannot be discussed in detail in this part of the work, but will be treated of hereafter. We cannot refrain, however, from once more calling attention to the importance of the method, espe- cially with reference to otology. As regards demonstrations and apparatus for magnifying the rhinoscopic picture, the reader is referred to what has already been given in a previous chapter, when speaking of the same subject in connection with laryn- goscopic examinations. RHINOSCOPY.1 Czermak was the first to apply the term "rhinoscopy" to a 1 Besides the majority of text-books on Laryngoscopy, compare Semeleder, Die Rhinoskopie. Leipzig, 1862, and Stbrck, Laryngoskopie. Wien, 1859. 60 FRAENKEL.—DISEASES OF NOSE, PHARYNX, AND LARYNX. method of examination by means of which the naso-pharyngeal cavity and posterior portion of the nasal cavity could be in- spected through the pharynx. Although it is questionable whether it is well chosen, it is perhaps advisable, out of respect for the memory of the discoverer of the art, to retain the term, which is now sanctioned by custom, in the same sense that was given to it by him. That Czermak was the inventor of the method cannot be doubted, for although other observers, especially Bozzini (1. c), had previously claimed to have seen objects hanging behind the Fig. 16. Fraenkel's rhinoscope. soft palate by means of a mirror, at the time that Czermak pub- lished the result of his labors, and gave the perfected method to the profession, it was so entirely unknown that even Turck still maintained that it was impracticable.' For the purposes of rhinoscopy, the only instruments which are required are, 1, a tongue spatula (see p. 6); 2, a suitable 1 Czermak, 1. c, p. 42. Semeleder, 1. c, p. 2. Here one may find the entire previous literature of the subject cited. RHINOSCOPY. 61 means of illumination, which is used under the same conditions as in laryngoscopy, and the reader is therefore referred to page 16 et seq. ; and 3, a pharyngeal mirror. An ordinary laryngo- scopic mirror may be used instead of the latter, but it will be found more practical to use mirrors such as are represented in Fig. 16, which are especially prepared for the purpose, and which differ from the laryngeal mirror only in the form of the rods and handle. The drawing represents a modification of the pharyngeal mirror, introduced by myself, in which a square or round mirror (a) can be made to change the angle at which it stands upon the rod ; this is accomplished by means of a sliding bar, which reaches to the handle of the instrument, and, when moved up and down, causes the mirror to revolve about an axis (b) running at right angles to the rod. The same rules with reference to the position of the patient, the position of his head, and the direction and method of illu- mination, apply in rhinoscopy as in laryngoscopy, with the one exception, that the patient, after opening his mouth widely, should allow the tongue to remain behind the lower incisor teeth, where it may be depressed by a spatula, according to the method described when speaking of the inspection of the pharynx (p. 6). The patient himself, if sufficiently adroit, may hold the depressor firmly with his right hand, after it has been placed in position by the examiner. The latter then introduces the mirror into the pharynx by passing it as closely as possible over the lower teeth and along the back of the tongue in the median line, until it is in the free space between the base of the tongue, the laryngeal opening, the posterior wall of the pharynx, and the velum palatinum. It should not stand directly in the median line, on account of the uvula, which would lie in front of it and obstruct the view, but rather on the right or the left side, under one or the other of the arches of the soft palate, with its upper edge brought close to the posterior wall of the pharynx. The problem to be solved in introducing and placing the mirror, is not to touch the patient. If my rhinoscope be used, it should be introduced into the mouth with the mirror lying depressed in the direction of the handle, until its upper edge approaches closely the pharyngeal wall; by then drawing upon the ring the mirror 62 FRAENKEL.—DISEASES OF NOSE, PHARYNX, AND LARYNX. may be gradually raised until it forms almost a right angle with the rod, while at the same time the end of the instrument is gradually lowered towards the mouth of the larynx. The introduction of the rhinoscopic mirror also requires prac- tice, and beginners usually fail because they not only touch and irritate the parts while introducing it, but also raise the rod of the instrument too far above the lower incisor teeth, and do not introduce the mirror either low enough or far enough back into the pharynx. It also requires considerable practice to be able to recognize readily the various parts of the rhinoscopic picture, and the examiner will find the septum to be a valuable land- mark, it being easily recognized as a thin, straight partition, extending in the median line from above downwards, growing thicker anteriorly, and dividing the posterior nares into two equal halves. The walls seen in the rhinoscopic mirror join each other at various angles, and in order that the cavity which they enclose, seldom exceeding in size a walnut, may be thoroughly inspected, it will be necessary to change the angle and position of the mirror considerably, and turn it in all directions. It is for this reason that I introduced the above-described modification of the ordinary rhinoscope into my instrument, and in using it it will be readily understood that when the mirror lies nearly horizontal in the pharynx, a view of the posterior parts will be afforded; while, if it forms a right angle with the rod, the parts lying anteriorly will be reflected in the mirror, and the more the edge of the mirror towards the examiner's left side be turned downwards, the more of the right wall of the patient's pharynx can be seen, and vice versa. These points are of more importance and demand greater attention in the performance of rhinoscopy than in that of laryngoscopy, and the surgeon will therefore need to practise them faithfully until he is perfectly familiar with their practical application. When they are once understood, it will be easy for him to recognize readily the vari- ous parts of the constantly changing picture revealed to him by the rhinoscope,—changes which depend upon the position of the mirror and the individual patient. Posteriorly in the rhinoscopic view appears the fornix pharyngis, the vault of the pharynx, which is attached to the RHINOSCOPY. 63 base of the skull and the anterior surfaces of the bodies of the cervical vertebrae, merging below into the posterior wall of the pharynx. Its red mucous membrane will appear in the perspec- tive view as shortened, although, in consequence of its position, not so much so as the posterior wall of the pharynx, as seen in the laryngoscopic picture. Its surface is covered with ridges, running irregularly, occasionally in a longitudinal direction, and its structure can be more or less distinctly seen, consisting of a dense adenoid tissue, on which account this region deserves the name of tonsilla pharyngea. Occasionally an orifice, the size of a poppy-seed, which represents the opening of the bursa pharyngea, can be detected ; this latter consists in a sac which lies immediately behind the mucous membrane, and is probably connected in embryonic life with the pituitary body. Laterally the posterior wall of the pharynx loses itself in the recessus pharyngei, or the fossa of Rosenmuller, from which anteriorly rise on either side the pharyngeal extremities of the Eustachian tubes. By looking on both sides of the septum, towards the front, through the posterior nares and into the cavity of the nose, the posterior portion of the middle turbinated bone and part of the middle meatus of the nose can be distinctly seen. Parts only of the superior and inferior turbinated bones, and of the inferior meatus of the nose come within the field of vision, varying greatly in extent. With the exception of the septum, the mucous membrane covering the walls of this region has a fresh red color; the turbinated bones, usually covered with more or less mucus, stand out in contrast thereto, appearing as steel- gray or yellowish-red protuberances. The erectile bodies' found on the posterior portion of the turbinated bones frequently lead to sudden swellings. In the lower part of the rhinoscopic image we overlook the whole nasal surface of the velum. The lateral wall especially engages our attention. Here, as has been already mentioned, the pharyngeal orifice of the Eustachian tube protrudes forwards from the fossa of Rosenmuller, from the lower edges of which 1 Vide Kolliker, Gewebelehre. Leipzig. 1867, p. 741, twelfth line from bottom.— Editor's Note. 64 FRAENKEL.—DISEASES OF NOSE, PHARYNX, AND LARYNX. run downwards and inwards two folds of mucous membrane, which are termed respectively plica salpingo-pharyngea and plica salpingo-palatina. The surrounding, very movable, muscular apparatus some- times piles the mucous membrane up like a tumor against the velum. The large size of the pharyngeal extremity of the Eustachian tube, and especially of its orifice, into which the little finger can be introduced, commonly excites the wonder of beginners in the art, and this is explainable when it is remembered how little at- tention is paid to this important region in dissections and post- mortem examinations, and that commonly the surgeon receives his first idea as to the appear- ance of the parts from a rhino- scopic examination made in the living subject. The appearances just describ- ed are shown in figures 16 a and 16 b, taken from Luschka's work. For information concerning the pathological changes which occur in these parts, the reader is referred to what has been already said when speaking of this subject in connection with the examination of the larynx. One point alone may here be der of which runs the plica salpingo-pharyngea; 6, ,. -, -, , uvula; 7, musculus salpingo-pharyngeus; 8, levator mentioned., and. that IS, that the veli; 9, musculus pharyngo-palatinus. parts lying immediately below the pharyngeal orifice of the Eustachian tube are often seen to be of a yellowish color, and not of the bright red which charac- terizes the mucous membrane of the remaining parts. Besides the difficulties encountered in an examination of the pharynx, mentioned on page 10, another and much more serious one presents itself in the performance of rhinoscopy, often caus- Fig. 16 a. Anterior view of the naso-pharyngeal space ; on one side the mucous membrane has been dissected away (after Luschka). 1, Septum; 2. middle and 3, lower turbinated, bone; 4, tuberosity of the pharyngeal orifice of the Eustachian tube ; 5, soft palate, along the lateral bor RHINOSCOPY. 65 ing great embarrassment. This arises from the position of the soft palate. It is a sine qua non in rhinoscopy that this should not touch the posterior pharyngeal wall, and, easy as the matter seems to be, it will often be found to present an insurmountable obstacle. For our purposes the soft palate must be in a state of rest. If the examiner were only able, as he is in laryngoscopy, to cause the patient to execute movements which would assist his purpose, his task would be rendered considerably easier. But neither the phonation of strongly nasal sounds (Czermak), nor rapid and short respirations (Tiirck), nor the attempt to cause the patient to breathe exclusively through the nose (Low- enberg) will answer. For the position which we desire the velum to assume is precisely that which it takes when all mus- cular movement is suspended, and it therefore often becomes a genu- ine trial of patience to train a per- son to the task. Nor must it be supposed that uneducated persons are the most difficult to train to such a thing. It will be found that educated people, linguists, musi- cians, etc., are the very ones who try our patience most. The more they try to aid us, the more certain are they to make movements of the pharynx, which will perhaps com- pletely frustrate the physician's efforts. Yet it is absolutely neces- sary to train the patient, so that he will hold his mouth open and allow his tongue to be depressed especially without drawing it up towards the posterior wall of the pharynx. This can only be accomplished by a thorough training, in the majority of cases carried out according to the method described above (page 42), for overcoming the sensi- tiveness of the pharynx. If then the first sitting be fruitless, the patient may, after having examined his own pharynx by means of a mirror, and having had the position which the velum VOL. iv.—5 Fig. 16 6. Front view of the naso-pharyngeal cavity, with the ordinary fissured appearance of its aden- oid tissue (after Luschka). 1, Pterygoid process ; 2, vomer ; 3, posterior portion of the roof of the nasal cavity ; 4, orifice of Eustachian tube ; 5, mouth of the bursa phar- yngea; 6, recessus pharyngeus, or fossa of Rosenmuller; 7, irregularly fissured surface of the adenoid tissue, which lifts up the mucous membrane into a number of low hills. without moving the velum, QQ FRAENKEL.— DISEASES OF NOSE, PHARYNX, AND LARYNX. should occupy pointed out to him by his surgeon, practise in front of a mirror at his own home. Time for this preparation will always be afforded, as rhinoscopy is seldom urgent. Occa- sionally a rhinoscopic examination may be made if, as in laryn- goscopy, the patient is examined with the tongue protruded and held in a fixed position, a method which has hitherto been but little employed. By these means, then, the surgeon will attain his object with the great majority of persons, but some will still remain in whom he will find it impossible to cause the velum to assume the correct position for an examination. It is in these latter cases that certain instruments, formerly considered universally necessary, will have to be used in order to draw the velum away from the posterior pharyngeal wall; the amount of force employed being, as a matter of course, moder- ate. For the purpose of effecting this object, inventive skill has done all it could, and very many instruments, some of them quite ingenious, have been devised, a few of which would seem to be adapted to enlarge the pharynx, both '' certainly and perma- nently" (Storck). I have, however, seen but little benefit from the use of these instruments, and find, as my experience in- creases, that the careful training of the patient is of much more avail than the exertion of any amount of force, however gently applied, by means of instruments. ■»i! q Fig. 17. Uvula holders. Rhinoscope with uvula holder, according to Baxt. The instruments alluded to are either made in the shape of a hook, a noose, a forceps, or a spoon (Fig. 17), or consist in fenestrated blades, in place of which latter my fenestrated spa- RHINOSCOPY. 67 tula (Fig. 1) may be used. Following the example of Stork,1 Baxt,2 and others, I have attached a uvula elevator to the rhino- scopic mirror itself (Fig. 17), by means of which the operator is able to manipulate the spatula, mirror, and uvula elevator him- self without having the assistance of a third hand. For a long time I used a small India-rubber tube, which, being applied to the uvula by means of a small, cup-shaped extremity, and the contained air being exhausted, attached itself so firmly to the uvula that the whole velum could be drawn forwards. The best instrument, however, for the purpose is Tiirck's simple thread ]loose, introduced through a small silver tube. It possesses many advantages, among which the fact that the thread does not intercept any of the light in its passage through the mouth, is by no means the least. All these aids, however, are liable to the common objection that we fail to accomplish our object in spite of them. For although the velum may be elevated by instru- ments so that that part of the posterior pharyngeal wall formerly covered by it may be seen, the contractions of the upper con- strictor muscle of the pharynx, excited by this procedure in such persons, will effectually prevent rhinoscopy. Whilst, therefore, laryngoscopy is possible in all cases, there will always be a cer- tain number of persons in whom rhinoscopy is impossible ; their number will, however, stand in inverse ratio to the skill and per- severance of the examining physician. Another special obstacle to the complete performance of rhinoscopy is afforded by the presence of a large air-bubble, fill- ing the space between the velum and the posterior pharyngeal wall. If the examiner does not succeed in rupturing it by blowing into the mouth of the patient, or if for sesthetical rea- sons he does not choose to adopt this method—which, to say the least, is not very agreeable to the patient—he may break it easily and rapidly by means of the edge of his mirror. Finally, in regard to the demonstration of the rhinoscopic picture, to means for magnifying the same, and to the perform- ance of auto-rhinoscopy, it will be sufficient to refer the reader 1 Zur Laryngoskopie. Wien, 1859, p. 20. 3 Berl. klin. Wochenschrift, 1870, No. 28. 68 FRAENKEL.— DISEASES OF NOSE, PHARYNX, AND LARYNX. to the full discussion of these subjects under the head of Laryn- goscopy (pp. 54, 55), for the application of the principles there explained will scarcely require any modification for rhinoscopic purposes. TRANSILLUMINATION. Czermack ' has described under this name a method by which, with the aid of a laryngeal mirror introduced in the ordinary way, the larynx is made visible by means of a strong light thrown upon the neck externally. For this purpose sun- light may be directed, by means of a reflector, upon the tissues covering the larynx, the interior of which will then radiate a strong reddish light. Voltolini has availed himself of this method for the examination of the nose, by having the light thrown through its walls, either from the outside or through the septum, from one nasal passage, and he is the only author who has published any practical results as secured by this method.2 The method can only be of use in ascertaining the relative pro- portions as regards thickness of either the whole wall of the larynx or any of its parts, which are thus rendered transparent. The process has also been applied by Schrotter,3 to determine the degree of transparency and thickness of a membrane lying between the vocal cords. PALPATION. However brilliant may be the diagnostic results which the surgeon obtains by means of inspecting directly the regions of the body now under consideration, palpation is absolutely neces- sary to render the conclusions which he has arrived at certain in all respects; for besides aiding him very materially to detect changes in form, the procedure is the only one which will assist him in ascertaining the degree of elasticity and the consistency of the parts under examination. Palpation, therefore, should never be omitted in cases where possibly it might render valu- able assistance. The precautions to be taken by the surgeon when introducing his finger into the patient's mouth, have 1 L. c, p. 29. 2 L. c, p. 119. 3 Jahresbericht der Klinik fur Laryngoskopie, 1870. Wien, 1871., p. 68. EXAMINATION BY PALPATION. 69 already been alluded to (p. 5), and as the process is a very simple one, his attention is only called to the following points : By passing the forefinger behind the velum, and then turning its point upwards, we are able to touch not only the entire pharynx, but also the naso-pharyngeal cavity. Palpation of this region, as a means of diagnosis, was first recommended by Meyer, of Copenhagen, but is still practised far too little. The surgeon, having placed himself in front of the sitting patient, directs his forefinger into the pharynx of the latter, and during quiet inspiration passes it without force behind the velum, as far as to the posterior nares. The posterior surface of the velum, the septum, the pharyngeal orifices of the Eustachian tubes, the fossa3 of Rosenmuller, and the fornix pharyngis, are then easily touched and examined. For the patient's right side the examiner's left forefinger will be found most convenient, and vice versa. In so far as the lateral parts of the pharynx are without bony walls, they may be examined by the combined method—that is, by palpation externally and internally at one and the same time; the movements of the finger which has been introduced into the pharynx being followed by the corresponding finger of the other hand, which is placed upon the external surface of the neck. This method, it will be readily seen, is especially useful in ascer- taining the location and extent of deep swellings. In order to avoid retching and vomiting on palpation of the pharynx, it is necessary at first that the examiner should not prolong the examination. By degrees the patient will become accustomed to the process, and disagreeable as it is to him at first, it can, later, be prolonged until the desired results are reached. The larynx may be palpated either externally or internally. If internally, the examiner can feel distinctly the laryngeal surface of the epiglottis, the plica ary-epiglottica, and the ary- tenoid cartilages; but in consequence of the reflex contrac- tions of the aditus laryngis, which follow the introduction of the finger into the cavity, the remaining parts present them- selves to the examiner's touch only as indefinite outlines, if indeed he be able to pass his finger that far down. 70 FRAENKEL.—DISEASES OF NOSE, PHARYNX, AND LARYNX. The larynx is palpated externally in order to ascertain whether pressure be painful, and what sort of fremitus the vibrations of the vocal cords produce through the laryngeal walls. The movements of the larynx should also be observed, and especially the position of the thyroid cartilage in relation to the cricoid cartilage and the hyoid bone. The crepitant noise sometimes heard when the larynx is moved to and fro laterally is caused by the rubbing of the greater cornua of the thyroid cartilage, uncovered by muscular tissue, against the vertebral column. The points in the larynx and in the nose which the surgeon is unable to reach with his finger, may be palpated by the assistance of a sound (Fig. 12), and the same instrument may be employed to demonstrate the amount of sensibility which given parts pos- sess. In this way we may ascertain not only the degree of reflex excitability, but also the points of greatest irritability. Interference with the larynx causes immediate reflex movements, followed generally by retching and spasmodic closure of the superior strait of the larynx. In the pharynx direct irritation is rarely followed by coughing. In the larynx the true vocal cords appear to be less sensitive than the false cords. This method of examination, however, is so little practised that but few observations exist throwing light upon the patho- logical significance of sensitiveness of the pharynx. The method of introducing instruments into the laryngeal cavity will be described hereafter. EXAMINATION BY AUSCULTATION AND BY THE SENSE OF SMELL. Besides the senses of sight and touch, those of hearing and smell often offer valuable means of diagnosis to the surgeon in his examination of the parts now under examination. The sense of smell, for instance, will inform us whether the patient's breath is offensive, and if we find this to be the case, it will be our rather unpleasant duty to discover whence the odor proceeds. An affection of the nose is the usual cause. If this be the case, the breath will lose its offensiveness, if the patient close the nose tightly with the fingers, and breathe through the mouth EXAMINATION BY AUSCULTATION". 71 alone. But, occasionally, it will be found that the smell pro- ceeds either from the decomposing matters in the crypts of the tonsils, or from the secretions of the pharynx, the larynx, etc.; to locate its site, therefore, the surgeon will need to touch the suspected points with a small pledget of cotton or a piece of blotting-paper, which being contaminated by the affected part, will demonstrate the fact most clearly. The ear is employed for diagnostic purposes in the follow- ing manner: If the patient expire forcibly through one nostril —the mouth and the other nostril being kept closed—the ful- ness of the current of air escaping through a nostril of normal calibre will be readily appreciated by the ear. If the air be not heard to escape under these circumstances, some obstruction in the calibre of the nasal passage in question surely exists. Again, if the surgeon should listen attentively while the patient speaks, changes in the quality of the sound [Klangfarbe— clang-tint] will indicate changes in the adjoint-tube,—the nasal passages,—and impurity of the tone, changes in the laryngeal cavity, especially of the vocal cords. Purity of tone may be interfered with: 1, by alterations in the elasticity, moisture, etc., of the vocal cords ; 2, by insufficiency of force in the column of expired air which strikes them, and should throw them into vibration ; 3, by defective formation of the glottis, which latter may be caused by, a, changes in the configuration of the vocal cords and of their adnexa ; b, paralyses of the muscles; and, c, mechanical obstacles ; 4, by insufficient tension of the cords ; and, finally, 5, by obstacles which prevent their proper vibration. If, again, the patient be incapable of pronouncing certain con- sonants, the surgeon may, by ascertaining to which class these consonants belong, whether labials, Unguals, etc., early deter- mine the locality of the lesion. His ear must also inform him as to the character of the patient's cough, which, if a laryngeal affection is present, will usually be hoarse and barking; and whether the inspired air finds entrance into the lungs without meeting with any obstruction in its course. If there be obstruc- tion, stridor will be produced, which may depend either upon a narrowing of the calibre of the air-passages, upon certain forms of paralysis of the glottis by which it is contracted, or the point 72 FRAENKEL.— DISEASES OF NOSE, PHARYNX, AND LARYNX. of the arytenoid cartilages is bent forward, or upon spasm of the glottis. Finally, the patient should be asked to communicate his sub- jective symptoms, whether he experiences pain on deglutition or in phonation, and whether his sense of smell is affected; and it is only after all these points have been thoroughly investigated that the surgeon can render his opinion in an intelligent manner. GENERAL THERAPEUTICS. In considering the subject of the therapeutics of the nasal, pharyngeal, and laryngeal cavities, our intention is to familiarize the reader with those therapeutic means which are not only topically applied to these cavities, but whose remedial action is confined to them. All methods of treatment, therefore, in which the above-mentioned parts are employed as points of application for remedies designed to act at a distance, are omitted, as well as the consideration of any plans of treatment in which remedies are applied to other parts of the body, skin, stomach, etc., for the purpose of acting upon the organs now under consideration. The only special preparation which is necessary, upon the part of the surgeon, is with reference to the introduction of instruments into the larynx. This procedure, however, not only demands a considerable amount of practice, but also a certain degree of skill, in order that the instrument may be introduced rapidly and safely into the larynx, and applied to the desired point. Not only the surgeon, therefore, who undertakes special and bloody operations upon this part, but every physician who treats patients suffering from the ordinary diseases of the throat, should acquire this necessary skill by long-continued practice. For almost all local therapeutic procedures in the larynx render the introduction of instruments necessary, and this subject, therefore, comes legitimately within the scope of this Cyclopae- dia, which does not treat of purely surgical procedures. The larynx was treated locally even in pre-laryngoscopic times. The surgeon either fixed the epiglottis by means of his left forefinger, and then, guided by the sense of touch, carried a sponge-holder into its cavity, or he excited retching or caused the patient to swallow in order to profit by the elevation of the 74 FRAENKEL.— DISEASES OF NOSE, PHARYNX, AND LARYNX. larynx which followed both acts.1 It is only, however, since Czermak made the laryngeal mirror a "sure guide for the operating hand," that therapeutic or operative procedures in the interior of the larynx have become safe and sure. He himself cauterized a larynx, with the aid of a mirror, in February, 1859. Since this time the method has come into universal use, opening a safe way into the larynx, so that the old plan of making local applications during an act of retching, when the epiglottis was thus brought into sight (see p. 4) is now only permissible in very exceptional cases, or, if I may be allowed the expression, as a sort of pons asinorum. It is advisable that the introduction of instruments should first be practised upon a dummy, with probes (Fig. 12), before attempts are made upon the larynx itself. The surgeon, holding the mirror in the left hand, introduces a probe with his right, in the median line of the mouth, until he has carried it over the epi- glottis, and has entered the laryngeal cavity without touching anything on the way. This procedure can only be learned by practice, and not from descriptions, no matter how detailed, and therefore it will be sufficient at this point to direct the examiner's attention to the following two points which experience has shown to be the most difficult to the beginner. As the laryngeal picture hardly admits of being viewed with both eyes, and as the ante- rior and posterior parts of the larynx appear, respectively, as upper and lower in the picture, as seen in the mirror (p. 51), it is not easy at first to localize the various parts, or to determine exactly at what point the tip of the sound is applied. Begin- ners, therefore, usually hold the sound at some distance above the vocal cords, and must be made to introduce it more deeply to the proper point of destination. Secondly, the beginner often fails from not appreciating the short curve which the sound has to describe over the epiglottis to pass into the larynx, and not posteriorly into the oesophagus. To accomplish this it is only necessary for the examiner to elevate his hand, and with it 1 Trousseau et Belloc, Traite pratique de la phthisie laryngee. Paris, 1837. (Medi- cation topique. Medicamens liquides), p. 316. Buhle, Kehlkopfkrankheiten. Berlin, 1861, p. 31. GENERAL THERAPEUTICS. 75 the handle of the instrument, a movement which it is impossible for him to accomplish without raising his elbow. Although, then, the introduction of a sound into the larynx requires some practice, it is not a matter of witchcraft, but may be learned in a few hours. The surgeon, once having learned to introduce the sound successfully, is prepared to undertake the use of any other instrument, and to conduct intra-laryngeal pro- cedures with an assurance which inspires confidence, and a rap- idity which gives the patient no time for reflection, and hardly lets him know that anything has taken place within his larynx until it is all over. After the laryngeal mucous membrane has been touched, and still more certainly after an application of caustic has been made to it, retching, and occasionally attacks of suffocation occur, the latter being caused by a spasmodic contraction of the aditus laryngis, or of the glottis, and generally passing away in a few seconds. It is only in rare cases that the attack appears threat- ening, and there is no case on record where tracheotomy has been rendered necessary by a spasm of this kind. Calmness, on the physician's part, and a swallow of water given to the patient, have hitherto always been sufficient to overcome it. Water must always be conveniently at hand when instruments are introduced into the larynx, in order that a few swallows may be immediately given to the patient in case an attack of this kind supervenes. Besides the water the surgeon will do well to have a convenient vessel read)' into which the patient may spit, or, as sometimes happens, vomit. Before the special local therapeutic methods are more fully discussed, one or two outside matters, which are of some prac- tical importance, should at least be alluded to. In all cases where applications are used which cause a stain, care should be taken by the surgeon to protect both himself and his patient; this may be done by spreading over his lap and that of the patient, who sits opposite to him, an india-rubber cloth, or a piece of oil-cloth. It is, furthermore, of the greatest importance to insist upon it that, as far as possible, every patient should have his own individual outfit. The danger of infection and the dictates of cleanliness sufficiently explain the necessity for this. 76 FRAENKEL.—DISEASES OF NOSE, PHARYNX, AND LARYNX. Finally, we may be allowed to remark that no matter how great a value the surgeon attaches to a good armamentarium, less seems to depend upon the invention of new, and the im- provement of old instruments, than upon the skilful use and practical application of those which are already known. Beginners, especially, are more likely to attribute their want of success in an operation to the instrument than to their lack of technical skill, and instead of practising with the old instru- ments, they impose upon their inventive faculties the unneces- sary task of devising new ones, which are to satisfy their exces- sive demands. Medicinal substances and solutions are applied to the nasal, pharyngeal, and laryngeal mucous membranes for the following various purposes : 1. To act upon the circulation (astringents); 2, to destroy abnormal outgrowths of tissue or induce their retrogression (caustics); 3, to promote the reparative process and cicatrization of ulcers ; 4, to abort, to limit, and to reduce inflammatory action ; 5, to reduce or increase the amount of secretion, to alter its character and to neutralize it, disinfect it, etc. In the follow- ing pages, however, we shall not divide the subject according to the action of remedies—a division which, a priori, would cer- tainly be correct—but shall study the different methods of their use according to the physical characteristics of the means employed. I. THE APPLICATION OF SOLIDS. a. The Simple Direct Method. The principal medicaments to be considered under this head are, alum, borax, sulphate of copper, nitrate of silver, mitigated stick of the same, Vienna paste, and chromic acid; that is to say, astringents and caustics which are easily dissolved, and are designed to be applied lightly to the mucous membranes. The instrument necessary for the application of these remedies consists of a suitable holder, in which pieces of the above-men- tioned substances may be firmly held (forceps, crayon holders). If these pieces are rough, they should be smoothed, before being GENERAL THERAPEUTICS. t i used, by means of an ordinary file. The application of the weaker remedies to the pharynx may, in case of necessity, be entrusted to the patient himself. The importance of the subject demands that special mention be made of the method in which nitrate of silver is fused upon a flexible wire. The latter should preferably be of silver, but other kinds of wire may also be used. Special instruments have been devised for use in the larynx (Fig. 18), the advantages of which are not to be ignored. Fig. 18. Porte-caustiquea. 1, Made of hard rubber for the pharynx; 2, rod for fused nitrate of silver; 3, guarded porte-caustique, according to Tobold. The nitrate of silver is heated over a spirit-lamp, and when beginning to melt is brought into contact with the heated probe, when it adheres to the latter. But in order to ascertain whether this adhesion be firm or not, after the mass has cooled, it is advisable to strike the instrument against some hard object. The whole process is therefore a very simple one, and by means of a suitable probe admits of the application of the nitrate of silver to any part of the region under consideration. It may here be stated, once for all, that all instruments prepared for the larynx may also be used for the naso-pharyngeal space by simply reversing them. In coating a probe with nitrate of silver, this substance is applied either to its end alone or upon its side, the latter having been previously flattened; and, to protect the healthy tissues from the action of the caustic, the remaining 78 FRAENKEL.—DISEASES OF NOSE, PHARYNX, AND LARYNX. parts of the probe are coated with a paste of meal mixed with common salt. If Vienna paste is used, fat or oil, instead of the salt, will answer the same purpose. Chromic acid, recommended by Lewin, is applied principally in the pharynx, small crystals being used, which are brought into contact with the desired point by means of small wooden rods. The hygroscopic chromic acid becomes fluid at the point of application, where it causes a superficial necrosis and consid- erable shrivelling of the tissues. It is an efficient caustic, but its action is so intense that it should be employed only with great caution, and the surgeon will only select it when he desires to cause the rapid and complete destruction of some one small point of ulceration or hypertrophic outgrowth. In this, as in all other methods of treatment to be mentioned hereafter, a second application is only to be made after the effects of the former one have either begun to subside or have entirely disappeared. b. Insufflation of Powders. Pulverized substances may either be inhaled by the patient into the region of the body with which we are dealing, or be Figs. 19 and 20. Fig. 19. Insufflator of silver for the larynx, according to Bauchfuss. «, Slide, closed over the opening which contains powder; 6, rubber bulb for the compression of the air and the expulsion of the powder. Fig. 20. Insufflator of hard rubber for the larynx. a, Slide, pushed away from the opening, b; c, tube for blowing in air. blown in by the surgeon. The first method is still used, for the purpose of making applications to the nose, in the form of snuffs. GENERAL THERAPEUTICS. 79 It has long since been pretty much given up as a method appli- cable to the larynx, for which it was recommended by Trousseau and Belloc. For the purpose of insufflating powders, suitably shaped tubes of glass, of hard rubber, or of silver, and, in cases of necessity, a simple goose quill, are employed, being made straight for the nose and pharynx, and curved for the larynx. They must, moreover, be so arranged that they are easily filled with the powder (Fig. 19). I employ those provided with a flexi- ble tube of sufficient length (about twenty inches) and a mouth- piece, so that the operator can expel the powder by blowing (Fig. 20), and prefer them to other instruments in which the same thing is effected by the compression of an India-rubber ball (Fig. 19) attached to the extremity of the instrument. As this compression of the ball has to be effected by the same hand that holds the instrument, the powder can hardly be expelled with- out some motion being communicated to the point of the instru- ment, and a localization of the powder is therefore much less certain with this form of apparatus than with the former. On the other hand, the tubes first mentioned are themselves objec- tionable, inasmuch as they oblige the surgeon to blow into the patient's mouth; and to obviate this objection Bruns produces the requisite current of air by means of bellows placed beneath the foot. The articles most commonly employed in this way are tannin, nitrate of silver, alum, oxide of zinc, calomel, and sulphur. The amount put into the opening of the insufflator each time is from a grain and a half to four grains. It is therefore desirable to mix the stronger articles (silver, tannin), with the milder (alum, zinc), or with sugar of milk, prepared talc (Bruns), etc., in pro- portions varying according to the effect desired, and ranging from one part of the former to ten of the latter, to equal parts of the two, with the addition of narcotics (morphine). To avoid a reverse current, which may be caused by the expiration or cough of the patient, the surgeon should blow the powder into the larynx at the moment of inspiration^ or while the patient phonates softly, if it is desirable to prevent it from entering the trachea. The point of the insufflator must be directed towards the point at which the application is to be 80 FRAENKEL.— DISEASES OF NOSE, PHARYNX, AND LARYNX. made, without, however, touching it. The effect of the applica- tion of remedies in this way may be somewhat limited as to area, though by no means to the same degree as in the method just described (cauterization). Insufflation is, however, much more easy of performance. The patient frequently retches and coughs after such an application, but attacks of spasm of the glottis, so easily caused by the contact of caustics, very rarely occur. The method is applicable in the treatment of chronic inflammations, of superficial ulcerations, tumefactions, etc. c. The use of caustic darts is never attempted in the larynx, and but rarely in the nose and pharynx. Darts of equal parts of iodine and iodide of potassium prepared with dextrine, and made as fine as Carlsbad needles, are used however with success in the treatment of such forms of hypertrophied tonsils as pre- sent numerous wide-mouthed crypts. d. The application of ointments is, as far as the special regions now under discussion are concerned, only available in the anterior nares. II. THE APPLICATION OF FLUIDS. a. Pencilling. As fluids may be held by a brush or sponge, it is possible to apply solutions to the nose, the larynx, and especially to the pharynx. To accomplish it the surgeon needs for the pharynx Figs. 21 and 22. Fig. 21.—Sponge holder. Fig. 22.—1. Laryngeal brush. 2. Laryngeal sponge. a straight pencil, or a sponge-holder (Fig. 21), to which may be fastened a small bit of sponge or a pledget of cotton. The latter GENERAL THERAPEUTICS. 81 I am in the habit of using exclusively, on account of its simpli- city, convenience, and cleanliness. The pledget is prepared according to the size of the part which is to be treated, and is placed between the arms of the sponge-holder and fastened hy means of a sliding clamp. After it has been used it may be detached from the holder and thrown away, without touching it with the fingers, by simply drawing back the slide. By means of such an instrument applications can be thoroughly made not only to the pars oralis but also to the pars nasalis of the phar- ynx, but for the latter purpose it is advisable to fasten the pled- get of cotton by a corner alone, and pass it behind the velum. The contraction of the pharyngeal muscles which immediately occurs will then express the fluid contents of the pad. Special sponge-holders are also constructed for the larynx, but, on account of the serious results which would follow if the sponge were to escape from the grasp of the instrument in this region, it is advisable to use only the special forms of brushes or sponges represented in Fig. 22. The stem of such a holder must not be too flexible, and the sponge or the pencil must be firmly attached to it, so firmly that not the smallest piece, not even a single hair of the brush can fall away and be lost in the larynx. Each patient should have his own instrument, which he ma}- either carry away with him or leave at the office of the surgeon. Before being used the brush or the sponge should be moistened, and it will be found, as a rule, that the brush absorbs less liquid than the sponge. It is therefore preferable, if a small part of the laryngeal surface alone is to be treated, to use a very fine brush. Generally, however, its whole surface is brought into contact with the liquid, as the constrictor aditus laiyngis is tightly closed about the instrument as soon as the latter is introduced into the larygeal cavity, and on this account the present method of treatment admits of less local limitation as regards its effects on the tissues than those previously mentioned. By changing the degree of concentration of the solution, the surgeon will find it easy to regulate its effect according to the indications pre- sented. The use of a brush or sponge is more likely to result in staining the clothing, and as the brush is brought into contact with the mucous membrane this method is more disagreeable to VOL. iv.—6 82 FRAENKEL.—DISEASES OF NOSE, PHARYNX, AND LARYNX. the patient than insufflation. These points, then, will serve to render the advantages and the disadvantages of both the methods described apparent to the reader. I have been unable to discover any difference in favor of either brush or insufflator, after using both alternately in the same case, but the use of the brash cannot be dispensed with, for, in addition to other reasons, many medicaments are made available by its use which can only be applied in solutions. Water, or Mater with glycerine, is commonly used as the sol- vent ; but a linctus, made palatable by the addition of syrup, may be prescribed, especially for use in the pharynx. In order to avoid waste, only a small quantity of the solution, sufficient for one application, is poured into a small glass, which stands on the right of the surgeon, and into which the brush is dipped until saturated. The method of introducing the brush into the larynx is the same as that already described, when speaking of the introduc- tion of the laryngeal probe, etc., on page 74. The medicaments used may be solutions of any of the astrin- gents previously mentioned, preferably nitrate of silver (from ten to fifty grains to the ounce) and tannin (from twenty-five to one hundred grains to the ounce). Besides these we use solu- tions of the chloride of iron, tincture of iodine (or a solution of iodine in glycerine), corrosive sublimate, bromide of potassium, chlorate of potassa, chloroform, lime-water, alcohol, lactic acid, pepsine, pyroligneous acid, permanganate of potassa, carbolic acid, etc. b. Syringing. Liquids may likewise be applied to both the pharynx and larynx by means of the syringe. Any form of syringe will answer the purpose for the pharynx, but for the larynx the canula of the syringe must not only have a given form, but must also be so arranged that the fluid will not be discharged too quickly, and the jet not be too powerful. A detailed description of the very many forms of apparatus designed for this purpose is unnecessary, and only those of the simplest construction are shown in Fig. 23. ISo. 1 represents a syringe of hard rubber, GENERAL THERAPEUTICS. 83 similar in its construction to that of Pravaz, as used by gyne- cologists fo rintra-uterine injections, with the exception that the canula is curved in a direction suitable for entering the larynx, and that its end is perforated with small openings. Fig. 23, Xo. 2, shows an instrument of hard rubber, in which the suction is not performed in the usual manner by a piston, but by means of an elastic membrane, stretched over a small cup-shaped depres- sion in such a manner as to make it air-tight. This elastic mem- brane having been strongly depressed by means of the forefinger, the point of the instrument is immersed in the solution to be Fig. 23. Laryngeal syringes. used. When the pressure of the finger is withdrawn, the mem- brane recovers its former position, and the cup is filled by the fluid, drawn up into it through the tube of the instrument, and pressure again upon the membrane, after the instrument has been introduced into the larynx, ejects it. For the purpose of secur- ing an exact dispensation, the surgeon may use a graduated glass, from which to draw up the solution. The same purpose may be served by the use of simple curved tubes of glass, as follows : The point being placed in the solution, while the other end is held tightly closed by the pressure of the surgeon's finger, the tube is filled by simple removal, for a second, of the latter. The finger then being again pressed against the end, the tube may be introduced to the desired point of application in the larynx, and the contained liquid expelled by simply removing the finger. As a rule, but few applications are made to the larynx by means of the syringe. Besides narcotics (morphine), lime-water (for diphtheria) is almost the only one. With the nose, however, the case is different; its configu- 84 FRAENKEL.—DISEASES OF NOSE, PHARYNX, AND LARYNX. ration being especially adapted to this method of applying med- icaments. If liquid under a certain pressure enters one of the nostrils, the velum is elevated and closely approximated to the posterior pharyngeal wall, so that the nasal cavity is closed pos- teriorly in such manner that the fluid running through the pos- terior nares escapes by the opposite nostril. If the patient's head be inclined forwards, the liquid, as it runs out, is easily made to flow into a suitable vessel. It can therefore be readily understood why this method, which bathes the entire nose and upper parts of the pharynx, and is at the same time so simple and so complete, is preferred to all others. The instruments for Fig. 24. a. Nasal douche, according to Th. Weber; 6, irrigating apparatus for nasal douche; c, nasal syringe according to Weber-Liel. effecting this injection are either a common syringe, provided with a suitable nozzle (Fig. 24, c), or the so-called nasal douches, of which one, arranged on the principle of the irrigator, is shown in Fig. 24, b. Fig. 24, a, represents the form of douche most commonly used ; it is the one designed by Th. Weber. It con- sists of a flexible rubber tube, provided at one end with a nozzle, and attached at the other to a perfcrated plate of metal, usu- ally zinc, which is lowered into the water contained in a vessel placed above the patient's head. Suction upon this latter with- draws the air contained in the tube, and causes the water to flow through it, the whole apparatus then acting as a syphon. The patient himself may withdraw the air from the tube, after having GENERAL THERAPEUTICS. 85 introduced the olive-shaped nozzle into the nostril, by inspiring through the nose, the opposite nostril and the mouth being closed. The successful use of any of these instruments depends mainly upon the fact whether or not the olivary nozzle is fitted into the nostril in such a manner as to be air-tight. Troltsch' recommends the injection of a liquid mixed with air, for the purpose of cleansing the nasal cavities, and accomplishes this by introducing a suitable tube along the floor of the nostril, through which both air and fluid are propelled in the form of spray. It has been urged against the use of the nasal douche, that inflammations of the ear are often caused by it, the injected liquid penetrating, in spite of all precautions to the contrary, through the Eustachian tube into the cavity of the middle ear. On the part of others the douche is especially recommended for the purpose of injecting fluids into the Eustachian tubes, a pro- cedure which it is true may readily be accomplished thereby. If, during the application of the douche, the nostril which should be left free, is closed, and the patient make efforts at swallow- ing, there is no doubt but that fluid will enter the tubes. But this occurrence is by no means as dangerous as has been repre- sented, and is very easily avoided in patients who are not too stupid, by having them leave the nostril free, abstain from efforts at swallowing, and breathe calmly with widely opened mouth. The physician, therefore, at least as far as our present experience goes, need not be deterred by the above consideration from using this most useful apparatus ; but in all cases proper precautions must be taken, and as the patient is to use the douche indepen- dently of the surgeon's observation, he must previously be care- fully instructed as to the proper method to be followed, and in no case be allowed to use too high a pressure. In lieu of the douche, the patient may cleanse the nasal cavi- ties—with less success, however—by drawing up, or snuffing up, a fluid from the hollow of the hand. It would be far more rea- sonable to advocate drinking out of the hollow of one's hand, as an improvement on using a cup, for one can drink out of his 1 L. c, p. 339. 86 FRAENKEL.—DISEASES OF NOSE, PHARYNX, AND LARYNX. hand, whereas it is impossible to snuff up sufficient fluid to fill the entire nasal cavity. In contrast to the above is a method of treatment pursued recently by Friedel,1 in three cases of ozsena. It is worthy of attention, and is described as follows : The tamponing of the posterior nares was performed first on the right side, and the following day upon the left, with pledgets of lint of the thickness of one's thumb, saturated with carbolized oil. The patient was then placed in a horizontal position, and while the head was thrown so far backwards that the nostrils lay in an almost horizontal position, the nasal cavity of the side that was plugged was filled with a solution of carbolic acid (one per cent.). The corresponding nasal orifice was then closed by means of a bit of punk. The disinfecting solution was thus kept in contact with the diseased membrane as long as the patient could tolerate his position. After twenty-four hours the posterior plug was removed through the anterior naris, and it was found that the odor had almost disappeared from the nostril treated. The opposite nasal passage was then plugged, treated in the same way, and with the same result. In the mean- time the douche was applied to the free side of the nose, and although the following day it was not entirely free from dis- agreeable odors, the offensive smell diminished steadily. Later on, carbolized glycerine was used instead of the oil, and the nasal cavity filled with it as described, until the production of crusts and bloody pus ceased. A fifty-grain solution of sulpho-carbo- late of zinc was then used to fill the cavities, and also as a douche. The duration of the treatment—requiring the patient to lie upon his back for ten days—should not prevent a further trial of this method, which promises success in this class of cases, so tedious and almost desperate. The following medicaments are commonly employed in the douche : 1. As astringents: alum, tannin, nitrate of silver (a five-grain solution). 2. As resolvents, and to remove hyper- secretion : chloride of sodium, carbonate of soda, muriate and carbonate of ammonia. 3. As disinfectants : permanganate of potash, solution of chlorinated soda, carbolic acid, carbolate of 1 Deutsche militiirarztliche Zeitschrift, 1873, p. 533. GENERAL THERAPEUTICS. 87 soda, sulpho-carbolate of zinc, etc. As solvents and emollients : water, glycerine, infusion of chamomile, and remedies of a similar nature. For hay-fever: quinine (a grain to the ounce). For diphtheria : lime-water, etc. The dose of the simpler drugs varies from one part to two hundred to three parts to one hun- dred. The use of pure water is to be avoided in the douche on account of the swelling of the nasal mucous membrane which it causes. If the application of cold be not indicated, the tempera- ture of the fluid used in the douche may be regulated according to the feelings of the patient, generally varying from 77° to 95° Fahr. The application of solutions is still further extended by the use of the so-called gargles—a method of treatment which is familiar to every one, and convenient, because, except in children, it is thoroughly understood by the patient. But the space which is medicated by them is circumscribed, and invariably limited to the pars oralis pharyngis. Troltsch,1 however, recommends another method of gargling, which is much more efficient. In performing it the patient is required, while sitting or lying with the head inclined as far backwards as possible, to pass a large mouthful of the prescribed solution as far back into the throat as possible, while, at the same time, movements of deglutition are made, without, however, allowing any of the fluid to enter the oesophagus. It will at once be seen that this process brings the gargling fluid much more extensively into contact with the mucous membrane. The medicaments which may be used for the purposes of gargling are the same as those already prescribed for use with the brush, or those used for purposes of inhalation, to be men- tioned directly. The dose is usually double that used internally. The danger of absorption, and of swallowing the solution, ren- ders it unadvisable to employ them in a stronger form, and if, therefore, the surgeon desires to use more powerful solutions than those cited above, he must depend upon one of the other methods of application which have been described. *L. c, p. 343. 88 FRAENKEL.—DISEASES OF NOSE, PHARYNX, AND LARYNX. INHALATION OF ATOMIZED FLUIDS.1 In the year 1858, Sales-Girons described, under the name of " Pulverisateur des Liquides," an apparatus by means of which a fine jet of water could be thrown against a flat surface with such force as to transform it into a fine spray, which could without difficulty be inhaled deeply into the bronchise. Such a decided impetus was given to the treatment of the diseases of the respiratory organs by the discovery of this apparatus, that the subject soon attracted universal attention, a special litera- ture rapidly collected, and many different forms of apparatus were speedily devised. All of the latter, however, with the exception of the one which has already been described, may be divided, for purposes of consideration, into three groups, as follows : 1. Principle of Matthieu. Air is compressed in a tightly closed vessel which contains the liquid medicament; escaping then through a small open- ing, it meets with the liquid which has been driven by com- pressed air through a narrow tube ending at the same point with the opening just mentioned, and here a fine spray is necessarily produced. From the large list of apparatuses constructed on this prin- ciple, the syringe of Schnitzler 2 alone is selected for the pur- pose of illustration, and shown in Fig. 25, although Lister's apparatus, belonging to the same class, might be used for a similar purpose. By means of a rubber balloon attached at a, air is forced into the cylinder b, and its contained liquid caused to rise through the tube c into the common tube d, through which the tube c passes to its point. In the common tube d there is likewise a channel for the passage of the compressed air, which finally 1 Waldenburg, Die locale Behandlung der Krankheiten der Athmungs-organe. Berlin, 1872. Lewin, Inhalationstherapie. Berlin, 1865. Siegle, Behandlung durch Einathmungen. Stuttgart, 1865. 2 Wiener medicinisehe Presse, 1871, p. 791. GENERAL THERAPEUTICS. escapes at its point, meeting with the fluid and ejecting it in the form of a fine spray. This apparatus is easily managed and is very efficient. 2. Principle of Bergson. Compressed air is forced through the small orifice of a tube which is met at its point by a second tube, with an equally small orifice, arranged at a right angle to the first, the lower end of the latter being immersed in the solution to be atomized. The strong current of air passing through the first tube, and over the mouth of the second, causes a current in the latter, which carries the fluid upward and out at the point where it is transformed into fine spray by the strong current of air which strikes it. This princi- ple is the one which is so commonly made use of, not only for medical purposes, but also in the so-called " rafraichisseur." Fig. 26 shows the form of the original apparatus of Bergson, and Fig. 27 represents the modifications introduced by Wintrich, which per- mit the introduction of the instrument into the mouth of the patient, and the production of the spray there. Weber-Liel* has constructed an apparatus upon the same principle, which has received the name "Coni- antron," and by means of which the point of the instrument is introduced into the pars nasalis phar- yngis, and held there while the contained fluid is atomized. This apparatus also admits of an exact dispensation of the given drug or amount of solution. The same purpose may, however, be effected by means of Wintrich's apparatus, if the tubes be made of a thin and flexible metal, so that they may be turned upwards ; but, except in the case of the naso- pharyngeal space, little is to be gained by advanc- ing the point of the instrument beyond the opening of the mouth. The motive power for the apparatuses of both groups is gen- erally obtained by means of an india-rubber bulb, which, after Fig. 25. Schnitzler's In- halation Ap- paratus. a, Joint for the attachment of the balloon : &, cylinder of glass, closed at the ends by hard rubber caps; c, tube which pass- es below the level of the con- tained liquid: d, common tube, which is remov- able, in order to allow of the cyl- inders being fill- ed with the med- icated solution. 1 Deutsche Klinik, 1867, No. 51. 90 FRAENKEL.—DISEASES OF NOSE, PHARYNX, AND LARYNX. compression, expands again by its own elasticity. This bulb is arranged with valves, so that during its compression the con- tained air escapes only at one end, and immediately enters at the other when the pressure is removed. In order that a con- Fig. 26. Bergson's Hydrokonion. a, Bottle ; c, tube in which the fluid rises; d, air-tube ; b, rubber-bulb ; e, rubber-ball, serving as a reservoir. tinuous current may be produced, the air ejected by the first bulb passes into a second one, covered with netting, which serves as a reservoir, and for the purpose of compression either Fig. 27. Wintrich's Hydrokonion. b, Air-tube ; c, tube for fluid. the hand (Fig. 27) or foot (Fig. 26) may be used. If expense is no object, an air-pump may be attached to the apparatus, GENERAL THERAPEUTICS. 91 instead of the hand balls, an arrangement which will spare the surgeon the necessity of using either his hand or his foot, and which will only need to be worked at intervals. 3. Siegle''s Principle. Instead of compressed air Siegle employs steam under pres- sure, generated by means of a spirit-lamp. His original appa- ratus is figured in cut No. 28, and the modifications of it, trace- able to several authors, are shown in Fig. 29. The original apparatus consisted in a jar of glass (a) closed by means of a perforated rubber cork, in one of the openings of which was placed a thermometer (t), to register the pressure of the steam contained in the jar, and to indicate when there was danger of an explosion. In the second opening was a glass tube (b) for the purpose of conducting the steam jet to the point of the instru- ment, where it met the perpen- dicular glass tube (c), the lower end of which was immersed in the medicated solution (d). The whole apparatus was placed in a lantern-like covering made of white metal, designed to protect the patient in case an explosion occurred in spite of all precau- tions to the contrary. In the modified apparatus, the boiler (a) and the steam tube (b) are made of metal, while at (v) a safety-valve is attached. This latter, from motives of false econ- omy, is found wanting in some of the apparatuses which are sold. A valve, however, is essen- tial, for although a very rare occurrence, still occasionally an apparatus unprovided with a valve explodes, and damage is done. The screw (e) closes the opening through which the water is introduced into the boiler. The boiler is to be two-thirds filled with warm water. After sufficient pressure of steam has been Fig. 28. Siegle's steam atomizer. 92 FRAENKEL.—DISEASES OF NOSE, PHARYNX, AND LARYNX. produced in the boiler by means of the spirit flame beneath it, it passes out through the tube (b) over the point of the tube (c), and at first causes an upward current of air, then an ascension of the fluid in the latter; finally, the meeting of the steam jet and the fluid at this point causes an atomization of the latter, accompanied by a peculiar hissing noise, which shows that the apparatus is in good working order. Failure will depend upon one of two things, either that the heat of the flame is not suffi- ciently intense, or that the position of the tube (c) is not correctly adapted to that of the tube (b), that is, it is either not on the same vertical plane as the latter, or stands at too great a distance from its point. The steam atomizer differs in its practical application from the apparatuses of the first and second groups in the following points: 1. It produces a warmer spray. 2. The spray is expelled with less force. 3. The degree of dilution of the medicated fluid cannot be exactly determined. The steam apparatus, therefore, is adapted for purposes of treatment in affections of the lower respiratory passages, while in the apparatuses of the first group the effect of the application is limited exclusively to the pharynx and larynx. The arrangement of the hand apparatus, more- over, renders it desirable, if not necessary, that the requisite current of air be produced by some other person than the patient. The use of this instrument is, therefore, specially adapted to the hands of the physician, particular- ly in those cases where we wish to direct a powerful stream of spray against the posterior pharyngeal wall, in order Fig 29. Steam atomizer. GENERAL THERAPEUTICS. 93 to produce anaesthesia, for instance. With any of the forms of apparatus the jet of spray strikes the posterior pharyngeal wall with considerable force, thoroughly bathing it, and is so broken up there that, with the aid of deep inspiratory efforts on the part of the patient, it penetrates into the laryngeal cavity. Its effect is, however, mild, and the atomizing apparatus may there- fore be used in cases of recent inflammation; a localization of effect is, however, unattainable. The method of using the apparatus is simple: the patient allows the current of atomized fluid to enter his widely opened mouth, and favors its further progress by inspiring quietly and deeply, and by keeping the tongue as closety as possible upon the floor of the mouth. The atomizer is so placed that the plane of the stream is the same as that of the mouth, when the patient sits in a straight but easy position. Children may be held in the proper position, and screaming will only facilitate the procedure. The whole matter, then, is so simple, and is usually so quickly and so thoroughly understood by the patient, that, as the appa- ratuses are only of a moderate cost, the treatment may be in- trusted to the patient himself, and it is hardly necessary that the surgeon should now, as heretofore, carry it out at his own office. According to the form of apparatus which is used, the time devoted to inhalation at each sitting will vary from two to twenty-five minutes—from one-sixth of an ounce to an ounce or more of the medicated solution being employed during this time. Patients not infrequently complain that, "in spite of all in- spiratory effort" on their part, the amount of liquid in the glass does not diminish, when the steam inhalation apparatus is used. This is usually true, and the reason lies in the fact that the fluid, after condensing upon the glass cylinder (Fig. 29, k), which is used as a mouth-piece, flows back into the glass (c), which contains the solution. It may, however, be prevented from so doing by changing the position of the cylinder or glass, or cover- ing the latter with a piece of paper, arranged so that the fluid will flow off it. The inhalations may be taken by the patient either once or several (from two to four) times daily, and in some cases—for 94 FRAENKEL.—DISEASES OF NOSE, PHARYNX, AND LARYNX. instance, in diphtheria—they may be given at intervals varying from half an hour to an hour or two hours. The medicaments for inhalation can only be used in the form of solutions, preferably made up with water, and are usually prescribed in a concentrated form, to be diluted for use from one- third to one-tenth. The milder remedies may be prescribed in the form of a powder, and the solution prepared by the patient himself. High concentration of a solution is unadvisable, for the desired effects of the application do not correspondingly increase with the grade of concentration, and the inhaled medicated spray is, to a great degree, absorbed by the mucous membrane, and reaches healthy parts as well as those diseased. The following table, arranged by Waldenburg, presents the various medicaments commonly used for purposes of inhalation, together with the dose : 1. Astringents (to be used as cold as is practicable). Alum.............gr. 1 to gr. 12^ to the ounce of water. -* Tannin............ gr. 1 to gr. 15 " " " Liq. ferri chloridi >. TTL f to HI 9 " " " Nitrate of silver... gr. f0-to gr. 5 " " " 2. Resolvents (warm, or lukewarm). Chloride of sodium........... gr. 1 to gr. 15 to the ounce of water. Muriate of ammonia.......... gr. 1 to gr. 15 " " " Carb. of soda (pure).......... gr. 1 to gr. 10 " " " Carb. of potassa (pure)........ gr. 1 to gr. 10 " " " Bicarb, of soda (impure)...... gr. 1 to gr. 15 " " " Chlorate of potassium......... gr. 1 to gr. 10 " " " Bromide of potassium......... gr. 1 to gr. 15 " " " (Also as an anaesthetic.) The mineral waters of Ems, Salzbrunn, and Weilbach. 3. Narcotics. (Here the entire amount of fluid to be inhaled is to be deter- mined on, and as much of the narcotic added thereto as would n.3 ou_y pi/ii^o, iu uo used in stronger solutions, as high as gr. 25 to the ounce. 1 Corresponding to the " strong solution of perchloride of iron " of the British Phar- macopoeia. GENERAL THERAPEUTICS. 95 be given internally Usually, however, narcotics are only used in small doses, added to other remedies.) Morphine, tincture of opium, cherry-laurel water, stramo- nium, hyoscyamus, belladonna in infusion or tincture. 4. Alteratives, Disinfectants. Carbolic acid................. gr. \ to gr. 5 to the ounce of water. Iodide of potassium........... gr. 1 to gr. 25 " " " Also with an addition of pure iodine of gr. ^ to gr. £. Chlorine water................ -n[ 5 to lU 50 to the ounce of water. Liq. sodae chlorinatae.......... ttl 2 to th, 25 " " " Permanganate of potassa....... gr. -J to gr. 5 " " " Sulphate of quinia............ gr. -,1,; to gr. 1 (in whooping-cough) to the ounce of water. Against Diphtheria. Lime-water, pure, or diluted with eight parts of water ; also with the addition of solution of soda or potassa, m 12 to 300 to the ounce. Carbonate of lithium......... gr. 1 to gr. 10 to the ounce of water. Lactic acid.................. gr. 20 to gr. 50 " " " Against Syphilitic Affections. Corrosive chloride of mercury... gr. -}-6 to gr. 1 to the ounce of water. Aside from this, as emollients or solvents, infusions of elder, of chamomile, or of linden are used, as well as the guaiac solu- tion and glycerine. In every case the surgeon should carefully note how rapidly the apparatus used converts the solution into spray, and what degree of dilution it undergoes during the process. The various methods having now been fully detailed, by means of which the larynx, pharynx, and nares are medicated, the surgeon must be guided by his judgment, and the indica- tions presented in each individual case, in selecting the appro- priate means of treatment, for he will find that the method pur- sued in one case is often totally inapplicable in a second, and that, especially in chronic cases, frequent changes are advisable; 96 FRAENKEL.—DISEASES OF NOSE, PHARYNX, AND LARYNX. and although he may thereby seem to be acting inconsistently, he will find that he will accomplish his purpose sooner than if he adhere to one procedure alone, as the only practical and infalli- ble one. In addition to the method alluded to above, the following two are occasionally used in special cases. First. The inhalation of gases, such as bromine in diph- theria, and "Brand's remedy" for coryza (Schnupfenmittel). In both, the fluid is poured upon a sponge placed within a simple paper cone, which is held either under the nose or before the mouth, and the vapor inhaled. The formula of the latter remedy (olfactorium anticatarrhoicum) is: carbolic acid, eighty grains; alcohol, half an ounce ; water of ammonia, eighty min- ims ; distilled water, one hundred and fifty-four minims; and of the former, equal parts of a ten-grain solution of bromine and bromide of potassium. I myself have not been convinced of any special virtue in these methods, although the remedy of Brand is highly spoken of by several authors. Respirators, especially those prepared by Baschlin of Schaff- hausen, may also be used for the same purpose. They are so arranged as to enclose a sponge or tampon, which is saturated with certain solutions (carbolic acid), and are worn so as to render the inhalation of the gaseous vapor constant. Secondly. Submucous injections, which are used, first, in cases of hypertrophied tonsils; a solution of iodide of potassium, of iodized glycerine, or of tincture of iodine, being injected by means of a syringe such as is shown in Fig. 23, which is pro- vided with a fine canula needle; and secondly, in the neuroses of the larynx, and for inflammatory pain—in the latter cases morphine being employed. Recently I have employed this method in a few cases to test the efficacy of carbolic acid as an antiphlogistic, but have arrived at no definite results as to the value of the treatment. Both cold and heat are applied as well to the larynx and pharynx as to other regions of the body, and the apparatuses of both the first and second class, if used with ice-cold water, answer a most excellent purpose as refrigerators. A more detailed description of the application of electricity, GENERAL THERAPEUTICS. 97 for the various forms of paralysis of the muscles of the vocal cords, is necessary. This method of treatment owes much of its perfection to the labors of v. Ziemssen.1 Either the constant or the interrupted current may be used either externally or within the pharynx, the electrodes being Fig. 30. Mackenzie's Intra-laryngeal Electrode. A, Electrode; a, copper sound covered by a catheter: 6, small spring which closes the circuit; c, screw for the purpose of attaching one pole of the battery, with the intervention of the circuit closer; d, screw to attach the same directly, without the circuit closer. Ii, Collar to which the second pole of the battery is attached. placed, in the former method, laterally over the lower cornua of the thyroid cartilage, so as to reach the recurrent laryngeal nerve. As a rule, this plan is first undertaken in the treatment of a case, as being the easiest. To act directly upon any one muscle of the larynx, however, with the exception of the crico- thyroid, which from its superficial location is readily reached externally, the laryngeal electrode must be employed, prefer- ably that of Mackenzie (Fig. 30). After the introduction of the instrument into the larynx, with the aid of the mirror, the circuit is closed by depressing the small spring upon its handle (b), while the other pole is held at the same time externally over the recurrent nerve, either by the patient, by an assistant, or by means of the collar shown in Fig. 30, B. Ziemssen has carefully located the points at which the laryn- geal electrode must be applied, in order to act directly upon certain muscles, as follows : The thyro-arytaenoideus is reached from the interior of the laryngeal cavity, and the remaining muscles of the glottis, from the recessus pharyngo-laryngeus; 1 Die Elektricitat. Berlin, 1872, p. 262. VOL. IV.—7 98 FRAENKEL.— DISEASES OF NOSE, PHARYNX, AND LARYNX. the inter-arytsenoideus, posteriorly, behind the arytenoid car- tilages ; the crico-arytsenoideus posticus, laterally and somewhat deeper in the sinus pyriformis ; and the crico-arytsenoideus late- ralis, quite laterally, and near the superior border of the cricoid cartilage. The galvano-caustic treatment for chronic pharyngeal catarrh, which has recently been strongly recommended by Michel,; needs a more prolonged trial before a decided opinion as to its prac- tical results can be formed. The tamponing of the posterior nares—a procedure which stands on the border line between internal medicine and surgery —is undertaken both in the treatment of hemorrhage from these parts and in the method of treating ozsena as described by Friedel, and mentioned above. The only instrument which is necessary for the purpose is the catheter tube of Belloc (Fig. 31, A), or the Rhineuryn- _B- ^Q$W ter. Belloc's tube is intro- fig- 31. duced along the floor of the A, Belloc's tube; B, Rhineurynter. .., ,-> ■> nose until the pharynx is reached; the spring, a, is then advanced, and after passing around the velum, appears in the mouth. A thread attached to the tampon is passed through the small eye in the button b, at the end of the spring, and the latter is now withdrawn ; then the instrument and the thread hang from the nostril of the patient. By means of it, finally, the tampon is passed up into its position in the posterior nares. The Rhineurynter, or the Rhinobyon," Is a simple rubber balloon, inflated by means of a flexible tube, provided with a stopcock, which is attached to it. The apparatus is introduced into the nostril while empty, then inflated and maintained full by closure of the stopcock. 1 Deutsche Zeitschrift fur Chirurgie, II. Band, p. 154. 2 With regard to its history compare von Bruns, Berliner Klin. Wochenschrift, 1871, No. 31. DISEASES OF THE NOSE. FRAENKEL. DISEASES OF THE NOSE. INTRODUCTION. Diseases of the nasal cavity, in spite of the frequency of their occurrence, belong to a class which has hitherto been made the subject of very little accurate investigation. Until within a very short time clinical observation has been rendered entirely illusory by the fact that no method of examination was known which could give reliable information with regard to the nasal mucous membrane and the parts adjacent. The discovery of rhinoscopy, and the advance which has of late been made in viewing the cavity of the nose from in front, have indeed begun to throw some light upon the subject. But even at the present day the entire nasal cavity is not accessible to the eye of the explorer, and as the only other positive diagnostic means at our command is palpation, which is only practicable within a limited area, our knowledge with regard to diseases of the nose com- pares very unfavorably with the advances that clinical observa- tion has made in almost all other regions of the body. Here, too, pathological anatomy has done but little in sup- port of observations by the bedside. This is owing to two circumstances : First, that diseases of the nose very seldom lead to death, and therefore the attention of those conducting autop- sies is hardly ever called, primarily, to the condition of the interior of the organ. But, secondly, inspection of the nasal cavity is seldom possible, even on the dead body. If disfigure- ment of the face is to be avoided, but a small portion of the cavity can be exposed, and this only after great labor and care, with the assistance of a compass-saw and chisel. The only corpses, therefore, in which the entire nasal cavity can be examined, are those which no one claims, and in which, the 102 FRAENKEL.—DISEASES OF THE NOSE. features may be destroyed. At all events, an inspection of the nasal cavity does not belong to the ordinary course of official autopsies. Owing to these circumstances our knowledge of the processes of disease, and the morbid anatomy of the nasal cavity, remains quite fragmentary. • We have thought it necessary to make this statement, by way of introduction, both to avoid the necessity of frequently recurring to it, and as an incentive to those who may have an opportunity to enrich our knowledge of the dis- eases of this region, by all means to improve every opportunity that offers. Those diseases of the nasal cavity which belong to internal medicine, alter the secretion of its mucous membrane and dis- turb its function, which consists essentially in serving as the organ of smell and as part of the air-passages. In the latter capacity it is connected with the sense of hearing and with speech. We have preferred, instead of giving a general symp- tomatology, to describe the disturbances accompanying each disease when treating thereof, but we shall group together, in one general section, those manifestations which result from closure of the nasal cavity. For the same reasons we have not collected the literature of the subject in one group, but have referred to it at the various points where its assistance might be required. Diseases of the nose, as a whole, have been treated of particularly by Fried- reich ' and by A. Duchek.2 Both these authors give an abstract of the literature. We hope that the essentially practical considerations which have determined us to follow this arrangement will not be dis- approved. 1 Virchow's Handbuch der Pathologie u. Therapie, V. Bd. 1 Abth. Erlangen, 1865. 2 Handbuch d. spec. Path. u. Therap., I. Band, 2 Lief. Erlangen, 1864. STENOSIS AND ATRESIA. 103 STENOSIS AND ATRESIA OF THE NASAL CAVITY. Symptoms. Narrowing and closure of the nasal cavity are conditions that accompany various processes to be described hereafter, as well as other diseases, and the symptoms of which, owing to their clinical significance, we have thought it best to study as a whole. In the normal state of things the air drawn in, through the inspiratory movements of the ches , passes through the nose, the mouth remaining closed. The majority of men do not open their mouths, while awake, in order to satisfy the ordinary demand for breath, though many sleep with their mouths open. But even when the mouth is open, the nose, if in a healthy state, gives passage to the greater part of the air used in respiration. The entering current of air is comparatively small in diameter at the nostrils, and presses chiefly along the inferior nasal meatus and the space between the inferior turbinated bone and the sep- tum, towards the nasal portion of the pharynx, passing behind the relaxed dependent velum into the larynx and the respira- tory organs proper. It returns by the same route, in expiration, and it must be taken for granted that with every inspiration and expiration all the air within the nose is set more or less in motion by the current, whose main direction has just been described. In case of an increased demand for respiration, the ordinary avenue, through the nostrils, is insufficient; it is therefore enlarged, during inspiration, by the action of the levatores alse nasi—an appearance that may be taken as a sign of dyspnoea—and the mouth also assists as an air-passage. If, then, the main cavity of the nose is closed, or so far nar- rowed that its calibre is insufficient for the passage of the air required in respiration, the patient is obliged constantly to breathe through his open mouth instead of through his nose. The conditions of respiration are hereby materially altered for the worse. In its somewhat retarded passage over the ever- moistened turbinated bones of the nose, the air grows warmer, 104 FRAENKEL.—DISEASES OF THE NOSE. and reaches the deeper respiratory passages charged with an increased amount of moisture. Furthermore, the changes in the direction of its movement, which the current of air undergoes during its passage through the nose, naturally causes a portion of the dust-like particles floating in it to be deposited on the extensive surface of the nasal mucous membrane. Any one can easily convince himself of this, on blowing his nose after an evening spent at a ball, by observing, on his hand- kerchief, the number of such particles retained, which would certainly be more injurious to the lungs than to the nose. When the nasal cavity is closed, therefore, the air conducted to the lungs is drier, cooler, and more unclean. Hence we see the importance to respiration of habitually breathing through the nose, and the disadvantages resulting from habitual stenosis of this organ. A foretaste of this may also be experienced by those who habitually breathe through the nose, if they are obliged to speak aloud for any considerable length of time. The dryness of the mouth and throat which ensues is an evidence that these parts are less adapted to the immediate contact of the comparatively dry external air. It is evident, from what has already been said, that permanent closure of the nose—an organ, the respiratory significance of which is indicated by the fact that it is peculiar to those animals alone which breathe the air— must result both in disturbances of the respiratory organs and in derangements of the quality of the blood, and of nutrition generally. These disturbances reach a particularly high grade when closure of the nose occurs in infants at the breast. Rayerx and Billard2 first directed attention to the dangers that threaten a nursling when it is unable to breathe through the nose, a condi- tion which may arise from a simple "cold in the head." As the child is obliged, for its proper nourishment, to suck with the mouth for a long time, the difficulty of breathing, due to closure : Note sur le coryza des enf. a la mamelle. Paris, 1820. 2 Traite des maladies des enf ants, 2d edit., p. 480. Compare also Barthez and Rilliet, Maladies des enfants. Paris, 1861, p. 187; and other text-books on diseases of children, especially Kussmaxd, Zeitschrift f. rationelle Medicin, 1865, p. 225. STENOSIS AND ATRESIA. 105 of the nose, is greatly aggravated by every attempt to take the breast, soon reaching the point of suffocation, and obliging the child to quit hold of the breast almost as soon as it has com- menced, for the sake of getting its breath. In this way such obstacles are interposed to the proper nourishment of the infant that the most serious danger to life may result from this appa rently insignificant difficulty. Aside from the act of suckling, however, asthmatic attacks occur in nurslings when their noses are obstructed, because during sleep they breathe exclusively through the nose. Kuss- maul, in the work already referred to "On the Coryza of Nurs- lings," communicates some observations that were made by his assistant, Honsell, in the Freiburg Clinic, on the position of the tongue in new-born children during sleep, and on the part which the mouth plays as an air-passage during breathing. It appears from these observations, the results of which I can con- firm, that in healthy infants the mouth is almost always closed during sleep (296 times out of 328 observations), and the tongue lies in contact with the hard palate. More rarely the mouth is open, but the tongue still kept in contact with the hard palate, and most rarely (13 times out of 328 observations), is the mouth open and the tongue not thus in contact. In all cases, however, the mouth takes no part as an air-passage in breathing during sleep. It is thus easy to understand that little children are obliged to acquire the habit of breathing through the mouth during sleep, and that, therefore, if occlusion of the nose takes place, they are seized with severe dyspnoea as soon as they go to sleep, the tongue not yet having learned to abandon its physi- ological position of resting against the hard palate. Thus we can explain the asthmatic attacks of children during sleep, the occurrence of which, during coryza, though rare, has been noticed by children's physicians, and which, as was intimated by even so old a writer as J. P. Frank,1 threatens the lives of the little ones by robbing them of the possibility of refreshing sleep. Kussmaul, moreover, draws our attention to another expla- : BehandL d. Krankht. d. Menschen, aus dem Lateinischen. Mannheim, 1797, V., p. 102. 106 FRAENKEL.—DISEASES OF THE NOSE. nation of these suffocative attacks, viz., that in nurslings suffer- ing from coryza vigorous attempts at inspiration, while nursing or asleep, which are rendered futile by closure of the mouth and nose, may sometimes give rise to very acute hyperemia of the lungs. Bouchut,1 and, before him, Stammer2 also called attention to the fact that suffocative attacks in children, under these circum- stances, might also be accounted for in another way. According to these authors, the inspiratory movements may become so violent that the tongue—which in the cases described was but loosely attached, through the frenulum, in front—is swallowed, as we often find it to be during ansesthesia, and, as we would add, probably closes the respiratory passage by pressure of the epiglottis against the entrance of the larynx. These attacks are certainly deserving of all attention, if for no other reason, because, as described by Henoch,3 they re- semble spasm of the glottis, on superficial observation, by their sudden advent and a certain whistling breathing produced in the nose. Hauner4 also states that such cases have been mis- taken for and treated as true croup. Even in adults, under certain circumstances, closure of the nose may give rise to attacks of asthma, or even of positive asphyxia. Thus Traube6 describes two cases in which asphyxia in adults was due to the fact that with every inspiration the alse of the nose (the only point in the passage of the inspiratory stream of air which is not prevented from falling together by the presence of cartilage or some other resisting tissue), instead of dilating, as is the rule in dyspnoea, were pressed together. Nasal stridor ensued, a phenomenon which Traube attributes to the beginning of paralysis of the respiratory nervous sys- tem, and to which patients usually succumb within twenty-four hours, unless properly treated. 1 Traite prat, des maladies des nouveaux-nes, etc., 5. edit. Paris, 1867, p. 237. 2 Ein Fall vom sog. Verschlucken der Zunge, mitgetheilt von Dr. Droste, in Osna- briick, in Casper's Wochenschrift, February, 1834. 3 Beitrage z. Kinderheilkunde, N. F. Berlin, 1868, S. 124. 4 Jahrbuch f. Kinderheilkunde, 1802, V. Jahrgang, S. 73. "Verhandlg. d. Berl. Med. Ges., 1869-71, II., S. 141. STENOSIS AND ATRESIA. 107 One of these patients was suffering from pneumonia, and the other from paralysis ascendens. Traube does not tell us why they could not breathe through the mouth. In the first case he mentions that the patient breathed with his mouth shut; in the second, that he had not for a long time been able to talk nor to protrude his tongue. In a similar case which I observed in a child with meningitis, the mouth was open, but was occluded by the tongue pressed against its roof. But, aside from these hindrances to respiration through the defective working of the levatores alee nasi, tumors of the nose are accompanied by asthmatic attacks ; for which we cannot, as yet, give any sufficient explanation. As far as I know, Volto- lini was the first who called attention to the connection between nasal polypi and asthma. He describes two cases1 (amongst several which he claims to have observed, in some of which there was not complete closure of the nose), both occurring in men, one thirty-three and the other forty years of age, in whom repeated asthmatic attacks, usually occurring at night, were cured,—that is, they disappeared, after the removal of numerous polypi from the nose. In one of these cases there was emphysema present, which Voltolini regards as the result of the hindrance to respira- tion due to the obstructed nasal breathing. I myself have seen two cases in which nocturnal asthma of long duration disap- peared after the removal of nasal polypi. In these cases, both of which were men of about forty years of age, there was no other explanation for the asthma except the closure of the nose, espe- cially no emphysema nor difficulty of the heart. In both cases the patients waked up at night with difficulty of breathing, were obliged to leave their beds or sit up, and after being awake a little while the asthma left them. On going to sleep again, how- ever, the dyspnoea would soon return, and thus they were obliged to get up repeatedly every night, suffering thereby no little dis- comfort. I have been able to offer no other explanation of these phenomena than to suppose that, during sleep, either an accu- mulation of mucus in the mouth, or closure of the lips, or pres- sure of the tongue against the hard palate, or even the relaxed hanging down of the soft palate, closed the only avenue for respi- ration remaining after occlusion of the nose, and that thus an Galvanokaustik, 1871, S. 246 u. 312. 108 FRAENKEL.—DISEASES OF THE NOSE. obstacle was placed in the way of respiration which disappeared on waking, just as Kussmaul supposes it to be in the case of nurslings. Quite recently, Haenisch' has also reported two cases of nocturnal asthma which occurred in connection with nasal polypi. One case, belonging to Voltolini's practice, and occur- ring in the person of a young lady twenty-three years of age, who did not suffer from emphysema, is highly characteristic, in this connection, because the nasal polypi, which complicated an ozsena of years' standing, recurred; so that the occurrence of asthma on the return of the polypi, and its disappearance on their removal, was observed several times. The attacks described by Haenisch differ from those of my patients in this, that in the young lady just mentioned the acme of the paroxysm occurred some time, even though but a very short time, after waking. Haenisch observed at the same time increased volume of the lungs ; hyper-sonorous resonance ; the lower boundary of the lung, in front and on the right side, on a line with the margin of the sternum, remaining immovable at the upper margin of the sev- enth rib ; cardiac dulness somewhat diminished ; and the asthma, especially expiratory. After lasting for from three-quarters of an hour to an hour and a half, the attacks ended with the expec- toration of tough, mucous sputa. Voltolini believes that these manifestations can only be explained on two suppositions: " Polypi either produce asthma by means of reflex action, or, by hindering breathing, they bring about an alteration in the chem- istry of respiration and the texture of the lung tissue." The effect of long-continued nasal stenosis on respiration has been fully set forth in the preceding pages, and we decline to pass any judgment on the view—which certainly needs further proof, but the possibility of which, in view of the frequent simultane- ous occurrence of stenosis and emphysema, cannot be denied,— that such serious changes in the lung-tissue as accompany em- physema may be produced in this way. We should have difficulty in accounting for the sudden occurrence of asthma, especially at night, on the ground of mechanical hindrances to respiration, even if the closure of the cavity of the mouth should 1 Berl. klin. Wochenschr., 1874, S. 503. STENOSIS AND ATRESIA. 109 be confirmed by observation. I have never yet met with such a case myself, but it appears from Haenisch's description that over-distention of the lung takes place; that, therefore, the impediment affects the act of expiration more than that of inspi- ration. Accordingly, the hindrance to respiration, in stenosis of the nasal cavity, cannot be considered as similar to that which exists in stenosis of the larynx, for in the latter it is inspiration that is made especially difficult. Of course it is admitted on all hands that respiratory movements carried on with obstructed mouth and occluded nose must materially disturb the relations of the blood and the air in the lungs, and the only doubts that can exist must be with regard to the finer points in the process. Movements of the polypi themselves cannot be regarded as the cause, because in one case observed by me asthma was occa- sioned by a polypus attached to the inferior turbinated bone by a broad base, and in which changes of position were impossible on account of its form. As regards reflex action, however, we are in possession of some experimental evidence which may be used in explanation of this circumstance. According to the experiments of F. Kratschmer,1 an irritant, acting upon the mucous membrane of the nose, produces a narrowing of the nostrils and an arrest of breathing in the act of expiration, as well as an arrest of the heart's action, which is followed by a series of retarded pulsations. The reflex action originates, not in the olfactory but in the trigeminus nerve. Haenisch thinks we are justified in the belief that the irritation caused by a polypus is more likely to result in reflex action the more the interchange of gases in the lungs is interfered with. Further observations, which we desire to call forth by these remarks, must lead to more accurate conclusions with regard to the connection between occlusion of the nose and asthma. Another result of closure of the nose affects the organ itself, inasmuch as one of its functions, the sense of smell, is in the highest degree interfered with. As the olfactory nerve is only distributed to the upper portion of the nasal cavity, the ordi- 1 Sitzungsb. d. kaiserl. Akad. d. Wissensch. Math.-naturw. Kl., II. Abth., 1870, B. LXIL, S. 243. 110 FRAENKEL.—DISEASES OF THE NOSE. nary respiratory current of air, as was shown above, does not penetrate in full force into the true olfactory region.' Therefore, even in a normal condition, if we want to perceive a smell accu- rately we take deep inspirations, or else do what is called snuff- ing. In snuffing we draw the air into the upper part of the nose by several short inspirations, followed by a powerful expiration. For it is an inevitable prerequisite to smelling that the matter to be smelled must come in contact with the terminal expansion of the olfactory nerve, and therefore, when the nose is closed, the sense of smell is dulled just in proportion to the diminished respiratory ventilation of the olfactory region, and the consequent lessened amount of odoriferous matter that reaches it. But it is not only this principal function of the nose that is disturbed by stenosis or occlusion, the nose itself is also other- wise injured. The removal of secretions, etc. from its cavity is seldom left entirely to the force of gravitation, but is usually accomplished voluntarily by blowing the nose, or involuntarily by sneezing. The removal of secretions is rendered difficult, both in front of and behind the seat of obstruction, in proportion as the expiratory current of air is prevented from acting as a motive power, through narrowing of the canal. As it will appear from what follows that an accumulation of secretions may pro- duce nasal stenosis, we thus have a "vicious circle" established, which is in the highest degree worthy of our attention and of therapeutic interference. These are the results, as regards breathing and the nose itself, brought about by disturbed nasal respiration. But this does not exhaust the symptoms of nasal stenosis. Aside from the fact that closure of the nose obliges the individual always to breathe with his mouth open, thus imparting to his countenance a vacant, silly expression, which to a careful observer indicates the nature of his difficulty from afar, nasal stenosis also pro- duces disturbances of speech and of hearing. In ordinary par- lance we refer to people who speak with their noses stopped up, as "speaking through their noses," whereas this expression should be reserved for quite the opposite condition, in which, by ' Compare Bidder, Wagner's Handwort. d. Physiol., II., S. 920. STENOSIS AND ATRESIA. Ill closure of the isthmus of the pharynx, the air, in speaking, is prevented from entering the mouth, or, for other reasons, is made to escape through the nose; the same position of things existing as is normal in the pronunciation of the nasal ng sound. When the nose is stopped up, the tone, as it were, stagnates— to use the expression of Merkel '—in the side cavities into which it has digressed for the sake of complete resonance ; it is obliged to return by the same way through which it entered, in order, finally, to find a way of escape through the mouth. (Obstructed nasal tone, Rhinophonia narium perperam clausa- rum.) The tone then becomes hollow and discordant. As regards the effect of nasal stenosis on hearing, Lucae1 was the first to observe that in every act of swallowing, under these circumstances, Toynbee's experiment was repeated, produc- ing changes in the atmospheric pressure both in the fauces and the ear, accompanied by abnormal tension of the membrana tympani. If this tension is not regularly equalized, difficulty of hearing gradually supervenes. We believe that in the preceding pages we have noticed all the symptoms of nasal stenosis, and cannot subscribe to the declarations of Uhlenbrock,3 who assigns disturbed nasal respi- ration as a cause of dacryocystitis and lupus. The diagnosis of closure or narrowing of the main cavity of the nose is easy. We have already indicated the aids thereto under the head of General Diagnosis (p. 70), and will merely add the following : When the nose is occluded, the flame of a candle held before the nostril affected will not be disturbed, or will be disturbed less than in a normal condition by the expiratory cur- rent of air. Wintrich has also noticed that the tympanitic sound produced by percussion of the larynx becomes perceptibly deeper, and at the same time weaker, as soon as (the mouth being closed) the nose is held shut. The difference of sound that ensues on closure of one nostril is less marked. If, then, no difference in the percussion sound of the larynx can be produced by holding one or both nostrils shut, it follows that there is 1 Stimm- u. Sprachorgan, S. 652. 1 Verhandlg. d. Berl. Med. Ges., 1867-68, S. 133, und Archiv d. Ohrkr., IV., S. 188. 3 Deutsche Klinik, 1868, S. 401, u. 1869, S. 193 u. f. 112 FRAENKEL.—DISEASES OF THE NOSE. nasal stenosis. As a general thing, however, the latter is so easily recognized that such procedures are more valuable for demon- stration than for diagnosis. Mode of Occurrence and Causes. Narrowing or closure of the nose may be unilateral or bilat- eral, and may occur at any portion of the nasal cavity, in front, in the middle, or in the vicinity of the posterior nares. As before remarked, we shall have occasion in the following pages to describe various causes for this condition. All circumstances that close the naso-pharyngeal space likewise cause similar manifestations. Aside from the beginning of respiratory para- lysis, already alluded to (p. 106), we will here only consider more closely congenital errors of development. The first that may be mentioned is closure of the nostrils by a membranous growth, though a far more frequent one is bend- ing of the septum toward one side, generally the left. With regard to this, Semeleder' states that in forty-nine skulls he found the septum straight ten times; bent toward the left, twenty; toward the right, fifteen; and four times bent in the shape of an S. Bending of the septum implies a diminution in the calibre of the nasal cavity on its convex side, so that often there is but a very minute space remaining, and even slight swelling of the mucous membrane may be enough to induce com, plete closure. But in these cases it rarely happens that the other side of the nasal cavity is uniformly widened. Fre> quently, and that not only in cases in which a very apparent S-shaped bending of the septum is present, a point is also found on the concave side of the septum at which the turbinated bones approach nearer than is normal to the septum, so that there is not complete compensation for the narrowing of the other side. In this way there is almost always a unilateral, and sometimes a bilateral, nasal stenosis brought about by bending of the sep- tum. It may here be remarked that not only congenital, but also accidental dislocations of the septum, as by fracture, etc., may produce the same results. Rhinoskopie, S. 64. STENOSIS AND ATRESIA. 113 We may have a congenital bony closure of the posterior nares, though this is apparently very rare. Emmert' operated successfully on such a case in a boy seven years old, who had never from his birth been able to breathe through his nose, who was, therefore, as a nursling, reared with great difficulty, and who had, furthermore, often had suffocative attacks during sleep. No air ever came out at his nostrils, but mucus did, as well as a stream of tears when he cried. In some respects, there- fore, this boy may serve as a model of the manifestations pro- duced by atresia of the nose. The closure was occasioned by a bony wall, covered on both sides with mucous membrane. Luschka2 had the opportunity of amplifying this observation on the cadaver of a girl who had died soon after birth. In this case the bony framework was formed by the palatal bones on both sides. The posterior normally free and concave border of the horizontal plate was continued in a somewhat oblique direction, upward and backward, to the lower surface of the body of the sphenoid bone, being attached to the latter by a serrated edge. Laterally, the bony plate reached the inner side of the lamina interna of the pterygoid process. In the median line, the lamella joined its fellow of the other side at the point where the posterior nasal spine usually rises, while the two, in their further progress upwards, were separated by a very narrow slit, into which the lower extremity of the rudimentary vomer had penetrated. I myself once saw a case of closure of the posterior nares, on the right side, in a young man, the conditions of which corre- sponded most accurately with those of bilateral atresia. Dr. J. "Wolff, who sent the patient to me for a rhinoscopic examination, had established his diagnosis by means of palpation of the pharynx and probing the nasal canal, and had succeeded, by means of an operation, in perforating the bony partition wall. I was enabled by inspection to satisfy myself of the existence of a smooth and solid wall, covered on both sides with mucous membrane, and closing the right fossa in precisely the manner described by Luschka. The crista of the septum showed itself, even on the closed side, as a narrow strip. No other abnor- mality could be seen. The artificial opening eventually became reduced to the size of a pea, but it was still sufficient to relieve the patient from all annoyance. This had been caused exclusively by the fact that the patient had been unable to blow his right nostril, and that he had been excessively troubled by the accumulations sometimes escaping spontaneously in front. ' Lehrb. d. Chir. Stuttgart, 1853, B. II, S. 553. 2 Der Schlundkopf. Tubingen, 1868, S. 27. VOL. P7.— 8 114 FRAENKEL.—DISEASES OF TIIE NOSE. Treatment. As regards the treatment of nasal stenosis, we again insist on the importance of the permeability of the nose for the general well-being of the individual, and on the need of removing ste- nosis, where it exists. I can confirm the remark of Troltsch,1 that parents report their children as having improved in every way, physically and mentally, after the energetic treatment of chronic "cold in the head"—which was leading to habitual impermeability of the nose. The treatment falls principally within the domain of surgery. The methods of treatment be- longing to internal medicine will be spoken of in connection with those diseases which demand them. We will here confine our- selves to the following remarks : Traube used mechanical means against the inspiratory narrowing of the nostrils at the beginning of respiratory paralysis. He introduced two hair-pins into the nostrils, with the round end turned inward, and fastened the points to the forehead with sticking plaster, thus keeping the alse of the nose removed from the septum. Hoppe2 prefers the use of hollow bougies as dilators, in nar- rowing of a moderate degree; a method which especially com- mends itself in the coryza of the new-born, in whom breathing during the act of suckling is rendered possible by the rigid tubes (pieces of gum elastic catheter) which are introduced into the nostrils. This author also advises forcible distention by means of a pair of thin, long-armed forceps, by the opening of which the abnormally approximated bones are to be driven apart from one another. Rupprecht3 describes a pair of biting forceps, similar to the instrument with which railroad conductors punch tickets, and which is to serve the purpose of cutting out the bent portion of the septum. According to the inventor of the instrument, not only is a communication established between the two sides of the nasal cavity, but the permeability of the closed side is also restored. 1 Lehrbuch d. Ohrenheilkunde. Leipzig, F. C. W. Vogel, 1873, S. 306. 2 Neue Ztg. f. Med. u. Med.-Ref., 4, 1850. 3 Wien. med. Wochenschrift, 1868, S. 1157. "COLD IN THE HEAD." CORYZA. Ho- lt needs hardly to be said that in nurslings who refuse to take the breast, on account of closure of the nose, artificial feed- ing with a spoon, and, if necessary, with an oesophageal tube, and the injection of milk, etc., into the stomach, must be under- taken. Kussmaul describes this process, which Thiersch success- fully employed in the case of his own child. It should be remembered, however, that in many cases the disturbances were aggravated as soon as the children were laid in a horizontal posi- tion. It is therefore better to hold them, or lay them, with their heads high. "COLD IN THE HEAD," RHINITIS, CORYZA. History. The nose is the classical seat of catarrh. The name catarrh, from fcarappeco, to flow down, which has remained attached to the whole family of diseases which we designate as such, originated in the idea which the ancients had with regard to that secretion, especially, which escapes from the nose. Hippocrates, as well as Galen, believed that the secretion of the nose, and to some degree also that of the larynx and pharynx, flowed down out of the brain. These matters flowing away were considered a sort of cerebral purge, and it was believed that the pituitary gland as well as the sphenoid bone indicated the path by which these excretions of the brain reached the nose. Schneider, Professor in Wittenberg, whose name, under the appellation of Schnei- derian membrane, the mucous coat of the nose still perpetu- ates, in his comprehensive treatise, " De Catarrhis," published in Wittenberg in 1660, showed the falsehood of this supposition. He based his declarations, above all, on the anatomical demonstration that no canals existed through which such a distillation could take place. His work is divided into three books, the first of which treats, "De speciebus Catarrhorum, et de O.sse cuneiformi per quod Catarrhi decurre finguntur" (Of the Varieties of Catarrh, and of the Sphenoid Bone through which Catarrhs are supposed to flow down). In the second he shows that Galen's theory of catarrh was false, and in the third he announces the new theory. Therein he comes to the conclusion that the secretion is separated from the blood by the mucous membrane itself. The 116 FRAENKEL.—DISEASES OF THE NOSE. nasal mucous membrane sweats constantly—Schneider calls the exudation chiefly "sudare"—in almost all men, to a slight degree, even under normal conditions. " Si vero natura ex massa sanguinea humores in has membranas pellit, plus humoris se de illis effundit, ut tandem catarrhus hominem exerceat. Atque multus vel paucus humor etiam alieni coloris, saporis, et denique habitus esse potest. Est vel visu sanguineus, vel nigricans vel croceus, est acrior et salem recipit, vel sapore dulcior, interdum fluxior, est vel constantior, nunc tenuior aut spissior, et, ut cum illo loquar, corpulenior."—Lib. III., cap. VII, p. 578. (If, in truth, nature expels humors from the mass of the blood into those membranes, it will the more relieve itself from such humors where the man is troubled with catarrh. And, indeed, the humor may be abundant or scanty; it may even be varied in color, taste, and quality. For to the sight it may be blood-red, or blackish, or yellow; it may be acid and salty, or of a sweetish taste; it is sometimes transitory, at others constant; now thin, then again thick, and even, if I may call it so, fleshy.) He believed the accumulation of catarrhal matter in the blood to result from luxurious living— " Qui abundant divitiis, laborant plerumque abundantia pituita?."—Lib. III., p. 600. (Those who abound in riches generally suffer from an abundance of phlegm.) For this reason, he thinks, man is more frequently attacked with catarrh than the lower animals, and dwellers in the city than country people. The religious aspect of Schneider's work, which is evident in various places, shows itself plainly in his therapeutics of catarrh, as contained in the following sentence: " Ut ex luxu ac otio nascuntur Catarrhi, ita horum medicina est in sobrietate, in continentia, in exer- citationibus corporis, in mentis tranquillitate." (Inasmuch as catarrhs are born of luxury and indolence, therefore their appropriate medicine consists in sobriety, in continence, in bodily exercise, and in tranquillity of mind.) The old view of the cerebral origin in the brain, which Schneider, at great labor, annihilated forever in his learned work, and which a physician now only hears of when he studies the history of medicine, has still perpetuated itself to the present day in various popular expressions and beliefs. Among these maybe mentioned the French name for coryza, "Rhume de cerveau ;" the supposed efficacy of hellebore and other ster- nutatives in brightening the understanding; and the beautiful custom of wishing a hearty "good health!" to him who, by a vigorous sneeze, has embraced the shortest way of clearing up his brain. At the present day we know that mucus does not exist already formed in the blood, and we regard catarrh of the nose, like that of any other mucous membrane, as an actual inflamma- tion of the same, whose peculiarities are imparted to it chiefly "COLD IN THE HEAD.7' CORYZA. 117 by the qualities characterizing this portion of the mucous mem- brane, and which runs its course accompanied by a free exuda- tion of a serous or muco-purulent character. Etiology. In considering the etiology of coryza, we shall be obliged at this time to avoid entering into the etiology of catarrh in general —and especially its relations to the act of taking cold, its dependence on atmospheric influences and geographical position, as well as peculiarities of race—inasmuch as, according to the plan of this work, these questions are to be discussed elsewhere. We shall therefore confine ourselves here to those considerations that particularly concern the nose. Catarrh of the nose is met with sporadically and in the form of an epidemic, and one of the first questions to be considered is whether or not it is contagious. Among the laity it is regarded as an incontrovertible fact that a cold in the head may be com- municated from one person to another, both by direct contact with the secretion (as in using the same handkerchief, etc.), as well as by mere approximation of the diseased organ to a healthy one—in the act of kissing, for instance. And indeed it cannot be denied that there is a great deal of evidence in favor of the theory of contagion. In this connection the almost uni- form propagation of the evil from one nostril to the other might be mentioned, as a unilateral acute rhinitis is quite a rarity. We likewise often have occasion to observe how one member of a family after another is attacked—and not all simultaneously— without our being able to find any etiological reason (such as changes of weather, exposure to cold, etc.) for the production of the later cases. I have also repeatedly noticed that a bride- groom, who had never had a cold in his head, was seized with one, for the first time, during fine weather and without any other perceptible cause than that his bride, who was subject thereto, had coryza. Similar observations might easily be mul- tiplied which cannot, without violence, be reconciled to any other theory than that of the contagiousness of coryza. The fact of the epidemic occurrence of acute catarrh is also 118 FRAENKEL.—DISEASES OF THE NOSE. difficult to explain in any other way. Those who deny its conta- giousness attribute the epidemic spread of catarrh to influences of a universal character, such as the state of the weather, etc., and quote, in this connection, the observations of Anglada,1 according to whom, after a severe thunder-storm, coryza sud- denly broke out, as an epidemic, among the French troops returning from Salamanca (1812), the other mucous membranes remaining free. Such observations, which may often be made on a small scale by those taking part in some excursion into the country, after all only prove that circumstances sometimes occur capable of producing rhinitis simultaneously in a large number of people. Of themselves they neither constitute an argument against the contagiousness of coryza nor do they furnish a legitimate expla- nation for epidemics of any considerable duration. On the other hand, we may not ignore the fact that up to the present time no one has succeeded in demonstrating the contagiousness of coryza by experiment; on the contrary, all attempts in this direction have resulted negatively. Thus Fried- reich 2 inoculated his own nasal mucous membrane with the secretion of persons in various stages of coryza, with a uniformly negative result. Hiller,3 too, who succeeded in producing a purulent secretion upon the genitals, and in transferring this from the genitals of one animal to those of another, failed in his attempts on the nasal mucous membrane. Hiller explains his failure on the ground that the matter to be inoculated was washed away by the secretions of the nose, and that thus an essential element of success, the retention of the vehicle, was lost. He admits that in the case of the genital mucous mem- brane he accomplished this end by mechanically producing an irritative hyperemia. It may therefore be raised as an objec- tion to all previous experiments, that the conditions under which this contagion develops its efficacy are unknown to us. On the other hand, the nose shows itself unequivocally sus- ceptible to the contagion of gonorrheal matter; at least it is 1 Du Coryza simple. Paris, 1837. 2L. c.,p. 398. 3Untersuch. iiber die Contagiosity purulenter Secrete. Berl. Diss., 1871. "COLD IN THE HEAD." CORYZA. 119 certain that this secretion is capable of infecting the nose. For the nasal mucous membrane, just like the conjunctiva of the eye, may be attacked by the gonorrhoeal poison. Indeed this infection is not accomplished indirectly alone, as by the fingers, cloths, instruments, etc., but, according to Siegmund,1 it may be direct, as in one case which he narrates of an impotent old roue who introduced his nose into the vulva of a whore who had the clap, and by means of this unnatural and disgusting use of his nose caught a purulent inflammation of the nasal mucous mem- brane, which afterwards spread to the conjunctiva. Siegmund believes that the pointed condylomata often found at the entrance of the nose are probably due to such nasal gonorrhoeas that have been overlooked. Now, as the specific nature of the gonorrhoeal virus is, at pre- sent, almost universally denied, it does not appear on what ground one would be justified in assuming, at the outset, that infectious secretions are not contagious to the nasal mucous membrane, as it is evident, from the above and many other cases, that gonorrhoea may be communicated to this membrane just as well as to the conjunctiva, or any other mucous surface. It is also more than likely that the coryza of new-born children originates in the same way as ophthalmia neonatorum, viz., through infection of the nasal mucous membrane by the vaginal secretions of the mother during birth. The connection between these two has hitherto not been sufficiently insisted on ; in fact about the only allusion to it that I find in literature is a case that occurred in the German Hospital in London, and was reported by Herm. Weber.2 A well-developed boy, whom they were not able to wash until some three hours after his birth, and whose mother, during the last weeks of pregnancy, had shown an abundant vaginal leucorrhoea, soon developed a yellow dis- charge from his nose, and inflammation of the left eye, with secretion of pus. In the same way, on closer examination, it will be found that by far the larger proportion of cases of coryza neonatorum, arisino- within the same period as the ophthalmia of 1 Wien. med. Wochenschrift, 1852, S. 572. 2 Medico-Chirurg. Transact., XLIII., p. 177. 120 FRAENKEL.—DISEASES OF THE NOSE. that age, and sometimes associated with it, is to be attributed, not to taking cold immediately after birth, nor to a peculiar sus- ceptibility of the mucous membrane, but to an infection in the vagina of the mother. At least in almost all cases of coryza neonatorum that I have investigated, I have been able to show the existence of leucorrhoea in the mother. It appears, then, beyond a doubt, that the nose does not differ from other mucous membranes in its capacity for being- infected by secretions. Nor is there any ground for considering the secretions of the Schneiderian membrane as less infectious than those formed elsewhere. The question of the contagiousness of coryza, then, in spite of the negative result of experiments, must be considered as one and the same with the question of the contagiousness of catarrhal or purulent secretions in general, and in the light of clinical observations must, for the present, be answered in the affirmative, especially as regards purulent secretions. As regards the etiology of sporadic rhinitis, aside from all considerations of infection, it may be remarked that some men show a decided predisposition thereto, an attack being brought on in them by very slight causes which would not affect the majority of people. The most frequent causes of coryza are atmospheric influences and taking cold, especially by means of sudden cooling of the surface of the body after being heated. Many people attribute a cold in the head to having got their feet wet, and it is not to be denied that the feet are a portion of the body which we generally clothe most warmly, and which are most exposed to those vicis- situdes that produce what we call " a cold." As was previously stated, we must here abstain from any discussion of the relation between " taking cold" and catarrh. Coryza may also be produced by irritants affecting the nose directly. There are persons who cannot step into a room con- taining powdered ipecac without getting a cold in the head. Hiihnerwolff reports the case of a man who could never inhale the perfume of a rose without being thus seized. Sensitiveness to the impression of iodine and its haloids is more universal, while there is a not inconsiderable number of people in whom ■'COLD IN THE HEAD.77 CORYZA. 121 the internal use of these remedies will produce the disease. We cite the use of iodine under the head of direct irritants to the nose, because probably the iodine which is taken up by the vessels of the mucous membrane, and which can easily be demon- strated in the secretions, produces the coryza, In this connec- tion we may state that Stadion * was seized with a severe coryza during good weather, on the second day before concluding his experiments on himself with regard to the action of digitaline. He undertakes to prove that it was due to the action of the digitaline. The inhalation of acrid gases may produce coryza ; so also extreme cold, dust, or other impurities of the atmosphere. Di- rect wounding of the nose and the entrance of foreign bodies into it seldom lead to extensive catarrh, even when they produce a circumscribed inflammation. On the other hand, the entrance of the pollen of plants appears to produce the disease known as "summer catarrh" or "hay fever" (compare this Cyclopedia, Vol. II., p. 544). Coryza constitutes a symptom of the initial stage of various acute infectious diseases, especially of measles (this Cyclopaedia, Vol. II., p. 71), and of exanthematous typhus {ibid., Vol. I., p. 314, as well as of influenza {ibid., Vol. II., p. 529). Other infec- tious diseases, especially typhoid fever and scarlatina, are at first almost a protection against coryza {ibid., Vol. L, p. 129, and Vol. II., p. 107). The subject of glanders has been treated of in the third volume. Although the reverse of this generally holds true, yet it is not altogether uncommon for rhinitis to result from inflammation of the neighboring organs ; thus it may follow pharyngitis, lar- yngitis, conjunctivitis, or facial erysipelas. Nurslings and children during the first years of life are the most subject to this disease ; next to them, in point of liability, are persons of middle age, youth and old age being compara- tively exempt. Symptoms. The forerunners of coryza are a feeling of lassitude in all 1 Prager Vierteljahrschrift, XIX. Bd.. S. 129. 122 FRAENKEL.—DISEASES OF THE NOSE. one's members, slight chiliness, and a sensation of weight and pressure in the head, especially about the forehead. Patients feel as if they had a board bound to their forehead. It was from this symptom that the affection received its name of Gravedo or Coryza. At the same time there is prickling and dryness of the nose, and a frequent disposition to sneeze. Redness and swelling of the nasal mucous membrane soon supervene, and an increase of the secretion of the organ begins. At first the flow is watery, then of a salty, mucous quality, according to Donders and Schonbein also containing ammonia; and, finally, it is, as a rule, more or less purulent in character. It is either discharged from the nostrils spontaneously, or removed by sneezing and blowing the nose. The amount of the secretion poured out during a given time varies ; often, however, especially at the height of the affection, it is very copious, amounting to a continuous dripping. There is usually a partial loss of the sensation of smell, more rarely also of that of taste, with fever which is probably always slight, though no exact measurements of it are on record. The symptoms depicted above are those of the light form of coryza, one of the most common forms of disease. In an acute rhinitis, however, all of them may be met with in an aggravated form, according to the severity of the disease or the peculiarities of the individual; for there are men whom this ordinarily insig- nificant affection attacks like a severe disease. The following symptoms may be studied more closely :— The degree of sioelling of the mucous membrane, like every- thing else about the disease, is very variable. In most cases, however, it is enough to produce stenosis, if not actual occlu- sion of the nose; conditions, the signs of which have been described above. The swelling often arises very suddenly, and subsides as suddenly, a circumstance which led Weber1 to explain the occurrence of nervous asthma in the same way as this closure of the nose, viz., by hypersemic swelling of the mucous membrane. But the anatomical relations of the nasal mucous membrane are quite peculiar, and are different from those of the bronchi, being so arranged as to admit of a sudden 1 Tgbltt. der 43. Naturforscher-Vers., 1873., S. 159. "COLD IN THE HEAD." CORYZA. 123 rise and subsidence of swelling. Through the publications of Kohlrausch,1 the existence of cavernous or erectile bodies between the periosteum and mucous membrane on the turbinated bones, especially on their hinder portions, has become better known ; and it is probable that these venous cavities, supported by the numerous anastomoses that here exist among the arteries, play an important part in the swelling of the nasal mucous membrane, through the inflammatory changes produced in the walls of the vessels. Hence, entirely irrespective of the correct- ness of Weber's theory in itself, the nose cannot, in this respect, be compared to other portions of the respiratory apparatus. The fact, that the swelling in such cases depends on changes in the vascular system is evident on ocular inspection, which shows us the mucous membrane dark-red and bursting with blood. Kohl- rausch calls attention to the fact that, as a result of the venous network described by him, settling of the blood, by the force of gravitation, explains a circumstance which may often be noticed, viz., that on lying down the nostril that is undermost is the most likely to be stopped up. The secretion, even aside from its admixture with tears, is at first serous. After a time, mucus in considerable quantities is added to it, giving to the fluid a thickish, tenacious character. The nose is one of those organs of the body in which the question of the origin of mucus is capable of several different answers. The olfactory region contains tubular glands (Bowman's), while the nasal mucous membrane proper contains better developed glands, resembling the lobulated variety. But even the latter, according to A. Haidenhain,2 furnish a secretion which does not throw down a precipitate on the addition of acetic acid, and the chemical reactions as well as microscopical appearances of which justify us in classing it among the serous secretions, and consequently in separating these glands from the muciparous variety. It appears, then, that here also the mucous secretion is a product of the entire mucous membrane, which in this locality, in man, is ciliated throughout ; and that, if Haidenhain's obser- 1 Midler's Archiv, 1853., S. 149. 2 Ueber die acinosen Driisen der Schleimhaute, u. s. w. Bresl. Dissert., 1870. 124 FRAENKEL.—DISEASES OF THE NOSE. vations are confirmed, the glands take no part in its production. Mucus appears either as the product of the separating power of the epithelium, or it is formed by the mucous degeneration and melting down of these cells, and is carried to the surface by the stream of fluid escaping from the vessels. But the coryzal secre- tion always contains mucus as soon as the short, initial, serous stage is passed, as may be plainly proved by the addition of acetic acid, and by its behavior generally. Microscopic examination of the mucous secretion always shows white blood- (pus-) corpuscles, besides the so-called mucus corpuscles, and sometimes red blood-corpuscles and epithelium. A large number of those little structures, recently so much spoken of and called micrococci, ma)' generally be seen, also covering the cells. In accordance with his general theory of in- flammation, Hueter: regards these micrococci as the true sources of irritation in coryza. In addition to the above, the secretion sometimes contains accidental formed ingredients, which floated on the inspired air, and were thus mingled with the fluids in the nose. The number of pus-corpuscles is very variable. They usually increase with the duration of the secretion, until, owing to the greater power which these cells possess of refracting light, they give to the entire mass that turbid, opaque appearance char- acteristic of what we call a muco-purulent or purulent secretion. On close observation, a stage, even though quite short, will appear towards the end of a coryza, during which the fluid effused will at least be entitled to the name of muco-purulent. The secretions accumulated in the nose, when they are moved by the air passing through them, produce a peculiar moist or snuffling sound which can generally be heard at a distance. The ear so surely indicates the seat of this sound that it can hardly be mistaken for anything else. Course. The same thing that takes place everywhere else may be observed here, viz., that the appearance of a secretion on the surface is associated with relief to the inflamed parts. Hence 1 Allgem. Chirurgie. Leipzig, 1873, p. 257. "cold in the head." coryza. 125 no doubt originated, first, the idea that the secretion was a "purgamentum cerebri;" and second, the disposition of the laity to deduce a general principle from the observation that pain in the forehead and pressure in the nose are relieved when the secretion begins, and to think that wherever these feelings exist there ought to be mucus to be loosened and brought out. Coryza is an affection which, in the vast majority of cases, terminates in recovery. A fatal termination is extremely rare, and only takes place in nurslings, owing to the disturbances of respiration and nutrition incident to closure of the nose, as was described above ; or in very old people who have about reached the limits set to all organic life and would have died soon under any circumstances. Acute rhinitis does not very often end in the chronic affection ; when it does, it is either owing to neglect, or dependent on some dyscrasia, or happens in persons who frequently suffer from coryza. The duration of the attack is usually from two to seven days, according to individual peculiarities and the severity of the causes producing it; at the end of this rime, if no complications exist, acute rhinitis generally ends in recovery. Complications. The first complication to be noticed is the invasion of neigh- boring organs. The most common propagation is to the epi- dermis,—the mucous membrane, even before leaving the interior of the nose, passing into the epidermis without any well-marked line of demarcation. The external skin of the nose swells and grows red, and the epidermis in the vicinity of the nostrils is often excoriated, both by the irritation of secretions flowing over it and the violence it suffers in the frequent act of blowing the nose. Furthermore, it is not very uncommon for erysipelas of the face to result from rhinitis ; indeed, this is the most frequent exciting cause of the disease in those who habitually suffer from erysipelas.1 Extension of the inflammation backward leads to pharyngitis, and not rarely to catarrh of the Eustachian tubes, producing ringing in the ears, difficulty of hearing, etc. Pha- 1 Compare Vol. II. of this Cyclopaedia, pages 429, 458, 473. 126 FRAENKEL.—DISEASES OF THE NOSE. ryngeal catarrh may extend further down the respiratory tract, to the larynx, the trachea and bronchi. But there is a laryn- gitis, tracheitis, etc., which may be associated with rhinitis of longer standing, without any evidence, subjective or objective, of implication of the pharynx, either beforehand or at the time. In these cases, then, the anatomical connection is lost, and every one is left to fill the gap according to his own judgment, on the theory of an after-effect of the original poison, or on that of the aspiration of the secretion. The inflammation may also spread through the lachrymal duct to the lachrymal sac and the con- junctiva, and even affect all the cavities contiguous to the nose. If the catarrh involves the frontal sinus, the cavities of the ethmoid or sphenoid bone, it is said that there is a marked increase of headache; if the frontal sinus, the pain is in the forehead. If the antrum of Highmore is attacked there will be severe pain in the cheek. But it is to be remembered, in this connection, that neuralgic pains, radiating in the course of the trigeminus and neighboring nerves, may also exist when the antrum is not involved. The fifth pair of nerves has a large terminal distribution in the nasal mucous membrane, and its tendency to radiating sensations is otherwise sufficiently well known. Such neuralgias of the fifth pair, dependent on nasal catarrh, have been described by Duchek,* Oppenheimer,2 Rollet3 and others. Swelling of the lymphatic glands is another complication of coryza, occurring especially in scrofulous individuals. Little is known with regard to the lymphatic vessels of the nasal mucous mem- brane. Heiberg-Hjalmar,4 in Christiania, describes an open system of canals therein, fron which, however, the lymphatic vessels could not be injected. Edmund Simon * describes the course of the lymphatic vessels as being such that the main trunks of the same, which open into the lymphatic glands, run in a sort of furrow between the forward end of the Eustachian tube and the rear end of the turbinated bones. Here they form a small network, from which two or three trunks of about one millimetre in diameter arise; these run obliquely backward and outward 1 L. c, p. 441. 2 Verhandl. des naturh. med. Vereins zu Heidelb., VI., S. 198. 3 Wiener Presse, 1873, S. 1145. 4 Jahresbericht, 1872, I., S. 45. " Schmidt's Jhrb., 107. B., S. 161. "cold in the head." coryza. 127 between the levator and the tensor palati mollis muscles, and after they have passed these muscles, one branch passes along the external wall of the pharynx, between the internal carotid and the stylopharyngeus muscle, and, after various windings, terminates in a gland in front of the vertebrae. Hence retropharyngeal abscess may arise in consequence of diseases of the nose. The second trunk (and also the third, if there is one) passes obliquely downwards, outwards, and backwards, separated from the pterygoideus muscle by masses of fat; perforates the digastric, passes to the outside of the lingual nerve, and to the inside of the stylo-hyoid muscle, of the pos- terior belly of the digastric, and of the internal carotid; divides into two branches, and terminates in two lymphatic glands lying under the sterno-mastoid muscle. At all events the lymphatic passages of the nose eventually lead into those of the neck, and in coryza swollen glands will be found under or behind the sterno-cleido-mastoid, if these organs are at all implicated. It is not very uncommon for swelling of the glands to outlast the catarrh which caused it, and then it may remain as an independent affection, subject to further changes. Pathological Anatomy. As regards the pathological anatomy of rhinitis we have no records of any special observations made on the dead body, and it is not yet determined which region of the nose is especially affected by acute inflammation, whether the olfactory or the respiratory. According to clinical observations the latter should be the preferred seat of this disease. Treatment. The attempt at an abortive treatment of this affection, by means of the Hager-Brand remedy, has already been discussed under the head of General Therapeutics, on page 96, and the treatment of nasal stenosis in nurslings has also been given above. We may further add that the treatment of this disease, which usually soon terminates in recovery without any interfer- ence, is attempted in two different ways. While one set of people recommend fresh air, open windows, and cool baths ; another set insist on diaphoretic treatment with appropriate medication, Roman or Russian baths, and a rigid diet. I cannot recommend either of these methods, as they neither cut short 128 FRAENKEL.—DISEASES OF THE NOSE. the attack nor modify its severity. In ordinary cases of cold in the head, an essentially expectant plan of treatment, with some care as to the person's diet and surroundings, seems most desir- able. Where circumstances permit, it is better that patients should not go out except in good weather, but remain in-doors, the rooms being, of course, well ventilated. It is not neces- sary to take to one's bed unless fever is high, or the attack uncommonly severe, and even then care must be taken not to pile on too many bedclothes. These precautions are especially to be recommended in the case of children, or of those adults in whom experience has shown that coryza is likely to be followed by bronchial catarrh of greater or less severity. Whoever has had a cold in the head knows that while it lasted his skin was especially sensitive to cold, and that he was instinctively dis- posed to protect himself against those changes of temperature which, when he was well, would not have been noticed. While we cannot recommend vigorous diaphoretic treatment, in which the laity have too great confidence, we would just as little advise any one utterly to disregard a cold in the head, and look upon it as not being a disease. It is well, especially where there is considerable pain, or the tendency to sneezing is excessive, to apply morphine locally, either by snuffing up a teaspoonful of a solution of from three- quarters to two and a quarter grains in a fluid ounce and a half of water, or by using this as an injection; or, in the form of a powder, from a sixth to a quarter of a grain being snuffed up dry. Opium is also recommended instead of morphine. Aside from this we may order injections or inhalations of a five- or ten- grain solution of common salt, or of carbonate of soda, with the addition of glycerine, etc., all these being especially intended to loosen and remove the mucus. In case of excessive secretion, as well as extreme swelling, or after abatement of the inflamma- tory symptoms, the topical application of astringents may be indicated (borax, tannin, alum, nitrate of silver. See General Therapeutics). Although we believe that the foregoing means are sufficient for the treatment of coryza, yet we must not fail to mention that the following methods have also been recommended. Amongst the means for abortive treatment are ice-cold foot-baths ; PURULENT NASAL CATARRH. 129 the dry diet, that is to say the withdrawal of all drinks and moist articles of food for two days; stopping up the nostril invaded with a piece of sponge, or with a pledget of lint dipped in collodion; the snuffing up of the vapor of acetic acid for ten minutes, out of a bottle filled with the acid; the application of a five-grain solution of nitrate of silver. Furthermore, as treatment for the catarrh, the snuffing up of calomel; the application of mercurial ointment; poultices over the nose, etc. A favorite popular remedy in the coryza of children is anointing the nose exter- nally with various oily matters, especially " ointment of sweet marjoram." Prophylactic measures consist in avoiding the inducing causes, and in people who are often troubled with coryza, and unable to determine the cause, it is well to undertake a syste- matic hardening of the skin. PURULENT NASAL CATARRH.—RHINITIS BLENOR- RHOICA. By this name we designate a disease which represents an aggravation of ordinary catarrh, that is, a coryza gravis, and whose most prominent feature is the flow of a purulent secretion accompanying inflammatory manifestations. In view of its character it would be etymologically more correct to call it a pyorrhoea than a blennorrhcea. But I have not chosen to give up the former name of blennorrhcea, both because it is only used in one sense, and, therefore, no confusion can arise, and also because the same condition in other organs, especially of the neighboring structure, the conjunctiva, is designated by the same name. Etiology. Purulent nasal catarrh is a tolerably rare disease. It occurs, first, in new-born children, and this is the form in which I have principally seen it, being due, in my opinion, as above stated, to infection of the nose with the blennorrheal secretion of the maternal vagina. Just as conjunctivitis neonatorum shows different grades of severity, so the same causes produce different degrees of inflammation in the nasal mucous membrane, and this is one reason why the connection of cause and effect, which vol. rv.—9 130 FRAENKEL.—DISEASES OF THE NOSE. in the present case is very striking, was mentioned under the head of simple catarrh. The time of its appearance, during the first few days of life, its occurrence simultaneously with vaginal blennorrhcea in the mother, and the exclusion of other causes, make it probable from the outset that the etiology of nasal blennorrhcea of the new-born is the same as is now universally accepted for ophthalmia neonatorum. In the literature of the subject, this origin of nasal blennorrhcea is not made prominent, and yet many facts are adduced which support the assertion of the origin of this severer rhinitis from infection within the maternal vagina. I would especially cite the fact, in this con- nection, that in many cases in which this disease is described, particular mention is made of its having manifested itself either immediately, or, at all events, very soon after birth, through sneezing, or a bloody serous discharge from the nose. I allude to Weber's case above, and would here like to make a quotation from the essays of Hauner,1 who is particularly emphatic in calling attention to this malignant nasal catarrh of nurslings. He says: "The cause of this nasal catarrh must doubtless be sought in an individual predisposition to catarrhs in general, and in the fact of taking cold. Dyscrasias, espe- cially syphilis, never cause this- malady, and the coryza syphi- litica, which is either a forerunner of the constitutional out- break, or occurs coincidently with other similar affections in various organs, can never be mistaken for this cold in the head by a person of any knowledge. I have seen children of this kind possessed of great irritation of the nasal mucous mem- brane from the moment of their birth, so that they were greatly troubled with sneezing and an excessive secretion from the nose." He also explains the fact that Rilliet and Barthez do not mention this disease, on the ground that they could never have seen it, as the children that fell under their observation were all over fifteen months old. What was once true with regard to ophthalmia will hold good here, viz., that "individual predispo- sition" and "taking cold" will only play their role as long as infection with the secretions of the maternal vagina are not •Jahrb. der Kinderheilkunde, N. F., 1862, V., p. 74. PURULENT NASAL CATARRH. 131 taken into account. Extension from the conjunctiva, which is quite possible, cannot be accepted as the only explanation of this disease, for I have seen cases of nasal blennorrhcea without any coincident conjunctivitis. It is a singular thing, though, that the nose, which is not provided with any protective appa- ratus, is not as frequently infected during its passage through the vagina as the conjunctiva. It may possibly be that movements of the lid favor the entrance of infectious material into the conjunctival sac. But if we take into consideration the failure of attempts to infect the nasal mucous membrane (see above), and other circumstances, such as the rarity of primary nasal diphtheria, it seems probable, not that there is a special predisposition of the conjunctiva, but that the Schnei- derian membrane must in reality have some physiological pro- vision (perhaps its ciliated epithelium) which protects it from the influence of this contagion. Later in life the same provision enables this organ to act as a sort of filter to the inspired air, with almost complete immunity against morbific influences excepting those which occasion that comparatively innocent affection—coryza. N^sal blennorrhcea may be caused, secondly, by the action ,1 gonorrheal matter. Here, too,, it may vary in intensity from that of an apparently simple catarrh to that of the most severe blennorrhcea and diphtheria. Nasal blennorrhcea occurs, thirdly, during the course of scarlet fever (which see) and under the influence of variola; fourthly, in diphtheria of the pharynx and of the conjunctiva ; fifthly, after burns and cauterizations of the mucous mem- brane ; sixthly, by extension from the conjunctiva or pharynx; seventhly, from unknown causes, perhaps from the aggravation of simple catarrh. A circumscribed purulent inflammation may take place in the mucous membrane of the nasal cavity after wounds, cauterizations, and other therapeutic interference, as well as after operations within the same (compare below: Para- sites of the Nasal Cavity). Symptoms. The symptoms of acute nasal blennorrhcea consist in an 132 FRAENKEL.—DISEASES OF TIIE NOSE. aggravation of all the manifestations described above under the head of coryza. The general appearances, in particular, from the beginning, are those of a serious illness, and the swell- ing of the mucous membrane is also much more considerable than is usually encountered in an ordinary cold in the head. But what especially distinguishes this disease is the secretion. Whereas after the serous initial stage of ordinary coryza the mucous secretion is the most prominent one of the three, both as to quantity and duration, in blennorrhcea a purulent flow appears very soon after the beginning of the disease. Sometimes it is thin and glutinous, sometimes it resembles laudable pus in appearance, and again it may be decidedly fetid, or discolored from an admixture of blood, but it always has the characteristics of a purulent secretion, and maintains this character uninter- ruptedly throughout the duration of the disease, unless, indeed, it becomes ichorous. As a rule, the discharge is rather solid in consistency, and thus, owing to swelling of the mucous mem- brane and the accumulation of the secretions rich in albumen, considerable nasal stenosis accompanies blennorrhcea. Here those manifestations which were described above as character- izing nasal stenosis in nurslings will present themselves in an extreme degree. Nasal blennorrhcea is often complicated with ulcerations of the mucous membrane, and may spread to the conjunctiva and to the pharynx (ear). The external skin in the vicinity of the nose, especially that of the upper lip, is almost invariably in- volved and excoriated. Course and Terminations. Blennorrhcea of the nose is always a disease of considerable duration. This is especially true of blennorrhcea neonatorum, because, being regarded as a harmless cold in the head, it is not subjected to medical treatment for some time, and usually lasts seven, eight, or nine weeks, or even longer. The structure of the nose offers particularly favorable opportunities for a purulent inflammation to take root, while extensive regions thereof (the neighboring cavities, etc.,) are almost entirely inaccessible to PURULENT NASAL CATARRH. 133 local therapeutic treatment. Purulent rhinitis is a disease which may, and sometimes does, terminate in death. Not only because in many instances it arises during other severe diseases (diph- theria, scarlatina), but because it robs the individual attacked of quiet sleep, and in nurslings interferes materially with nutri- tion. Severe brain symptoms may also be associated with it, and infants especially are liable to be very dull and sleepy from the outset. Herman Weber (1. c.) reports severe evidences of cerebral disturbance (cramps, partial hemiplegia), in cases in which the secretion of the nose was suddenly diminished, and he gives special prominence to the fact of the disappearance of these symptoms on the return of an abundant purulent dis- charge. It is evident that the retention of purulent secretions in parts so near the brain may produce such disturbances. But even in cases of a favorable termination the ulcers pro- duced by the suppuration, which are disposed to penetrate deep, may lead to caries, and thus blennorrhcea may lead to destructive processes in bone and cartilage, and to correspond- ing cicatrizations. Purulent catarrh may also lead to chronic rhinitis. In spite of these various possibilities of an unfavorable termi- nation as regards life or complete recovery, the majority of cases of nasal blennorrhcea, so far as my experience goes, result in per- fect restoration to health, e v en though it may not be until after prolonged treatment. Diagnosis. The disease we are now considering, in view of the duration of its purulent secretion, can hardly be confounded with simple coryza. On the other hand, the differential diagnosis between this and diphtheria is often very difficult, and sometimes impos- sible. We must decide in favor of diphtheria when inspection shows a membranous deposit upon or within the tissues, or when fragments of a pseudomembrane can be demonstrated in the secretion. The mere existence of diphtheria in the neighbor- ing organs is not sufficient proof, for a simple blennorrhcea of the nose may be associated with diphtheria of the pharynx or con- junctiva; but at the same time the occurrence of diphtheria 134 FRAENKEL.—DISEASES OF THE NOSE. elsewhere cannot but influence our estimate of the disease in these cases, nor does it, then, make any difference, in a thera- peutic point of view, whether in addition to blennorrhcea of the nasal mucous membrane, it is the seat of a pseudo-membrane or not. Greater importance is to be attached to the differential diagnosis between this disease and affections of the larynx and deeper respiratory organs. As already stated, it has actually been confounded with croup, but the resemblance is only very superficial. The fact that, especially in nurslings, sudden dys- pnoea and whistling inspiration may be caused by affections of the nose, together with the existence of disturbances of the nasal cavity, and the absence of symptoms pointing to the larynx and the lungs, ought to be enough to guard any one who knows this from seeking the disease where it does not exist, and overlook- ing it where it does. We would only further remark in this con- nection that even before the appearance of any secretion, the swelling of the mucous membrane may be so great as to result in complete closure of the nose. Abscesses of the nose, which will be described below, also present some points of resemblance to blennorrhcea. The diag- nosis, however, is settled by the course of the former affection, in which after several days of inflammatory action, there is sud- denly a more or less copious discharge of pus, with great relief to the patient. Blennorrhcea almost invariably involves the entire mucous membrane of both sides, which is probably never the case with abscess. It proves no easy matter in many cases to establish the ori- gin of gonorrhoeal infection. This is not only on account of the thick vail of secrecy which patients often feel obliged to throw around the origin of all this class of diseases, but because they often do not fall under our observation for days and weeks after infection has taken place. It is well, however, in all cases in which a purulent discharge from the nose, beginning with in- flammatory symptoms, lasts some time, to bear in mind the pos- sibility of the conveyance of gonorrhoeal pus to this organ, and to make inquiries accordingly. Edwards' describes the case of 1 Lancet, 1857, No. XIV. PURULENT NASAL CATARRH. 135 a lady suffering from gonorrhoea of the nose, in which some time after the infection he succeeded in proving that she had used a handkerchief which her son, who had the clap, had pre- viously worn as a suspensory bandpge. Treatment. At the beginning of the disease antiphlogistic procedures are indicated (the use of cold, leeches, etc.). After the appearance of the secretion, our attention must be directed to keeping the nose clean (injections with solutions of carbonate of soda, com- mon salt, etc.) and to limiting the secretion. For the latter pur- pose the application of astringents, particularly of nitrate of silver in substance or solution (pencilling, injections), is prefer- able to all other means. As our purpose is merely to produce an astringent effect, not to destroy, we must be careful that the action of the lunar caustic is only superficial ; hence we must not bear on too hard if using the stick, nor make our solutions too strong. Infants must not receive injections into the nose while lying down, as in this position the medicated fluids are very apt to pass through the pharynx into the opening of the larynx, producing severe spasm of the glottis. For the same reason only very small quantities of fluid may be used as injec- tions in infants, and it will be well to do away altogether with the use of Weber's nasal douche. In discussing the treatment of nasal stenosis above, attention was called to the introduction of elastic tubes into the nose and to the artificial nourishment of infants ; also to the advantage of holding them in an upright posture. AVe refer to them again here, because these precautions will almost always have to be employed in blennorrhcea. Aside from this, what has just been said, in addition to the principles laid down under the head of general considerations, will be enough to indicate the treatment of the disease. As a prophylactic measure, however, we would strongly commend the value of disinfecting injections (perman- ganate of potassa) to be thrown into suspected vaginas, before the passage of the head in labor. 136 FRAENKEL.—DISEASES OF THE NOSE. DIPHTHERIA OF THE NASAL CAVITY. Diphtheria of the nasal cavity is very rarely a primary dis- ease. Schuller * describes such a case in a boy five weeks old, who had, however, suffered with coryza from his birth, and with regard to whom we may therefore remain in doubt whether the pseudo-membranous disease observed might not have devel- oped itself on the foundation of an infection within the maternal vagina. Usually the nasal cavity is only secondarily invaded by diphtheria, and hence we refer, at this time, to the description of the disease as found in the first volume of this Cyclopaedia. ERYSIPELAS OF THE NOSE. With regard to this affection, too, we refer to the description contained in the second volume. The nose may be invaded by erysipelas spreading from the pharynx or the external skin, or it may itself be the spot which affords entrance to the disease. The diagnosis cannot be positive until erysipelas of the external skin is apparent. RHINITIS CHRONICA. — OZiENA.—STOCKSCHNUPFEN. — STINKNASE. Etiology. We have already stated that acute rhinitis may pass into the subacute and chronic form, and yet in the vast majority of cases this only takes place in persons suffering under a dyscrasia. Scrofula and syphilis are particularly liable to induce this tran- sition. In scrofula a catarrh once set up is liable, in any event, to last longer and to assume a subacute form. If we take into consideration the tendency to relapse peculiar to all scrofulous affections, we can readily see why this dyscrasia in particular 1 Jahrb. fur Kinderhkde., N. F., IV. Jahrg., 1871, p. 331. CHRONIC NASAL CATARRH. 137 3hould so readily lead the way from the acute to the chronic form of inflammation. The very succession of appearances found in catarrhs, as described in what has been said, gives us clinical evidence that they emanate from that form of weakness to which we have given the name of scrofula. The same thing holds good with regard to syphilis (which see). Here the purely irritative beginning of the disease is com- paratively rare, a subacute catarrh usually occurring coincidently with other lesions (mucous papules, ulcerations, etc.). But in this dyscrasia, too, there is the most decided tendency in the acute or subacute process to assume a chronic character; and, especially in children, the tendency of acute catarrhs, after many relapses, to pass over into chronic inflammation may be regarded, even in the absence of other symptoms, as indicating the presence of syphilis. Trousseau and Lasegue,' in particular, call atten- tion to this. Although in the majority of cases the development of chronic catarrh from the acute form depends on the existence of a dys- crasia, yet it cannot be denied that in persons having no dys- crasia, an acute rhinitis, under bad care, continuance of the irritant, and other injurious influences, may relapse, and finally terminate in the chronic form. But, as was stated above, this is comparatively rare. Blennorrhcea more frequently terminates in chronic inflammation. Aside from any connection with acute processes, we often find chronic inflammation of the mucous membrane with deeper lesions of the nasal cavity. Caries of bone, ulcerations, foreign bodies, and abnormal growths within the nose are quite com- monly associated with chronic rhinitis. This affection may also arise by communication from a neighboring organ. Symptoms and Course. While the manifestations of acute catarrh may be entirely accounted for by the inflammatory processes taking place in the vessels, and their results, chronic inflammation implies the exis- tence of still further changes. Newly developed blood-vessels, 1 Archives, 4. serie, t. XV., p. 156. 138 FRAENKEL.—DISEASES OF THE NOSE. newly developed cellular tissue, and perhaps newly formed lym- phatic elements appear. We can distinguish two forms of chronic catarrh in the nose : the hyperplastic and the atrophic forms. They often coexist, but in most cases the atrophic form seems to be the result of the hyperplastic ; at least it is most commonly found in old cases, and after the prolonged continu- ance of the latter form. In the hypertrophic variety the mucous membrane appears thickened and livid, so that many places in it look bike new growths, and as these sometimes occur sym- metrically they may even cause some doubts as to their nature in careful observers. In the atrophic variety, on the contrary, the mucous membrane is thin, often pale, apparently consisting of connective-tissue and blood-vessels alone, and hardly worthy the name of mucous. In both varieties, however, the epithelial covering undergoes radical changes. The epithelial cells are partly destroyed, or they become turbid, and the mucous mem- brane thus loses its natural lustre — it appears opaque and uneven. The secretion in chronic rhinitis varies very much both in quantity and quality. There are forms in which the amount produced is very abundant, while others deserve the name of " dry." The secretion itself is generally of an almost exclusively purulent character. In many cases it carries enough fluid with it easily to flow away (chronic blennorrhcea); but it is often very thick, with a tendency to form crusts. These become firmly attached to the subjacent surface, perhaps owing to the large amount of albumen they contain, and by reason of their wealth of morphological elements (numerous epithelial cells) and their dearth of fluid constituents, are easily dried by the air passing over them. In general, it may be asserted that the older the affection, and the more it inclines to the atrophic form, the greater will be the tendency of the secretion to dry into crusts. While we thus account for the retention and the drying of the secretion by its abundance of cells, its paucity of water and its stickiness, there is no doubt that defective cleaning of the nose aids in accomplishing the result. This may be owing to habitual failure to blow one's nose ; to feebleness of the expiratory current of air at the point affected (stenosis); or to diminished reflex irritabil- CHRONIC NASAL CATARRH. 139 ity and the absence of a disposition to sneeze. We cannot, at present, say how far it may be influenced by the possible cessa- tion of ciliary movement. The crusts present an unnatural, greenish appearance, and if they contain blood, or colored particles adhere to them (soot, paint stuffs, etc.), they may be parti-colored. They vary in size, being usually about that of a silver five- or ten-cent piece, though sometimes they cover an entire turbinated bone like a pseudo-membrane. They are occasionally so firmly adherent to the mucous membrane that they cannot be washed away from it by a stream of water directed against them. This quality of the secretion gives rise to a phenomenon which imparts a peculiar aspect to chronic rhinitis. By the decomposition which takes place in the secretion a peculiar stench is produced, which is communicated to the expired air. This stench, it is true, is of various shades, still it is of a pecu- liar and specific nature, and is so penetrating that it may often be perceived from afar. It has been compared to the smell of crushed bed-bugs (hence the French name, Punaisie). When this complication appears, chronic rhinitis is called ozsena (from 6£eiv, to stink). This symptom has received great attention, and all the dif- ferent conditions under which it appears have been grouped together, as a separate disease, under the name of ozsena. We cannot, however, agree to this, as the stench is merely the result of stagnating and decomposing nasal secretions, and may exist as well in chronic rhinitis as in caries, ulcerations, etc. While this symptom occurs under various conditions—indeed many dis- tinguish between an ozsena ulcerosa and non-ulcerosa—it is not, in spite of its seriousness, worthy of being regarded as a separate disease. To claim the existence of an ozsena without decompos- ing secretions, as has been done by some writers,1 seems to me to be contrary to the facts in the case, for the smell is not exhaled by a mucous membrane free from secretion, but it ad- heres to the secretions, as any one may most readily satisfy himself by a direct examination, and grows less on a diminutioa Compare, among others, Hedenus, Deutsche Klinik, 1861, No. 28, S. 269. 140 FRAENKEL.—DISEASES OF TIIE NOSE. of the same. If a case should come under observation where no stinking masses could be discovered on inspection, it must be remembered that all parts of the nose cannot be seen, and that the smell may also originate in the secretions of neighboring cavities. Certain authors have held that ozsena always depends ulti- mately on some dyscrasia, and it must be remembered that there are cases in which, for a long time, ozsena is the only symptom of constitutional or hereditary syphilis. But there certainly is such a thing as ozsena not depending on any dyscrasia, and un- accompanied by deeper lesions of the nose,—one, therefore, which arises entirely from the retention of adherent and decom posing secretions. There is a young lady at present under my treatment, with the most well-marked ozsena, in whom the same offensive greenish crusts, which may be seen in the nose, are also to be found in the pharynx, in the larynx, and even in the trachea, and in whose case, in spite of the most careful exami- nation, no other cause for the condition is to be found than chronic catarrh, without any dyscrasia. Unless, then, one is willing to pronounce in favor of scrofula or syphilis, from the presence of ozsena alone, in a person giving no other evidence of a dyscrasia, it will be necessary to admit the existence of simple chronic rhinitis with ozena. Still, it cannot be denied that these cases are the more rare ones, and that ozsena is generally developed after chronic rhinitis has long persisted in a person who is the subject of a dyscrasia. During the first period, the duration of which is variable, the secretions are still fluid enough to be removed. Later, especi- ally in the development of the atrophic form of chronic rhinitis, the formation of crusts occurs, and the remains of hyperplasia often give rise, at the same time, to stenosis and retention. According to my observation, this occurs as often in wide, roomy nasal cavities as in those that are flattened or contracted. Indeed, in some of these cases the cavity is even exceptionally wide, probably in consequence of previous long-continued hyper- plasia. If, then, under influences thus far unknown, specific decomposition takes place, the picture of ozsena is completed. On careful inquiry, the majority of patients suffering from CHRONIC NASAL CATARRH. 141 simple ozsena will admit that, for a long time, indeed, as far back as they can remember, they have very frequently suffered from a cold in the head, that this subsequently developed into chronic catarrh, and that finally the offensive smell appeared. The chief annoyance of patients subject to chronic rhinitis is due, on the one hand, to the swelling and consequent obstruction of the nose as an air-passage (see above), and, on the other hand, if ozsena is present, to the offensive breath. Occasionally pa- tients can perceive the smell themselves; generally, however, they are unable to recognize the foul odor of the air expired, even when their sense of smell, for perfumes existing in the air inspired, still remains. But those who have to deal with a per- son suffering from ozsena are so annoyed by it that a sensitive patient feels incessantly embarrassed, and some are even driven to a life of solitude. Ozsena not very infrequently interferes with the pursuit of one's avocation in life, and many social and business relations are influenced thereby. Complications. Among the first complications of chronic rhinitis to be noticed is its almost invariable predisposition, especially at first, to acute exacerbations. An ulcerative process may also be devel- oped under the crusts; the fluids retained may throw down chalky deposits, and thus form stony concretions; and hyper- plasia of the mucous membrane may lead to actual new-forma- tions and polypoid excrescences. As the ulcers alluded to also penetrate deep, and sometimes, after destroying the periosteum, produce caries, it is evident that, just as in the case of occlusion and catarrh (see above, page 110), so here, too, a "vicious circle" is established; all these processes being able to induce chronic rhinitis, and being in turn produced and maintained by that disease. Chronic rhinitis may also involve neighboring parts. It may extend posteriorly into the pharynx, or anteriorly into the epidermis. The cavities adjacent to the nose may also be attacked, and this produces a complication generally hard to diagnosticate and difficult to cure. The most familiar are the processes that take place in the cavity of the upper jaw, which 142 FRAENKEL.—DISEASFiS OF THE NOSE. may thereby be distended and present the affection known as "Hydrops antri Highmori." The secretions collected in this cavity sometimes thicken into a syrupy consistence, not infre- quently disposed in layers, and thus resemble the so-called "pearl tumors" [cholesteatomata] in appearance. The dis- tention of the cavity takes place not only toward without, but also toward the nose, and may thus result in stenosis of an entire nasal fossa. The periosteum and perichondrium are involved somewhat oftener in connection with chronic rhinitis than with acute catarrh, and yet they are but seldom involved even in the former affection. In this way caries of the bones may ensue, even of those belonging to neighboring cavities and entering into the formation of the base of the cranium. The inflammation is more likely, however, to spread to the skin surrounding the nostrils. This becomes infiltrated and swells, while excoriations of the upper lip, and swelling of the glands of the neck, com- bine to present a typical picture of " the scrofulous habitus," as taught in the schools. In the majority of cases the sense of smell is either destroyed or interfered with, and indeed this may prove true where the remaining conditions for smelling are unchanged. Diagnosis. As to the diagnosis of the disease under consideration, enough guides thereto have been given in the preceding pages. We would remind our readers of the methods of examination described under the head of general diagnosis for determining the spot which is the seat of the foul odor imparted to the breath, and thus guarding themselves against attributing to the nose a stench which may originate elsewhere (for instance, in carious teeth or in collections within the crypts of the tonsils). Inves- tigation will have to extend beyond the mere diagnosis of chronic rhinitis, to the etiological grounds, which alone afford the basis for rational therapeutic interference. And it must here be remembered that those forms essentially dependent on a dyscrasia are not to be distinguished from the simple ones by CHRONIC NASAL CATARRH. 143 anything in themselves. The differential diagnosis must be based on the most careful study of the history of the case, and of all its accompanying manifestations. As regards complica- tions a fixed pain in the cheek or the forehead would indicate the implication of the corresponding cavities. Sometimes caries, which was not otherwise to be recognized, is betrayed by the appearance of spiculse of bone in the secretions on microscopic examination. Prognosis. Chronic rhinitis almost always admits of a favorable prog- nosis as regards life. On the other hand, it is an obstinate evil, often proving very refractory to all attempts at treatment, and sometimes being healed spontaneously. The prognosis becomes more unfavorable in proportion to the chronicity of the cases and the degree to which they have assumed the atrophic form. Treatment. In the majority of instances we do not have an opportunity to treat chronic rhinitis until the period for its rapid cure is long past. This is only in part the fault of the laity, for many physicians regard a subacute or chronic nasal catarrh of a child as an ailment that is neither worthy of nor amenable to treatment. Usually friends and physician are satisfied with the diagnosis of a "chronic cold in the head ;" the most that may be done will be to order some remedies to combat scrofula, and so the little patient is allowed to become gradually accus- tomed to having frequent attacks of acute coryza, and, even in his comparatively well days, to having a partially obstructed nose and being obliged to breathe with his mouth open. It is only when the ripening youth, and especially the budding dam- sel, is attacked with ozsena, that the evil is regarded as one that must by all means be removed. But then, in many cases, it is already too late, and, at all events, much more extensive thera- peutic apparatus, and much longer treatment will be required than if one had taken the trouble to subject the rhinitis of the child to the action of local therapeutics. We have already 144 FRAENKEL.—DISEASES OF THE NOSE. called attention to the fact that the general condition of children is often improved if we succeed in curing their chronic catarrh. In no case, therefore, should appropriate therapeutic measures be omitted. In the local treatment of rhinitis our efforts must be directed, first, to loosening the secretions, hastening their removal, and preventing their retention ; second, to restoring the hyperplastic or abnormally secreting mucous membrane to its normal condi- tion ; and third, to removing the stench, if it is present. We have purposely put the cleaning of the nose at the head of the list, because in all cases, even those depending on a dyscrasia, this indication must first be fulfilled. For this purpose we use, either in the form of douche, injection, or spray (compare Gen- eral Therapeutics) solutions of common salt, pure carbonate of soda, chlorate of potassa (Siegle), and chloride of ammonium of the strength of from two and a half to ten grains to the ounce. Cousin1 very properly recommends the addition of glycerine, or the application of glycerine with a brush. In the use of the douche, which is here most frequently employed, care should be taken, especially at first, not to use too concentrated solutions. The sensitiveness of the nasal mu- cous membrane is usually diminished in chronic inflammation ; still there are cases in which it is easily irritated even by the use of weak preparations. If it is evident, on trial, that the case in hand is not of that character, then we may gradually increase the degree of concentration, always remembering that a portion of the fluid used for a nasal douche is often swallowed, and that there is no denying the possibility of absorption by the nose. The precautions which patients should be instructed to observe in using the nasal douche have already been given in the general portion of this article. We would repeat, at this point, that the maximum of the pressure to be employed should consist in an elevation of the floor of the cup to a height which the patient can reach by raising his arm. If only one nasal fossa is clogged or narrowed, it is best to introduce the bulb of the tube into the nostril of that side, as otherwise the return fiow through the 1 Bullet, de Therap., 75, p. 504. CHRONIC NASAL CATARRH. 145 nostril may be hindered, and too high a pressure in the pharynx may result. If the douche is not tolerated, injections or the inhalation of atomized fluids (see General Therapeutics) may be ordered. The second indication must be governed by the etiological conditions. In syphilitic rhinitis, corrosive sublimate (from one- twentieth to one-fourth of a grain to the ounce of water with alcohol or glycerine) used as a douche, or applied with a brush in the strength of from five to ten grains to the ounce will be found of great value. So also (Trousseau) is the snuffing up of a powder of calomel and red precipitate (calomel, forty grains ; red oxide of mercury, fifteen grains; white sugar, half an ounce), of which a pinch should be taken five or six times a day. The discoverer of Lugol's solution recommends it in these cases of scrofulous inflammation, and I have found its ust*, as well as that of the diluted tincture of iodine, especially effective when the circumscribed hyperplasia could be reached with the brush. In cases of chronic rhinitis without any consti- tutional cause, especially in those with a very abundant secre- tion, the entire array of astringent remedies is employed, for par- ticulars concerning the use of which readers are referred to the genera1 portion of this treatise. We may remark, however, that Cazenave particularly recommended nitrate of silver, in sub- stance, in solution applied with a brush, as injections, or as an ointment (one part to twenty of fat). As a snuff, tannin or alum are commonly used, or the two combined, one part to from ten to fifteen of the vehicle (sugar, magnesia, etc.). Borax is also recommended, as well as lead ointment, or pledgets of bibulous paper dipped in lead water. Circumscribed hyperplasia of the mucous membrane, espe- cially such as causes stenosis, demands vigorous action. Here the use of caustic applications is indicated—nitrate of silver in substance, pencillings with Lugol's solution, tincture of iodine, etc. Galvano-cautery also answers an admirable purpose, either for the removal of the parts involved or as a caustic. As regards the third indication, we must also refer chiefly to the general observations already alluded to for specific instruc- tions on the use of carbolic acid, permanganate of potassa, and VOL. IV.—10 146 FRAENKEL.—DISEASES OF THE NOSE. other disinfectants (chlorinated lime, chlorinated soda, creo- sote, recommended by Wetzlar1 in the form of an ointment, from twenty to forty minims to the ounce of simple cerate). We must also mention Hedenus" recommendation of the use of charcoal (animal charcoal, from fifteen to sixty grains ; cinchona, myrrh, each forty grains; cloves, from six to ten grains; or wood charcoal and myrrh equal parts. A pinch of either of these snuffs to be taken every hour). But it must be remem- bered, as was remarked above, that the offensive odor cannot be cured unless the secretions are removed, and that there- fore the use of disinfectants is not the primary and radical fea- ture of treatment. The most that disinfection accomplishes is the removal of one symptom, though a very prominent and trou- blesome one, and that only temporarily. This is especially true of permanganate of potash, which only reaches the surface of the offensive crust. In addition to these means, therefore, cura- tive measures fulfilling the other indications must be adopted. It may be remarked, in conclusion, that the use of astringents is only indicated as long as swelling of the mucous membrane and an increase in its secretion is present. The dry and atrophic forms do not bear astringents, and in them we must confine our- selves to cleanliness and disinfection. SUBMUCOUS INFLAMMATION AND ABSCESS OF THE NASAL CAVITY. The mucous membrane of the nasal cavity lies immediately upon the periosteum, except that at certain points the venous cavernous bodies already alluded to intervene. True phlegmon- ous inflammation of the nose, therefore, can hardly exist. Still, acute inflammations, similar to those of a phlegmonous character, do arise here, though very rarely, involving the deeper layers of the mucous membrane and the periosteum. Such inflammations are encountered particularly after traumatic injuries to the nose ; 'Arch. f. Chir., I., S. 246. 2 L. c, 270. ABSCESS OF THE NASAL CAVITY. 147 they may, however, be associated with catarrh or blennorrhcea, or depend on rheumatic causes, or even appear without any demon- strable cause. In the epidermoid portion of the lining of the nose, which is supplied with vibrissse, therefore, in the neighborhood of the nostrils, inflammations resembling acne or furuncles (in their nature and course) may arise, which lead to circumscribed abscesses. Symptoms. A circumscribed inflammation is liable to arise within the nasal cavity, usually attacking only one side, but sometimes symmetrical portions of the septum. The swelling of the mucous membrane is very great, it is pouched out "like a sac," and may even, according to Barthez and Rilliet' and Henoch,2 project from the nostrils as a polypoid tumor. The mucous membrane is highly reddened, and fluctuating to the touch. At the same time there is cedematous swelling of the external skin, even of the skin of the face, and sometimes of the lower eyelids. Pa- tients complain of severe pain in the nose ; if the upper part is attacked, also of pain in the forehead, or if the lateral portion, of pain in the cheek. The discharge from the nose is sometimes normal, at others more or less increased, and in the latter case usually purulent. A serious degree of fever is always associated with this condition, and at times severe brain symptoms appear. Leisrings describes a case, which is of great interest not only on account of the wide extent of the inflammation, but also because on the dead body it was demonstrated that the trouble had extended to the meninges of the brain. An inflammation developing into gangreno arose in the mucous and periosteal covering of the right nasal fossa in a strong man. It may have been caused by inflammation of the antrum of Highmore, following unsuccessful attempts at the extraction of a tooth. In the left cavity only the bony septum was attacked. On the eleventh day the patient began to squint and to vomit; grew stupid and died, with evidences of meningitis. Post-mortem examination revealed purulent menin- 1 Arch. f. Chir., I., S. 196. SL. c, S. 29. 3 Deutsche Klinik, 70, S. 129. 148 FRAENKEL.—DISEASES OF THE NOSE. gitis of the right side. The bones of the middle meatus and the ethmoid bone were colored grayish-green. The mucous membrane of the bony septum of the antrum of Highmore, of the cavities of the sphenoid, and of the ethmoidal cells were colored grayish-green, and covered with a purulent coating. The mucous membrane of the bony septum was detached by purulent masses, which had in part already become cheesy. Diagnosis. The diagnosis of this affection, especially as regards its loca- tion, is at first not easy, and can only be made positive when a fluctuating swelling can be demonstrated. (Edematous swell- ing of the face may be taken as confirmatory of the diagnosis. Termination. The course of this affection is usually rapid, a ripe abscess appearing at the end of a few days. The spontaneous or artifi- cial opening of the same, through the mucous membrane, brings the patient speedy relief, and usually leads to a rapid cure. In the furuncular form plugs are expelled or extracted. The prognosis is not always favorable, although cases in which extension to the dura mater, or venous thrombosis and embolism occur, are among the greatest rarities. The disease generally ends in recovery, but sometimes caries remains, prob- ably as evidence that the disturbance originated in the bone or its adnexa. Treatment. Antiphlogistic means (leeches, cold, etc.) should be tried at the beginning. As soon as we can diagnosticate an abscess in process of formation our aim should be to favor its maturing (by the inhalation of warm vapor, etc.) and its opening. ULCERATIONS OF THE NASAL CAVITY. Etiology. The ulcerations that occur in syphilis and in glanders have ULCERATIONS OF THE NASAL CAVITY. 149 already been treated of in the third volume of this Cyclopsedia, at pages 207 and 356, as well as 359 and 362. If we except those dependent on caries of bone and the extension of lupus on to the mucous membrane (which see) there only remain for our con- sideration those ulcerations of the nose which are catarrhal or scrofulous. Tubercular (phthisical) ulcers of the nose seem to be among the greatest of rarities. I myself have never seen any- thing like them, and only find one allusion to tuberculosis of the nose in literature. Willigk1 states that in the Institute of Patho- logical Anatomy at Prague, tuberculosis of the nasal septum was encountered but once among the 476 tubercular corpses found in 1,600 post-mortems, made from February 1st, 1850, to February 1st, 1852. AYith regard to the origin of ulcers, it has already been stated that they may result from superficial losses of sub- stance in the epithelium, at first flat and circumscribed, and espe- cially liable to be formed underneath encrusted secretions. Not only in syphilitic subjects, but in scrofulous individuals as well, such little ulcers sometimes have a tendency to penetrate deeply, and finally even to attack and destroy the bony walls so that they may result in extensive losses of substance in the gums, the septum, and the turbinated bones. Although such extreme forms are not frequent, yet they do certainly occur,2 and one is therefore not justified in pronouncing in favor of constitutional syphilis exclusively on the ground of such ulcerations and de- fects. This conclusion is still less justifiable in the case of chil- dren, because even primary diseases of the bones and their adnexa may lead to the same results. Diagnosis.—Treatment. The diagnosis of these cases is easy, so far as the eye is con- cerned, and the question of the implication of the bony structure is readily determined by touch with the finger or a sound. It is a much more difficult matter, however, to decide whether the local process, so easily recognized, is of purely irritative origin, or 1 Prager Vierteljahrschrift, Bd. 38, S. 4. a Compare, for instance, Semeleder, Rhinoscopie, S. 55, Beobachtg. 21, with illus- tration. 150 FRAENKEL.—DISEASES OF THE NOSE. dependent on syphilis or scrofula. With the same appearance of the local manifestations we can only arrive at a diagnosis by careful sifting of the history, and by exclusion and a comparison of the appearances in other organs. Finally, in the light of all these aids, we must endeavor to arrive at a conclusion. Treatment is directed on the one hand to the general ailment, and on the other to surgical manipulations and the topical appli- cation of caustics and astringents. The chronic rhinitis which complicates these cases is to be treated in accordance with the principles set forth above. NOSEBLEED.— EPISTAXIS. Etiology. Hemorrhages from the nose are of very common occurrence, and may depend on a variety of causes. In this connection we may remind our readers of the great wealth of blood-vessels, and the peculiar arrangement of the vessels within the nose, already spoken of above (p. 123). The nasal mucous membrane is thus endowed with a great tendency to bleeding, and is the organ niQst frequently subject to spontaneous hemorrhage. Nosebleed is of such common occurrence that few men remain free from it through life. At the same time there is no denying the fact that certain individuals possess a nasal mucous mem- brane peculiarly predisposed to hemorrhage, in whom more or less serious bleeding may be caused by etiological conditions which would produce no effect on the majority of mankind. Epistaxis may be arranged under two general heads, accord- ing as it occurs spontaneously or follows traumatic injuries. Under the latter head it may be occasioned by mechanical vio- lence as well to the outside of the nose and its surroundings as to the mucous membrane itself. In persons who are predisposed that way, hemorrhage may be caused by a degree of violence so slight as hardly to be worth mentioning, such as touching the mucous membrane with the finger or a sound, blowing the nose, etc. NOSEBLEED. 151 Spontaneous nosebleed depends primarily on local causes situated within the nose. All the conditions already men- tioned, and we may say all diseases of the nose, may be asso- ciated with hemorrhage. As a matter of course, ulcers involving the walls of blood-vessels, and all those acute diseases character- ized by hypersemia, are most liable to lead to hemorrhage, and therefore it is seldom absent in severe coryza or in erysipelatous and other inflammations. Special mention must also be made of vascular polypi, as they manifest a very marked tendency to hemorrhage.1 Aside from local causes, however, spontaneous nosebleed may also depend on manifold etiological conditions. The first to be considered are those diseases which give rise to a hemor- rhagic diathesis, and to hemorrhage in various organs, such as purpura hsemorrhagica, scurvy, variola hsemorrhagica, leukae- mia,3 hsematophilia, etc. In all these nosebleed is among the commonest occurrences. We must further mention those con- ditions in which the lateral pressure within the blood-vessels in the nose is altered, such, for instance, as hinder the flow of blood through the veins, or increase the pressure within the arterial system. Tumors of the neck, or whooping-cough, with its paroxysms of asphyxia, which suffice to induce stagnation in the superior vena cava, may be enumerated among the first, while contraction of the kidney, with hypertrophy of the left ventricle, serves as an example of the second. Epistaxis is therefore a frequent symptom in threatened ursemic attacks. The nosebleed that occurs during the ascent of high mountains, and which is due to the low state of the barometer, may also here be mentioned. Nosebleed also occurs in the various infectious diseases, as has already been mentioned in this Cyclopaedia, in connection with variola, influenza, measles, scarlatina, typhus, etc. It is found, though but rarely, in acute tuberculosis, trichinosis, and many other conditions. In these affections it may take place 1 Compare Virchoio, Geschwiilste, Bd. III., S. 463. J Mosler, Leukaemie. Berlin, 1872. (In eighty-one cases there were sixty-four hemorrhages, thirty-five of which were from the nose.) 152 FRAENKEL.—DISEASES OF THE NOSE. at the beginning, during their course, or introducing a crisis. It also sometimes occurs during an attack of intermittent fever, and intermittent epistaxis without fever has also been observed, and cured by quinine. Diseases of the spleen are often cited as a cause of epistaxis, doubtless because alterations in the spleen accompany all the diseases just mentioned. Epistaxis is worthy of special attention when, without any local cause, it recurs frequently in the same individual, and becomes, so to speak, habitual. It may appear vicariously for other customary hemorrhages, especially for those of a hemor- rhoidal character or in place of menstruation, and in both cases may return at regular intervals. It is of the most interest when appearing in the place of menstruation. The nosebleed may occur simultaneously with diminished menstruation or without any flow of blood from the genitals. Even in the latter case, in spite of the complete absence of menstrual bleeding, conception is possible. Among the cases described, we may notice that Kussmaul ' observed regularly recurring epistaxis in a woman having no uterus, but in this case he expresses doubts as to its menstrual character. In the case of a girl, nineteen years old, who had never menstruated, Fricker 2 saw nosebleed, with the menstrual molimina, recur every six weeks, and the loss of blood was so excessive that the patient finally succumbed to it. In a woman who was pregnant for the fifth time, Sommer 3 observed epistaxis recurring once a month during her entire pregnancy, and always lasting for one day. Nosebleed may also occur at regular intervals in persons suffering from leuksemia, and in women may assume the menstrual type.4 A case was observed by Otto Obermeier,5 in the Insane Division of the Charite Hos- pital, which is so characteristic of these conditions that we will quote the following portions of his description verbally : " The patient had one period of menstruation at the age of fifteen. It was ac- companied by feelings of drawing within the abdomen, and of bearing down; there 1 Kussmaul, Vom Mangel der Gebarmutter. Wurzburg, 1859. 2 Wiirtemberg. Med. Correspond., 1844, No. 21. 3 Heidelberger Ann., X., 3. * Mosler, Leukamie, S. 174. 'Virchow's Arch., Bd. LIV., S. 435. NOSEBLEED. 153 was no other pain nor dizziness. The loss of blood was very considerable during one night, so that it soaked through the bed. She was somewhat unwell for the next two days, but lost no more blood. Four weeks later she had the same feel- ings within the abdomen; and when she went up stairs, in particular, felt as if something would fall out between her feet. But there was no escape of blood from the genitals, and never has been, up to the present time. Instead of this, hemorrhage from the nose appeared, recurring several times a day for three days. During the first day she still had a general sick feeling, a sensation of dizziness, and things were black before her eyes. From this time on this nosebleed recurred every four weeks, at first regularly, varying perhaps one day, accompanied by the same symptoms, and continuing for three days. The loss of blood at each hemorrhage amounted to about a teacupful, and took place from one to three times a day. The feeling of dragging within the body, and of dizziness was always present the first day; at the same time her limbs were tremulous, and she was giddy, felt as if everything was spinning round her, or, as she herself expressed it, ' as if she were riding in a merry-go-round.' She used to be obliged to sit down, though she never fell, and never lost her consciousness. There never was any appearance of a flow from the genitals during the menstrual period. In March, 1870, this periodical nosebleed stopped. In December of the same year she was delivered. (The child was well developed, and died at the age of six months of croup.) During the pregnancy, which commenced in March, she often vomited after eating, from the fourth month to the time of her confinement. At the same time she had an unnatural craving for herring and cucumbers. Six weeks after her confinement, in January, the nosebleed returned, with the same symptoms, but it was more scanty, and did not last exactly three days, but distributed itself over a period of eight days. It returned about once in four weeks, and was last seen the beginning of August. She believes she has been pregnant since that time, and an examination confirms the belief." According to Puech,' among the regions of the body liable to be the seat of vicarious hemorrhage in the place of menstruation, the nasal mucous membrane ranks last in the frequency with which it thus acts. According to his observations, such vicari- ous hemorrhage occurred thirty-two times from the stomach, twenty-five times from the breasts, twenty-four times from the lungs, and only eighteen times from the nasal mucous mem- brane. We shall have to be cautious in assigning a vicarious char- acter to hemorrhages, as many an accidental flow may have the semblance of being such, without there existing, in reality, any etiological connection between the suppression of one hemor- rhage and the appearance of another. But that such a thing 1 Gaz. des hopit., 1863, p. 188. 154 FRAENKEL.—DISEASES OF TIIE NOSE. does take place can hardly be doubted, in view of the observa- tions that have been made, and especially of Obermeier' s case, as communicated above. Aside, however, from this nasal hemorrhage, which may, or must be regarded as vicarious for some other customary flow of blood, habitual nosebleed is of tolerably frequent occurrence, showing itself in persons of every age, but more particularly during the development of pubert}^, and especially in the male sex. Those attacked are otherwise sometimes in quite normal condition, sometimes bursting with blood, and generally ple- thoric, at others decidedly ansemic. The bleeding may arise either with or without an exciting cause. Epistaxis sometimes occurs daily, sometimes at longer inter- vals, and these intervals, as has already been said, may for a long time recur with more or less regular periodicity, presenting the appearance of a vicarious hemorrhage. In many cases, especially in plethoric persons, the accompanying symptoms (see below) give the epistaxis a decidedly fluxionary character; in others, such symptoms are lacking, and we must then suppose that there are alterations in the walls of the vessels, of which we know nothing more specific. Habitual nosebleed is hereditary in some families. Babing- ton1 describes a marked case of this kind. A woman who suffered from habitual nosebleed had six female children, three of whom also suffered from epistaxis; one of these also had six children, of which the two female ones were affected in the same way. The older of these two last had a son living who was similarly troubled. The sister of the woman first mentioned likewise has a daughter living who is subject to violent nosebleed. Here the pres- ence of severe epistaxis is demonstrated down to the fifth generation, Babington himself having witnessed it in the mother, daughter, and grandchild. In the latter the attacks were so severe that the tampon had to be used every time. It may be worthy of mention that Morgagni,2 in accordance with a tradition of his native country, alludes to an epidemic of nosebleed which is said to have prevailed in Etruria and the Romandiola in the year 1200, and which is reported to have been fatal within twenty-four hours, and to have carried off many 1 Lancet, 1865, II., No. 13. * De sedibus. Leipzig, 1827, XIV., 25, torn. I., p. 414. NOSEBLEED. 155 of the inhabitants. Nothing more specific appears from the description, and nothing like it is reported anywhere else. Symptoms. Hemorrhage from the nose usually takes place from one nostril only, and it is claimed that in affections of the spleen the left nostril is more frequently affected than the right. Still, even with diseases of the spleen, hemorrhage may arise from both sides, or even from the right side only. The amount of the hemorrhage is very variable. Sometimes but a few drops escape; generally, however, there is a pretty rapid dripping, and it is not uncommon to see an uninterrupted stream poured forth at the very beginning. It is extremely rare for the blood to flow in jets. The duration of the flow is equally variable. While the bleeding is sometimes confined to a few seconds, it may at other times last for hours, and even days. The total quantity of blood lost at each attack must necessarily vary very much according to the duration and the rapidity of the flow, running from a few drops or a few teaspoonfuls, or tablespoonfuls, up to enormous quantities. Johann Peter Frank' states that during a prolonged hemorrhage,- at one time " six pounds escaped within a little while." Martineau2 saw a case in which 4,500 grammes of blood (twelve pounds) were lost within sixty hours, and another case is reported in which, little by little, seventy-five pounds of blood escaped through the nose. Hemorrhage dependent on traumatic causes or diseases of the nose is much less likely to be accom- panied by an abundant flow than that which is caused by other conditions. The blood is generally clean, and, if it has not been retained long in the nose, is of a bright red color. It presents no special peculiarities as compared with the general blood of the individ- ual concerned. Under certain complications it may be mingled with mucus or pus. It coagulates as readily as the general Mood of the person attacked. Sometimes clots form before it 1 J. P. Frank, Grundstiize, u. s. w. Mannheim, 1807, VI, S. 135. * Union med., 1868, No. 104. 156 FRAENKEL.—DISEASES OF THE NOSE. escapes from the nose, and plugs of clotted blood similar to polypi may protrude from the nostrils. In severe hemorrhage there is not only a flow from the nostril of the side attacked, but the entire cavity of the nose and the naso-pharyngeal space are filled. In this way a flow from the healthy side, as well as into the throat, may result. Thus, epis- taxis of one side may appear to be double, and blood may also escape from the mouth. When nosebleed occurs in persons who are asleep, or otherwise unconscious, a part of the blood that reaches the pharynx is generally swallowed or passes into the trachea, and may then be vomited or coughed up. From these manifestations we may conclude that at least the severer hemorrhages are due to openings that are developed in the blood-vessels which anastomose and dilate into cavernous bodies, the blood pouring out at these openings. Severe hemor- rhages can hardly be explained without a solution of continuity in the walls of the vessels. Probably smaller vessels are rup- tured. We have as yet no anatomical investigations to prove whether, in certain forms of habitual nosebleed, the walls of the vessels undergo a previous change, such as varicose degeneration. In many cases, and especially those of habitual epistaxis, there are certain premonitory signs. They are appearances, as was indicated above, which may be regarded as evidence of the fluxionary character of these hemorrhages. They usually consist of symptoms which prove that not only the nose, but the whole half of the head, in fact, the entire head, is the seat of an active hypersemia. Among the objective signs are redness of the cheeks and of the head, as well as injection of the conjunctiva, sometimes only of one side. Patients complain of great pressure within the head, sometimes of dizziness, drow- siness, roaring or ringing in the ears, throbbing in the head, and a feeling of fulness, distention, and warmth within the nose. J. P. Frank's statement that sometimes a dicrotic pulse appeared in only one radial artery, has not been confirmed. These mani- festations vary considerably in different people, but they are usually repeated with great regularity in the same person, so that they know when they are about to be attacked with epis- taxis. The premonitory symptoms are so burdensome that NOSEBLEED. 157 patients long for the appearance of the hemorrhage; they greet it with joy, and often try to induce it artificially. For, with the appearance of bleeding, these unpleasant symptoms abate, espe- cially the headache ; and it is therefore very natural that people thus attacked should regard the nose as a safety-valve against hemorrhage of the brain or of other important organs. Course. Left to itself the hemorrhage either stops without any further sign—consequently by closure of the openings in the vessels—or clots are formed within the cavity of the nose, gradually produc- ing thrombosis of that cavity and of the calibre of the vessels. In the latter case it is not uncommon for such plugs to be expelled from the nostrils or driven into the posterior nares by the pressure of the blood behind them, and then for the hemor- rhage, which had apparently stopped, to begin again with vio- lence. The same thing may naturally also sometimes occur when the plugs are artificially removed, or come away on blow- ing one's nose or sneezing. In nosebleed, where the flow is rapid, evidences of acute ane- mia may arise, as in all other sudden losses of blood, and death from hemorrhage may finally result. Roaring in the ears, a small pulse, fainting, etc., in such cases, are symptoms worthy of the most careful attention. Frequent epistaxis may also materially affect the general condition. Evidences of chronic anemia appear, and hemorrhages in other organs may be caused thereby, so that finally it seems as if one might have been dealing with a hemorrhagic diathesis from the beginning. Even when clots prevent the escape of blood from the nos- trils, a continuation of the flow may be going on posteriorly. If, in such cases, the patient swallows the blood that flows into the pharynx, the most serious danger may arise, while to all appearances the hemorrhage has ceased. Fainting during a nosebleed is especially dangerous, for the reason that blood may pass into the trachea and cause asphyxia. The same danger exists at all times in persons who are uncon- scious, as is well known to be the case in patients who, while 158 FRAENKEL.—DISEASES OF TIIE NOSE. under the influence of chloroform, are subjected to operations in the mouth, the pharynx, etc. Prognosis. The pathological dignity of nosebleed depends on the quan- tity of blood lost, and the frequency with which these losses recur. It is a matter of course that very slight hemorrhages are only of importance if they are repeated very frequently, and that the prognosis of epistaxis will have to be determined in accordance with these facts. In the vast majority of cases nosebleed terminates favorably, either with or without artificial aid; it is but seldom that fainting, prolonged ansemia, or even death follows a single hemorrhage of uncommon severity or a prolonged flow. Some authors speak of disturbances of diges- tion supposed to be due to the blood swallowed. Habitual epistaxis during youth is regarded as an occurrence of ill omen by some writers, because they consider it as an introduction to future pneumorrhagia preceding pulmonary phthisis. I cannot coincide with this view. It is true that habitual epistaxis is not infrequently met with in delicate persons, who easily become ansemic, and that some phthisical patients prove to have formerly suffered from nosebleed. But this question, addressed to pulmonary consumptives, even to those who have suffered from hsemoptysis, is at least as often answered in the negative. But what is of more importance is the fact, according to my observation, that the vast majority of those who suffer from epistaxis during their adolescent years do not develop phthisis. If a causal connection between phthisis and epistaxis is to be established, it will have to be con- fined to this, that habitual nosebleed, just like all other weaken- ing influences, may occasion phthisis in persons predisposed thereto. Diagnosis. As regards diagnosis, it is usually a very easy matter, the fol- lowing points only requiring to be observed. We must reserve the name epistaxis for those cases in which the nasal mucous NOSEBLEED. 159 membrane itself, and its vessels, are the seat of the hemorrhage. We must therefore endeavor to exclude all hemorrhages origi- nating in another organ which empty themselves through the nose. The hemorrhages which will most frequently have to be thus distinguished are those of the naso-pharyngeal space and neighboring organs, and it may be mentioned that Koppe * has observed nosebleed that originated in the transverse sinus, and, there being disease of the cavity of the tympanum, was dis- charged simultaneously through the nose and the external audi- tory canal. Hemorrhage of the air-passages or of the stomach, when coughing or vomiting takes place, may at the same time be discharged from the nostrils. On the other hand, however, as was intimated above, true epistaxis may simulate hemorrhage of the throat, of the air-passages, or of the stomach. The differential diagnosis in these cases is easy, if one sees the patient during the hemorrhage. Direct inspection of the pharynx, through the mouth, at least settles the question, at once, whether the bleeding is from the nose and the naso- pharyngeal space or from the deeper respiratory or digestive organs. Cases which are not seen until after hemorrhage has ceased present greater difficulty. It will be necessary in such cases to try to determine the seat of hemorrhage by the more or less firm attachment of the coagula. But there are cases in which hemorrhage stops without the formation of clots, and in which none are to be seen immediately after the cessation of the bleeding ; we are then obliged to deduce our conclusions, with greater or less accuracy, from the statements of the patient, or of those about him, just as we have to do in those cases that come to us still later, and where we have nothing but the his- tory of the case to guide us. Under such circumstances we must remember that in the vast majority of cases of hemorrhage through the nostrils the nose is the part affected, and that hemorrhages from the respiratory organs or the stomach, escap- ing at the same time from mouth and nostrils, are always very profuse, and could hardly occur without other character- istic indications of the disease which occasioned them. Hemor- rhages of that kind are not likely to be mistaken for nosebleed, 1 Arch. f. Ohrenhlkde., Bd. II., S. 181. 160 FRAENKEL.—DISEASES OF THE NOSE. whereas, on the contrary, epistaxis may be confounded with hemorrhage from the lungs or stomach, though even this is not very frequent. The cases that are thus confounded are usually those of hemorrhage from the posterior parts, taking place dur- ing sleep, in which the patient, to his great alarm, spits up con- siderable quantities of blood on awaking, without being con- scious of any nosebleed, and, in fact, without having had any blood escape at the nostrils. If, in such cases, one has a chance to see the patient soon afterwards, one will usually find clots of blood more or less firmly adherent to the nasal or naso-pharyn- geal cavities, and thus be enabled to confirm the diagnosis. At a later date, either the absence of severe illness, or the repeti- tion of similar hemorrhages, giving evidence of their nasal origin, furnishes us with a basis for diagnostic conclusions. In many instances it is very difficult to determine whether the hemorrhage originates in the naso-pharyngeal space, the pos- terior, or some other portion of the nose. If there is any con- siderable flow of blood it is generally impossible by rhinoscopy or inspection from in front to determine the bleeding-point, because the entire field of vision is obscured by blood. We may suppose a hemorrhage to come from the naso-pharyngeal space if it likewise involves the ear, and we may set it down as coming from the front part of the nose if we can stop the bleeding or prevent its further flow posteriorly by pressing the upper part of the alse of the nose against the septum. This will be referred to again under the head of therapeutics. Treatment. Under this head we will first consider the therapeutic means to be employed against the hemorrhage itself, and we are obliged at the outset to inquire whether, on the whole, we wish to arrest this or not. As a matter of course we do not now refer to those cases of nosebleed, in which the bleeding is so scanty and of so short duration that neither patient nor physician thinks of such a thing as therapeutic interference, but to such as show a more abundant hemorrhage, and in which, at the same time, one has every reason to regard the nosebleed as evidence of hypersemia NOSEBLEED. 161 of the head which Nature is thus seeking to relieve. Such cases occur, not only in habitual nosebleed, but also sometimes in the course of acute disease. The same question will arise in connec- tion with vicarious epistaxis. In all these combinations, how- ever, we shall have to try to arrest the hemorrhage as soon as by its severity, or the frequency of its recurrence, it begins to produce symptoms of acute or chronic ansemia. In these cases of epistaxis, but in no others, it will be permissible to wait up to that point, without doing anything, as experience shows that the loss of blood affords relief; but as soon as the hemorrhage seems to be dangerous we must take means to stop it, even in fluxionary or vicarious cases, and this is all the more imperative, as no well-authenticated instances are on hand of evil results following a suppressed nosebleed. In every epistaxis that is at all considerable, it is well first to try to arrest the hemorrhage by external pressure. Either the physician or the patient should press the ala of the side affected, at the incisura pyriformis, against the septum in such a manner as to close the nostril and the front and upper part of the nose. This is for the purpose of causing coagulation of the blood, which may then serve as a tampon to the cavity, and lead to closure of the bleeding vessels. The patient must at the same time be brought into the most perfect possible state of rest of mind and bod)', removed from any anxious surroundings, and encouraged to breathe as quietly as possible without speaking or blowing his nose. It is also desirable to assign to him a certain posture, and the best one will be to let him sit upright, with his head inclined slightly forward, "as if he were about to write."1 In this posi- tion the floor of the nasal cavity, which when the head is held erect inclines to the rear, is changed to a horizontal plane, and it is made more difficult for the blood to flow back down the throat. As a matter of course, all articles of clothing that pre- vent the return flow of blood from the head (tight neckties, etc.) must be removed. Instead of external compression, Valsalva, as described by Morgagni,2 applied pressure by means of a finger introduced into the nostril. Valsalva believed it possible to reach and com- 1 Ilianl Gazette des Hop., 1861, p. 379. * L c. IV., S. 411. vol. rv.—ii 162 FRAENKEL.—DISEASES OF THE NOSE. press the bleeding vessels by the finger, and in the case referred to by Morgagni, in which Valsalva applied this "fortunate cure" against an otherwise uncontrollable nosebleed, the patient learned to introduce his own finger in this way and stop the bleeding. There is no denying the fact that the finger thus introduced may often effect compression and occlusion of the anterior nasal region, reaching a point higher up than can be reached from without. Instead of employing external compression, it is in many cases far easier to fill out the anterior region of the nose with a pledget of picked lint introduced through the nostril. Such an "anterior tampon" is also far pleasanter to the patient than pressure by the finger over the external skin, if it has to be continued long. The bunch of charpie is to be previously tied together with a firm thread, so that by drawing on this thread which is left hanging out of the nostril, the whole of it can be withdrawn at once. By such procedures it is possible, in a great many cases, to arrest the hemorrhage, as already intimated, by causing the for- mation of coagula in that part of the nasal cavity which is thus shut off, and so effecting the closure of the. bleeding vessels. This is true with regard to those cases, constituting the majority of all nosebleeds, in which the hemorrhage originates in that region ; and, on the other hand, we may ascertain by the results of this method of treatment whether we are dealing with that kind of a case, or not. When using external compression or the anterior tampon, we should also direct our attention to the ques- tion of whether the hemorrhage is not continuing into the phar- ynx, and, if the sensations or testimony of the patient are at all doubtful, we must satisfy ourselves with regard to it by ocular inspection. If we succeed by such means in preventing the escape of blood through the posterior nares, it is evidence that the bleeding is from the anterior nasal region, and we have every prospect that by means of sufficiently prolonged and systematic compression—during which, as the flow is stopped, nothing is being lost—the hemorrhage may be definitely arrested. For in tliese cases success depends upon giving the coagulated blood time enough to form firm clots. NOSEBLEED. 163 As an adjunct to these means we may employ compression of the carotid, which may be carried out in conjunction with a method of tamponing to be described below. If the foregoing means are not sufficient to prevent the escape of blood posteriorly, an array of more or less empirical methods may be tried next. First of all we will speak of the application of cold, both in the form of compresses over the nose, and in that of pouring or injecting cold water into the nasal cavity. The latter method has the disadvantage that, although contrac tion of the vessels is excited, the coagulation of the blood is hin- dered, and even clots that are already formed may be washed away. This occurs most frequently if one permits the patient to snuff up the cold water held in his hand, as the suction move- ments thus occasioned are often capable of exciting the bleeding again. We may also employ cold solutions of astringent drugs (alum, tannin, sulphate of zinc, singly or in combination, the solution of chloride of iron, nitrate of silver, alcohol, vinegar, and many others). Notwithstanding the great efficacy of these means, if one can recognize the bleeding point, and bring it into direct contact with concentrated solutions, or with the article in substance, I have seldom seen any good from their use in the weak solutions ordinarily employed, solutions the strength of which is dictated by a proper regard for the non-bleeding por- tion of the mucous membrane. Manipulations calculated to produce spasm of the vessels through reflex action have also been recommended, not only by the laity but by trustworthy authors. The principal means of this sort is the application of cold to distant organs—to the neck for instance, but particularly to the scrotum in men, and in women to the breasts. The laity often try the effect of frighten- ing patients, for the purpose of thus producing contraction of the vessels. In this connection it may be remarked that Mac- namara' cites several cases in which mental disturbances were the cause of severe epistaxis. In active forms of nosebleed, derivatives may be tried—dry * Dublin Jour., Vol. XXXIII., p. 43. 164 FRAENKEL.—DISEASES OF TIIE NOSE. cups to the neck, mustard foot-baths, or even a slight with- drawal of blood from other parts. Venesection, which was formerly recommended in this affection, is not to be employed, owing to the increased danger of ansemia. Negrier advises ele- vating the arms, in addition to compression. It may be laid down as a general rule that too much time must not be lost in the trial of these methods. Experience teaches that truly severe epistaxis grows more severe and harder to control with its increased duration. Therefore we should rely on the above means only so long as no danger from ansemia can be discovered. As soon as the slightest evidence of such danger appears, or if we have special reason to dread hem- orrhage on account of the constitution of the patient, we must give up dependence on all such means as soon as it is established that external pressure and the anterior tampon are unavailing, and must turn to the sovereign remedy, by which the great majority of all nasal hemorrhages may be arrested, viz., plug- ging the posterior nares. The simplest method of effecting this, with Belloc's canula or the rhineurynter, has been described under the head of general therapeutics. As a matter of course, the tampon introduced must be large enough really to fill the posterior nares. At the same time the anterior part of the nose must be plugged. If no Belloc's canula is at hand, a piece of gum-elastic catheter may be used, being passed through the nostril into the oral portion of the pharynx, then seized with forceps and brought out at the mouth for the purpose of attach- ing the tampon thereto. In the place of the rhineurynter, J. P. Frank* improvised a procedure which entitles him to be regarded as the actual inventor of the instrument—priority in the use of which has been a subject of contention among some of our con- temporaries. Frank, with the aid of a probe, introduces into the bleeding nostril a moistened piece of hog's intestine which has been dried in the air, and one end of which is tied with a fine thread. This being accomplished, cold water is injected into the opening of the intestine outside of the nose, and so a complete filling of the nose is accomplished. If no syringe is at hand, ' L. c, VI. Bd., p. 145. NOSEBLEED. 165 the gut can be inflated with air. After it is filled, the outer extremity, too, is tied. In place of plugging the posterior nares, many authors recommend the introduction into the nose, as far back as the pharynx, of wicks capable of absorbing fluids. Thompson,' Josiah Smyly,2 and many others, advise, for the carrying out of this method, which was employed by the ancients, the introduc- tion of strips of linen into the lower nasal canal. It is not to be denied that plugging the posterior nares is a tolerably disagree- able procedure for the patient, and that the filling up of the nasal cavity causes less even of the feeling of pressure and of the presence of a foreign body, which makes itself felt in a very disturbing manner on the introduction of a tampon from the pharynx. But the introduction of wicks is a less certain measure, and although it succeeds in many cases, and may therefore be tried, yet the operation of plugging the posterior nares should not be laid on the shelf, merely out of regard to the comfort of patients, nor turned to merely as a last resort in rare cases. Here again the statement made above is to be remembered, namely, that epistaxis is always more difficult to arrest when it has been of long duration. The proposition to introduce bibulous substances into the nose is based on the same theory as tamponing, the idea being to induce a coagulation of blood sufficient to fill the entire cavity, and finally to close the bleeding vessels. The wicks are expected to be soaked with blood, the blood to coagulate within them, and then a progressive coagulation to go on till the end is accom plished. For the sake of encouraging this coagulation some writers put astringents on the wicks before introducing them. Curtin3 sprinkles them with tannin; Gilruth * dips them in chloride of iron. But Frank thinks that in such cases the com- pression of the parts by means of the tampons is often more effective than the styptics, and recommends, therefore, that if 1 Brit. Med. Journ., 1867, No. 361. 3 In Macnamara, 1. c, p. 54. 3Phila. Med. Times, Aug. 1st, 1872. 4 The Lancet, 1871 (Dec. 2), II., p. 775. 166 FRAENKEL. — DISEASES OF THE NOSE. one wick is not sufficient, a thicker one and one better twisted be taken, which usually proves sufficient of itself to arrest hemorrhage. The tampons, wicks, or whatever has been used, whether introduced from before or behind, must be removed from the nose as soon as a bad smell attaches itself to the coagula. This is usually the case at the end of twenty-four hours, and in the vast majority of instances a tampon remaining in position for that length of time permanently arrests the hemorrhage. It hardly ever happens, except in case of a general hemorrhagic diathesis, that epistaxis recurs after a tampon has been applied for twenty-four hours. If it does, new tampons must be used. To facilitate the removal of a tampon the nose may be irri- gated with a five-grain solution of common salt or of carbonate of soda, which is cool, that is, neither lukewarm nor cold, care being taken to employ as low a pressure as possible. In addi- tion to the thread which passes out at the nose (in the case of a tampon introduced posteriorly), it is well to attach a second thread, which latter is to be brought out at the mouth, and to be used, if necessary, for the removal of the tampon. It is true that this thread may sometimes annoy the patient not a little, and is often superfluous. For, after loosening the thread brought out at the nostril, and usually fastened to the ear, a stream of water of very slight pressure, but of sufficient duration, is generally enough to loosen the tampon and carry it into the naso-pharyngeal space, or this may be accomplished by a slight push with the button of Belloc's canula, or any other insignifi- cant force. From here it generally passes into the mouth without any assistance, and is spit out. At the most we may have to move the velum a little with the finger, in order to assist in this descent, or even in this way to draw the tampon down out of the naso-pharyngeal space. There are cases, how- ever, in which the tampon seems to be wedged into the posterior nares, and in which, without the thread above referred to, there would be difficulty in removing it; hence it is not an unworthy precaution to add the thread that comes out at the mouth. If the latter is not employed, it is well enough to keep a finger in the pharynx during the removal of the tampon, so as to prevent NOSEBLEED. 167 it from being swallowed, unless one can place entire reliance on the patient in this matter. We have thus far indicated the means of relief which we con- sider of value against nosebleed, as such, during the attack. We may add that the occurrence of fainting during the fiow is worthy of special attention, for the sake of preventing the entrance of blood into the trachea. In patients who are sitting up, the head should be inclined as far forward as possible, and in those lying down we may place them with the vertex depen- dent, as is proposed by Rose for operations "on the hanging head." The determination of blood to the brain, thus produced, can under the circumstances only be desirable. In the severe nosebleed of unconscious persons, plugging the posterior nares is to be carried out as soon as possible, to avoid the flow of blood into the pharynx, etc. Aside from this, fainting, as well as acute or chronic ansemia, is to be combated by the means ordi- narily employed in these conditions. In appropriate cases, transfusion may also be indicated in epistaxis. According to Mosler,1 in one case of leuksemic nose- bleed, not only the attack, but also the return of epistaxis, as well as of any other hemorrhages, was prevented—in other words, the hemorrhagic diathesis was cured—by this means. - We believe that, in view of the existing experience in transfusion, it should not be put off too long. If serious evidences of acute or chronic ansemia appear, transfusion is a means which not only removes this condition, but also seems essentially to aid in the arrest of hemorrhage (by exciting the tonicity of the vessels?). We have purposely, thus far, avoided any reference to the internal use of hemostatics, because we have been dealing with the therapeutics of the attack of hemorrhage itself, and the effect of internal remedies is obtained so late that the most which could be expected of them is to serve as adjuvants to the means already described. But, on the other hand, these drugs serve a good purpose in preventing the recurrence of hemorrhage. Ergot ranks highest in this category, whether it be in habitual nosebleed or in that dependent on a hemorrhagic diathesis or on 1 Leukaemie, S. 267. 168 FRAENKEL.—DISEASES OF THE NOSE. infectious diseases, and it may be best employed in the form of the extract, whether given internally or by hypodermic injec- tion. A solution of chloride of iron, tannin, acetate of lead, sulphuric acid, and other styptics may also be ordered. As a matter of course, individual causal indications will have to be duly regarded in our therapeutics. Traumatic injuries, for example, will demand the application of cold; diseases of the nose will call for their own appropriate treatment. The habitual nosebleed of ansemic persons requires supporting treatment (quinine and iron). Vicarious epistaxis, or that accompanied with fluxionary manifestations, may be benefited by the use of an unirritating scanty diet, dilute sulphuric acid, and determination to the bowels (by the use of Friedrichshaller bitter water, etc.) In such cases, too, prophylactic abstraction of blood may be employed, the amount of which can be controlled (venesection, wet cups, leeches to the anus, scarification of the uterus). But they do not always prevent the occurrence of the hemorrhage that is feared. I know a girl who suffers from amenorrhcea, from a high degree of general plethora, and from frequent epistaxis, who, for that very reason, voluntarily offered herself as the blood-giver in a transfusion, and who suffered from spontaneous nosebleed during the operation, while the blood was being copiously withdrawn from her radial artery. These prophylactic abstractions of blood should be confined to full-blooded individuals. TUMORS OF THE NASAL CAVITY. Tumors of the nasal cavity are generally grouped together under the head of nasal polypi. If the designation " polypus " is appropriate anywhere it is here, for the term was originally used with reference to tumors within the nose, especially those that were pedunculated. The resemblance to the animal of the same name may have been found in the method of their attach- ment or in the appearance of the flesh. The matters falling under this head belong chiefly within the TUMORS OF THE NASAL CAVITY. 169 domain of surgery, and we shall therefore confine ourselves to the following remarks: The so-called mucous polypi are of most frequent occurrence within the nose. Tliese tumors, whose structure has been more particularly described by Billroth,' retain the elements of the mucous membrane from which they arise, and the epithelium of which still covers them ; the only difference lies in the fact that sometimes the glandular element and sometimes the connective tissue predominates. Generally, however, they consist of newly formed hypertrophic glands, which are held together by soft— frequently cedematous—connective tissue. In this case they deserve the name of adenomata. More rarely forms occur, which, according to their anatomical structure, must be desig- nated as cedematous fibromata, or as sarcomata. Mucous polypi occur at every age, but more especially between the period of puberty and about the age of forty. They are generally developed on tissue which is the seat of a chronic catarrh, and sometimes the fact that they spring from just the narrowest part of the nasal cavity (in acute bending of the septum, particularly at the opposite point of the mucous membrane) especially indicates their irritative origin. They are either pedunculated or attached by a broad base. They are sometimes solitary, being then generally located in the upper and anterior portion of the nose, and sometimes multiple, occu- pying one or both nasal fossse, and even the adjoining cavities. They vary very much in size, from the small excrescences, like condylomata, which are found particularly in the region of the posterior nares, to those extensive tumors which may project from the nostrils, or extend through the posterior nares into the pharynx. They may close the openings of adjoining cavities, or the lachrymal canal, causing epiphora, and in rare instances may lead to distortions of the bony walls of the nasal cavities. Mucous polypi give rise to spontaneous hemorrhage less fre- quently than any other variety. They do not extend to other tissues than the one first involved, and belong exclusively to the class of benign tumors. 1 Ueber den Bau der Schleimpolypen. Berlin, 1855. 170 FRAENKEL.—DISEASES OF THE NOSE. Mucous polypi arise and run their course without pain. Patients do not usually observe the presence of a polypus in the nose until its growth is so far advanced as to begin to pro- duce stenosis of the nasal cavity. Sometimes their attention is not attracted to the formation of a tumor within the nose until the polypus begins to be visible from without. Up to that time they rest easy in the belief that they are merely suffering from nasal catarrh. The diagnosis of polypi is made by palpation, but more par- ticularly by inspection. A tumor is observed which in general looks like the mucous membrane itself, though usually some- what paler and more transparent. The latter is especially the case in pedunculated tumors. Those polypi which are attached by a broad base often look so much like the surrounding mucous membrane that it is scarcely possible to tell with the naked eye whether one is dealing with a new-formation or merely with hypertrophied mucous membrane. If a polypus is pedunculated, and its club-shaped extremity is not wedged in, it may be moved back and forth by the respiratory current. In such cases, therefore, a polypus seated at the back of the nose may often be brought into view by causing the patient to make a forcible expiratory effort, especially through the affected nostril. Whereas follicular cysts are seldom encountered in the Sclmeiderian mucous membrane, they do sometimes occur in mucous polypi, and especially in those of the antrum of High- more. In this locality they are multiple, and may grow so large as finally to fill the entire cavity and even to begin dis- tending its walls. Virchow l considers it probable that the con- dition usually denominated hydrops antri is due, not to a free dropsy in the antrum, but to this kind of polypus, the walls of which, filling the entire cavity, might easily be overlooked. Neoplasms similar to mucous polypi are found in the vicinity of the nostrils ; their outer surface, however, more nearly resem- bling the skin, being covered with epidermis instead of mucous membrane epithelium. Sarcomatous and fibromatous tumors of the nasal cavity, 1 Geschwiilste, I., S. 245. TUMORS OF THE NASAL CAVITY. 171 generally taking their origin from the periosteum, rank next in frequency to mucous polypi. They may also grow into the nasal cavity from all the adjoining cavities (naso-pharyngeal poly- pus, tumor retromaxillaris), and through all the canals open- ing info it, just as, on the other hand, nasal polypi may extend outward through all tliese openings from the nasal cavity. They are distinguished from mucous polypi by their firmer and harder structure. They spread beyond the tissue in which they originate, destroying the neighboring parts, and therefore, as a rule, belong to the malignant tumors. They are furthermore particularly dangerous by reason of their disposition to penetrate into the cavity of the cranium. These tumors lead to hemorrhage much oftener than the mucous polypi, and they not infrequently present a telangiec- tatic structure. In the case of polypi originating in the posterior portion of the nasal cavity, Virchow' leaves it undecided whether any role is played by the growth of the erectile tissue here found (compare page 123), although he considers it probable that these tumors also are teleangiectatic fibromata and not true angiomata. Aside from this, the nose and contiguous cavities may be the seat of tumors of different varieties: chondroma and osteoma, myxoma, epithelial carcinoma, and carcinoma—tumors which we leave altogether to be considered in works on general sur- gery. In the same way we shall only refer to the presence of ecchinococci, which are of rare occurrence. We must not, how- ever, fail to refer to the possibility of nasal polypi being simu- lated by hernia of the brain, making it necessary to be on one's guard against this chance of error in case of congenital tumors. The diagnosis is determined by the presence of a bony canal and the possibility of a partial or complete replacement, which is usually of easy demonstration. As regards the symptoms of tumors of the nasal cavity, we may refer to what was said above under the head of stenosis and chronic coryza. The necessary points for diagnosis have also been given under the head of general considerations. 1 Geschwiilste, III., S. 463. 172 FRAENKEL.—DISEASES OF THE NOSE. The therapeutics of these tumors belongs in the domain of general surgery, as it is a question of their removal by torsion, cutting, crushing, burning, etc. The attempt to remove polypi by caustics is only practicable where they are small. In order to prevent relapses we must endeavor, by the methods indicated above, to cure the chronic rhinitis which usually exists as a com- plication. On the subject of glanders, lupus, and syphilis, the reader is referred to the appropriate chapters of this Cyclopsedia. FOREIGN BODIES AND CONCRETIONS. The foreign bodies found in the nose may originate within the organism of the person in whom they are found, having their source, 1st, within the nose and its neighboring cavities, or, 2d, elsewhere in the body, and being carried thither. Thus, for instance, carious bones of the nose may become detached, leave their original site, and serve as foreign bodies in some other part of the nasal cavity. In the same way secretions, pseudomem- branes, etc., may be loosened from their point of development, and become foreign bodies elsewhere. The substances falling under the second class may comprise portions of the respiratory or digestive organs which are driven through the posterior nares in the act of coughing, or more commonly, in retching or vomit- ing. If such a state of things is encountered in the dead body we must first inquire whether it was produced during life or after death, due, perhaps, to awkwardness in transporting the body. In the latter case the contents of the stomach, if present, may be recognized by their acidity and the presence of the sar- cina ventriculi. But it is hardly possible to exhaust the list of substances which may find their way into the nose from other parts of the body. The attention of physicians has been specially directed to the occasional presence of the ascaris lumbricoides, or round worm, within this cavity. Fr. Thiedemann' has col- 1 Von lebenden Wurmern und Insekten in den Geruchsorganen des Menschen. Mannheim, 1844, p. 7. FOREIGN BODIES AND CONCRETIONS. 173 lee ted a list of cases in which lumbrici, which had left their usual habitat and crawled into the stomach, were discharged by the nose instead of the mouth, or even remained for a considerable time within the nose or its contiguous cavities, sometimes caus- ing very serious disturbances. Foreign bodies not originating within the organism may enter the nose, first, through the nostrils ; second, through the posterior nares ; or third, through the integument of the face, in cases of wounding of the latter. . Of course they most com- monly enter through the nostrils, especially if we include in the category of foreign bodies the particles of dust floating in the air and the substances that are snuffed up the nose as remedies for coryza or by snuff-takers. Some children and insane people have a fancy for putting all sorts of things up their noses, besides which some articles may get into the nose by accident. Much more rarely such foreign bodies may enter the nose through the posterior nares. Thus Lowndes ' removed a ring from the posterior nasal aperture of a child fifteen months old. The size of the ring was too large to have admitted of its introduction through the nostril; it must have been swallowed, and have passed into the nose from the pharynx. When there is paralysis of some of the muscles of deglutition, the escape from the pharynx into the nose of articles that should have been swallowed is more frequent. Among the foreign bodies that enter the nose through the skin may be mentioned broken knife-blades,2 spent bullets, or other hard substances that are driven against the face with a certain degree of violence, and, entering the nasal cavity, may sometimes remain there a long time without producing any serious symptoms.3 It is manifestly impossible to enumerate all the foreign bodies that may thus be introduced into the nose, for anything that can be forced through the nostrils may at some time be passed into the nasal cavity by a child. Glass beads, peas, and beans seem to be used for this purpose oftener than anything else, and we must not forget that the latter sometimes germinate 1 Brit. Med. Journ., 1867, Sept., p. 206. 2 Bodolfi, Gurlt's Jahresb. d. Chirurg. fur 1863-65. 3 Cloquet, Ophresiologie. Uebers. Weimar, 1824. p. 405. 174 FRAENKEL.—DISEASES OF THE NOSE. within the nose, and produce quite considerable roots and sprouts.' Among the materials claiming attention are all the minute particles,that pass into the nose with the air inspired, such as soot and dust, with all the organic and other matters accompanying it, as well as the floating pollen of plants and grasses which have been mentioned above as well as in the second part of this work, as the probable cause of hay fever. The manifestations produced by foreign bodies within the nose vary greatly, according to their nature and amount, as well as the duration of their stay. The idiosyncrasies of the indi vidual attacked, however, also exert an important influence. Thus the susceptibility to hay fever is almost exclusively con- fined to persons of the more cultivated class. A still more familiar instance of the same thing is found in the very different degrees of irritation produced by snuff on the nasal mucous membrane of different persons. In some every pinch of snuff produces spasmodic sneezing. Canstatt2 even declares that a single pinch gives him a severe cold in the head, while others can use even the strongest varieties of snuff in large quantities without causing any reaction of the Schneiderian membrane. Here, of course, habit plays an important role, as well as predis- position, and just as snuff-takers become accustomed to tobacco, many artisans become tolerant of irritants which come in con- tact with their nasal mucous membranes incidentally to their daily employments. It may, however, be announced as a gen- eral rule, that the immediate effect of foreign bodies within the nose is to produce circumscribed inflammation. Still they do sometimes remain in the nasal cavity a long time without caus- ing any trouble whatever. Generally, however, if they are not soon expelled by sneezing or by artificial means, they eventually give rise to chronic rhinitis, ordinarily accompanied by ulcera- tion and ozsena, so that a bloody, purulent, and often fetid secretion is added to the other symptoms of the presence of a foreign body within the nose. If such bodies are at all volu- 1 Cloquet, 1. c, p. 414. Duchek, 1. c, p. 458. Th. Smith, Brit. Med. Journ., 1867, II., p. 547. 2 Handbuch der med. Klinik, II. Aufl. Berlin, 1840, III., 2, p. 7. FOREIGN BODIES AND CONCRETIONS. 17.1 minous, they of themselves cause stenosis of the nasal cavity on the side implicated, frequently accompanied by severe head- ache, which may be either local or radiate over the entire head. These pains are especially liable to be present when the body is lodged in one of the neighboring cavities. From time to ime the symptoms become aggravated, even if no changes take place in the body itself of a nature to cause fresh irritation, as for instance when beans germinate. Cases are also reported in which severe brain symptoms have disappeared immediately after the removal of foreign bodies from the nose. Great importance attaches itself to objects introduced into the nose when they become the nucleus for the formation of concretions. Rhinoliths' are not of ver}^ frequent occurrence, but most of them are found to contain some body not belonging to the organism, around which the calcareous deposit has taken place. It is very unusual to find nasal calculi developed only around retained secretions. Rhinoliths may attain a very con- siderable size. Verneuil* encountered one of such proportions that he was obliged to reduce it by lithotripsy before it could be extracted. Brown3 extracted one measuring an inch and three- quarters in length, an inch in width, and half an inch in thick- ness. Calculi may be formed in any part of the nasal cavity, but are most frequent in the inferior meatus. They are of vari- able consistency, and usually consist chiefly of phosphate and carbonate of lime. The formation of calculi is not to be confounded with cal- careous degeneration of the mucous membrane itself, which is sometimes found within the nose, usually of old, but occasion- ally of young persons, in consequence of what is known as the ossific diathesis. The mucous membrane of the cavities contigu- ous to the nose, particularly those of the sphenoid bone, are especiably liable to this change ; but the membrane covering the turbinated bones, too, may be thus affected, developing first fine, granular points, and afterwards plates of calcareous matter, and 1 Demarquay, Rhinolithie, Arch. gen. de Med., 1845, Juin. 4 Gaz. des Hopit., 1859, p. 152. ' Edm. Med. Jour., Dec, 1859, No. LIV., p. 501. 176 FRAENKEL.—DISEASES OF THE NOSE. assuming a corresponding change in appearance, that is, an almost white color.1 The diagnosis of a foreign body is always easy, if, in obtain- ing the history of the case, the introduction of such a body is reported. But the patients or their attendants often know nothing of the occurrence, and the way in which a foreign body was introduced is often explained only after its extraction. It is therefore well not to lose sight of this possibility in all cases of chronic rhinitis, or of the manifestations described above. The demonstration of foreign bodies takes place by means of palpation and inspection. In palpation with the probe, the touching of stones, pieces of metal, and the like, sometimes calls forth a characteristic sound.2 The only thing which, by the touch, may be confounded with a foreign body is a denuded portion of bone. We must not here be misled, and suppose we are necessarily touching bone because the patient perceives the v touch, for this likewise occurs on touching foreign bodies which lie in close contact with the mucous membrane, etc. As a rule, however, we shall obtain the necessary evidence for distinguish- ing between foreign bodies and bone by the mobility of the object, its site, the character of its surface, etc. As regards inspection, we must not forget that such bodies are usually covered with secretions, the removal of which is necessary before the body itself can be seen. When we have satisfied ourselves of the presence of a foreign body, it should be removed as soon as possible. After its removal the accompaning disturbances are usually cured with- out any of our assistance. If not, however, they must be treated according to the methods already indicated in the appropriate sections of this work. The removal of small bodies may be attempted by provoking the act of sneezing, through the use of snuff. In such cases, too, the employment of the nasal douche has sometimes been effective, the nozzle being, of course, introduced into the nostril of the sound side. If these methods fail, or if the size and posi- 1 Virchow, Cellularpathologie, IV. Aufl. Berlin, 1871, p. 453, and Note \\, as well as Kolliker, Gewebelehre, Geruchsorgan. 2 Kbstlin, Wiirttemb. Corresp.-BL, 7, 1854. PARASITES OF THE NASAL CAVITY. 177 tion of the foreign body satisfy us, in advance, that they are useless, we must proceed to extraction. The procedures to be undertaken for this purpose belong to the domain of surgery; we will therefore here only remark that extraction is accom- plished most readily by means of spoon-shaped or fenestrated instruments, and that if the object lies very far back we may endeavor to push it into the pharynx and extract it thence, at the same time carefully guarding the mouth of the larynx. PARASITES OF THE NASAL CAVITY. Among the vegetable parasites reference has been made by some writers to the occurrence of Oidium albicans within the nose. This, however, is very rare, the Schneiderian membrane, like all mucous membranes lined with ciliated epithelium, being but seldom infected with this growth. Among the infusoria different varieties of Cercomonas may be found within the nasal cavity. As regards the living creatures1 which are encountered within the nose, they must be regarded as pseudo-parasites. For there are no true parasites of the human nasal cavity, that is, no animals destined to find their nourishment and spend a certain period of their lives there. The entrance of living crea- tures into the nose is always more or less a matter of chance. This is particularly true with regard to those animals that naturally shun the light and are fond of living in dark holes, and which sometimes crawl into people's noses, no doubt during their sleep. Thus we have trustworthy observations2 confirm- ing the existence within the nose of centipedes (Scolopendrse), ear-wigs (Forficula auricularia), as well as the larvae of the bacon- beetle (Dermestes lardarius). Centipedes are particularly liable to be found in the frontal sinuses, where they may remain for 1 Compare Fr. TMedemann, Von lebenden Wtirmern und Insekten in den Geruchs- organen des Menschen. Mannheim, 1844. 2 TMedemann, 1. c, p. 11 et seq. VOL. IV.—12 178 FRAENKEL.—DISEASES OF THE NOSE. years, the secretions of these cavities furnishing them with suffi- cient nourishment. The entrance of leeches, worms, or insects into the nose is even more purely accidental than that of the creatures mentioned above. The occasional entrance of round or lumbricoid worms has already been alluded to. The most interesting fact in connection with this question, and one which has been established by the most numerous obser- vations, is the occurrence, within the nasal cavity, of the larvse of dipterous insects. These may be considered under three heads: 1st. Attracted by the perfume emanating from an ozsena, flies (Musca vomitoria and Musca carnaria) deposit their eggs in the vicinity of the nostrils, and these eggs when hatched are nourished by decomposing organic matters. This is especially easy in the case of persons sleeping in the open air during the day. Thus, now and then, we may find maggots present in a case of ozsena as on any other fetid purulent surface on the body. This occurs more frequently in the tropics, but may also happen with us.1 2dly. In the tropics, especially in Cayenne and Mex- ico, there is a fly (Lucilia hominivora) which sometimes forces its way even into healthy noses, and lays its eggs there, where- upon the larvse, measuring about half an inch in length, are developed there at the end of fourteen days.2 Now and then the larvse of the gad-fly (Oestrus), which are more frequent in the noses of sheep and cattle, may be found in the human nasal cavity. But in these cases the determination of the variety has not been carefully made. In a matter of such importance we should never fail to have any living creatures that are found within the nasal cavity accurately classified by a thorough zoologist. The symptoms which are caused by living animals in the nose vary according to the number, the size, and the variety of the' pseudo-parasite. The variety determines the length of time they may remain in the nose, and this has a great influence on the 1 Compare A. von Frantzius, Virchow's Archiv, 43, p. 98, and Mankiewicz, ibid., 44, p. 375. 2 Weber, Recherches sur la mouche anthrophage du Mexique. Rec. de mem. de med. rnH., 1867, Fevr., p. 158; Jahresber., 1867, I., p. 312. PARASITES OF THE NASAL CAVITY. 179 course of the symptoms. Centipedes may, as already intimated, remain in the nose for years, while maggots do not grow more than two weeks old before they leave the nose for the purpose of forming their cocoons. Almost without exception, however, parasites within the nose cause the most serious symptoms. They generally occasion violent pain, especially in the head, in the forehead, or in the region of the cheek. This may be bilateral or confined to the side on which the animal is located. The pain may be so violent as to drive the patient to despair, and soldiers of the French army in Mexico have been known to commit sui- cide because they could no longer endure the suffering caused by dipterous larvse within the nose.1 Sleeplessness, delirium, unconsciousness, dizziness, and psychical disturbances are like- wise among the symptoms, as well as radiating pains along the course of the trigeminus, sneezing, vomiting, and reflex spas- modic manifestations. Sometimes patients have a distinct feel- ing of the voluntary movements of some foreign body within the nose. Next in order follow the evidences of inflammation, which are both local and general, accompanied with fever. Inflamma- tory action is especially pronounced when the larvse of flies are present, and we are then, as in cases of blennorrhcea, very likely to find cedematous swelling of the face, and sometimes of the velum palati, the latter interfering with deglutition. During the limited duration of the life of maggots within the nose, there- fore, a well-marked group of symptoms arises, which, according to Labory, is designated in Hindostan by the name of Peenash.2 The name is said to come from the Sanscrit, and to indicate all diseases of the nose, but von Frantzius reminds us of its resem- blance to Punaisie. The presence of parasites within the nasal cavity does not always increase its secretions. There is usually, however, a sero- or puro-sanguinolent discharge. Frantzius calls attention to the fact that the discharge changes in character on the emigra- tion of maggots from the nose. As long as they remain within 1 Weber, 1. c. 2 Compare Hirsch, Hist, geogr. lathol. Erlangen, 1862-64, II., p. 19. 180 FRAENKEL.—DISEASES OF THE NOSE. its cavity the discharge is sero-sanguinolent and less fetid than afterwards. After their emigration it is purely purulent. The prognosis, in cases of parasites within the nose, cannot always be favorable. Fatal results, for instance, have followed the harboring of maggots within this cavity. The diagnosis of the affection depends on the demonstration of the living creatures within the nasal cavity. As has already been stated, the symptoms produced by the presence of maggots are sufficiently characteristic to induce us to look for them, even aside from any evidence that may be furnished by the patient. Maggots are readily recognized by the eye, on account of their incessant movements. As regards the other animals alluded to, our diagnosis is usually not established until they are brought away, or are found present at the autopsy. Tlierapeutic interference should be directed to the removal of the parasites. We must here guard against false therapeutic conclusions, as the spontaneous discharge or the physiological migration of the intruders, as in the case of the larvse of flies, may easily be accredited to some remedy employed. Where it is possible, we should take pains to seize the animals and extract them. Frantzius calls attention to the fact that the habit which maggots have of clinging in groups greatly facilitates their extraction, because on seizing them with the forceps one usually brings away not one, but a number. The other animals with which we have to deal here are usually so hidden that no direct attempts at their removal are to be thought of. It is worthy of mention, however, that according to Morgagni,1 the surgeon Csesar Magatus, in Bologna, opened the frontal sinus and removed a worm from there. If the animals cannot be seized, the attempt should be made to secure their expulsion by means of sneezing, and finally, means are to be used for killing them. For this purpose we may employ the inhalation of alcohol, ether, turpentine, or, as Weber proposes, of chloroform, or the injection of a solution of corrosive sublimate, of decoctions of bitter herbs or tobacco, or of turpentine. Frantzius recommends the use of calomel in powder, which should be blown into the 1 De sedibusl. 9, Advers. anat. VI., animadv. 90. PARASITES OF THE NASAL CAVITY. 181 nose. Mankiewicz has seen good results follow pencillings with balsam of Peru. The remaining symptoms should be treated according to the principles laid down in the previous chapters on ozsena and blennorrhcea. The neuroses of the nasal cavity are treated of in the eleventh volume of this work. I THE DISEASES OF THE LAKYNX. INTRODUCTION. AMMIA, HYPEREMIA, HEMORRHAGE, ABNORMAL COLOR, AND THE CATARRHAL INFLAMMATIONS OF THE LARYNGEAL MUCOUS MEMBRANE. VON ZIEMSSEN. / INTRODUCTION. General Literature. Cheyne, The Pathology of the Membrane of the Larynx, pp. Edinburgh, 1809.— Porter, Observations on the Surgical Pathology of the Larynx and Trachea. Dublin, 1826.—Alders, Die Pathologie undTherapie der Kehlkopfskrankheiten. Leipzig, 1829.— Colombat, Traite" med.-chir. des maladies des organes de la voix. Paris, 1834.—Ryland, A Treatise on the Diseases and Injuries of the Larynx and Trachea. London, 1837.—Trousseau et Belloc, Traite pratique de la Phthisie laryngge, de la laryngite chron. et des maladies de la voix. Paris, 1837.—H. Green, Treatise on Diseases of the Air-Passages. New York, 1846.—Hastings, Treatise on Diseases of the Larynx and Trachea. London, 1850.—Dufour, Sur le diagnostic special et differentiel des maladies de la voix et du larynx. Paris, 1851.—Friedreich, Die Krankheiten des Larynx und der Trachea in Virchow's Handbuch der spec. Pathologie und Therapie, Bd. V. Erlangen, 1858.—J. N. Czermak, Der Kehlkopfspiegel und seine Verwerthung fiir Physiologie und Medicin. Leipzig, 1860.—H. BiXhle, Die Kehlkopf - Krankheiten, klinisch bearbeitet. Berlin, Hirschwald, 1861.—Moura-Bouroillou, Traite de laryngo- scopic Paris, 1864.—v. Bruns, Die Laryngoskopie und die laryngoskopische Chirurgie. Mit Atlas. Tubingen, 1865.—L. Tiirck, Klinik der Krankheiten des Kehlkopfes und der Luftrohre, etc. Wien, 1866. Mit chromolith. Atlas. —v. Ziemssen, Laryngoskopisches und Laryngotherapeutisches, D. Archiv fiir klin. Medicin, Bd. IV, S. 221 und S. 376 ff, 1868.—Morell-Maclenzie, The Use of the Laryngoscope in Diseases of the Throat. London, 1865; third edit., 1871 ; Hoarseness, Loss of Voice, and Stridulous Breathing. Essays on Throat Diseases, No. I. London, 1868; sec. edit., 1870.—E. Nanratil, Laryngologische Beitriige. Leipzig, 1871.—Mandl, Traite pratique des maladies du Larynx et du Pharynx. Paris, Bailliere, 1872.—Cohen, Diseases of the Throat. New York, 1872.—Tobold, Laryngoscopie und Kehlkopfkrankheiten, Klinisches Lehrbuch, III. Aufl. Berlin, Hirschwald, 1874.—L. Schrotter, Laryngologische Mittheilungen, Jahresberichte der Klinik fiir Laryngoskopie an der Wiener Univcrsitat (pro 1870) 1871 und (pro 1871-1873) 1874.— Heinze, Laryngo- skopisches, Archiv der Heilkunde XVI., Heft 1, 1875.—Burow, Laryngo- logische Mittheilungen, v. Langenbeck's Archiv fiir Chirurgie, XVIII., S. 228 ff., 1875. See also the Hand-books of Special Pathology and Therapeutics, by Canstatt, Vol. HI., Wunderlich, Vol. III., Duchek, Vol. I., as well as L. MerkeVs Reports on 186 VON ZIEMSSEN.—DISEASES OF THE LAEYNX. the Recent Progress in Laryngoscopy, Schmidt's Jahrbucher, Vol. 108, 1860; Vol. 113, 1862; Vol. 119, 1853; Vol. 133, 1867. A full bibliography of the older literature (up to 1859) will be found in Buhle's work, above referred to, on Diseases of the Larynx. HISTORY. On careful examination the pathology and therapeutics of the larynx are found to present three periods of development. The first period extends to the beginning of the present century; it displays a great meagreness of facts, and a lack of interest in the investigation of details. The darkness which prevailed in regard to the pathology of the larynx, or at least its anatomical changes, was illuminated only by a few rays of light from the genius of Morgagni. The second period includes somewhat more than the first half of the present century, and is characterized by the awaken- ing of a more lively interest in the promotion of the physiology and patholog}^ of the larynx. Here are to be mentioned a series of fundamental investigations, to which we are indebted for an important advance in laryngeal science, such as those of Johannes Miiller and Henle on the physiology and comparative anatomy of the larynx ; of Cruveilhier, Rokitansky, and Rheiner on its pathological anatomy ; and of Cheyne, Jurine, Albers, Ryland, Trousseau, and Belloc on its pathology and thera- peutics. The third period dates from the year 1858, and was inaugu- rated by the introduction of the laryngoscope into medicine by Tiirck and Czermack. The ocular inspection of the interior of the larynx disclosed so many new and unsuspected facts that it was necessary not only to fundamentally reform the whole of the pathology of the larynx, and part also of its physiology, but also to completely revolutionize its therapeutics. Such a rapid and brilliant progress as has taken place in laryngeal science within the past seventeen years has scarcely a parallel in the history of medicine. The nearest approach to it is the advance made in ophthalmology since the introduction of the opthalmoscope, and yet the improvements in diagnosis and HISTORICAL SKETCH. 187 treatment effected by this instrument are scarcely as striking as those gained by the laryngoscope. The literature of this period abounds in recorded obser- vations to a degree that is almost oppressive, and each day brings fresh material, as might be expected from the fact that this new-born and fruitful science has attracted to itself the general interest of investigators. In Germany, especially, we see much of the best talent engaged in completing the construction of a science of laryngeal pathology and therapeutics. More- over, the laryngoscope is beginning to be regarded and employed as an instrument indispensable in medical practice for the diag- nosis and treatment of laiyngeal diseases. That it has not yet come into general use among physicians is not to be wondered at, in view of the unusually great difficulties which the new art presents, and in view of the fact that it is only within the last few }rears that special attention has been devoted in the German universities to the theory and practice of laryngoscopy and laryngoscopical therapeutics. The general introduction of per- cussion and auscultation into medical practice, we should re- member, required several decades at the beginning of this century. Our universities should see to it that particular atten- tion is paid to this specialty, at least sufficient for the practical needs of the physician ; it is also especially the duty of clinical physicians to treat laryngoscopy as of equal importance with other methods of physical diagnosis, and to insist upon the indispensableness of the laryngoscope in the local treatment of laryngeal diseases. The portion of laryngeal science which has been most ad- vanced by the introduction of the laryngoscope, is that whic his really of the most importance, viz., the doctrine of acute and chronic catarrh, of ulcerative processes in the larynx, of laryn- geal stenoses, and of neoplasms and neuroses. On the whole it is no exaggeration to say that at the present time there is scarcely any department of medical science of which the physi- ology and pathology are so well understood, or the results of treatment so gratifying as is the case with the larynx. A word more in regard to the exposition and division of our subject may not be out of place. 188 VON ZIEMSSEN.—DISEASES OF THE LARYNX. In view of the fact that the modern methods of physical examination of the upper air-passages, and the methods of local treatment based thereon, have not yet become naturalized in medical practice to such an extent as to be generally well known, and their importance sufficiently appreciated, we have determined, in the consideration of these organs, to depart from the usual method, and to devote a separate chapter to their phy- sical diagnosis and general therapeutics ; a plan which we have no doubt will commend itself to the approval of the reader. A strict adherence to logical order is, in our opinion, inappropriate in a work which is designed to give a clear picture of the inces- sant commotion of clinical science. If the picture is to be drawn correctly, those questions, with which the scientific industry of the time is especially busied, should receive particular attention, and should be assigned a prominent position corresponding to their scientific and practical importance. DISEASES OF THE MUCOUS MEMBRANE OF THE LARYNX. ANiEMIA, HYPEREMIA, HEMORRHAGE, AND ABNORMAL COLOR OF TIIE LARYNGEAL MUCOUS MEMBRANE. Anemia. Etiology and Symptomatology.—In chlorosis, and after loss of blood, typhus, and other severe diseases, the mucous mem- brane of the larynx naturally takes part in the general ansemia. But besides this, a purely local ansemia, which it is difficult to explain, may occur at the outset of pulmonary consumption, and, as.Tobold1 and myself have noticed, in perfectly healthy individuals of ruddy appearance, especially females. The ner- vous symptoms, pain in the larynx, tickling, inclination to cough, convulsive cough, and sensitiveness to changes of tem- perature, which generally accompany this local ansemia of the larynx, are regarded by Tobold as due to the same cause as the ansemia, viz., a local derangement of nutrition. My own obser- vations have convinced me, however, that the neurotic-hysterical disturbance occurs first, and that upon these anomalies of sen- sibility—hyperesthesia, parsesthesia, and ansesthesia—there su- pervene vaso-motor derangements, which may manifest them- selves in the form of vascular spasm and ischsemia (see infra the article on Derangements of Sensibility). The epiglottis never presents the high degree of ansemia which is seen in the rest of the laryngeal mucous membrane. 1 Lehrbuch, S. 141. 190 VON ZIEMSSEN.—DISEASES OF THE LARYNX. Hyperemia. Etiology.—Fluxionary hypersemia occurs either in a diffuse, or in a partial form, and generally as a result of mechanical irri- tation of the laryngeal mucous membrane ; as for instance from long-continued loud speaking or singing, but in a higher degree from foreign bodies, such as particles of food, sand, or hard, sharp bodies, which have entered the orifice of the larynx. When acrid or sharp foreign substances of small size become impacted in these parts, as for instance in the ventriculus Morgagni, and are not quickly removed, the hypersemia increases rapidly to the highest degrees of inflammation with copious infiltration of the mucous and submucous tissues (see the section on Foreign Bodies and (Edema of the Larynx). Hypersemia may also be produced by chemical and thermal influences (acrid vapors, hot drinks, etc.). Passive hypersemia of an acute character may be produced by severe paroxysms of coughing, for example in pertussis, and in such cases may even lead to the rupture of blood-vessels. Chronic venous hypersemia is met with in valvular affections of the heart as a result of congestion in the general venous circula- tion ; also in emphysema of the lungs, etc. The anatomical changes are shown tolerably well by the laryngoscope. The injection of the mucous membrane varies with the intensity, quality, and duration of the irritation, and may be moderate or severe, diffuse or partial. The favorite situations for partial hypersemias are the vocal processes, the capitula of Santorini, and the inter-arytenoid region. In pas- sive hypersemia the color is rather livid, and the veins, especi- ally on the epiglottis, are considerably dilated. Hypersemia passes imperceptibly into catarrhal inflamma- tion, and it is impossible to draw a sharp anatomical or clinical distinction between the two conditions. Besides the lesions revealed by the laryngoscope, the symp- toms of hypersemia consist of more or less hoarseness, dryness, and slight pricking pains in the larynx. If the irritation cease, and proper rest be given to the part, these symptoms may dis- appear after a few hours, with the secretion of a little mucus; LARYNGEAL HEMORRHAGE. 191 but if the irritation be frequently repeated, and rest be disre- garded, all the signs of laryngeal catarrh are developed. Hemorrhage of the Mucous Membrane of the Larynx. Etiology.—Hemorrhages upon the free surface of the mucous membrane naturally occur most readily from solutions of con- tinuity ; also from wounds and contusions of the larynx, and from ulcerations of the mucous membrane. In the absence of such lesions a capillary hemorrhage may be induced by a very active inflammation,—such cases have been described by Semel- eder,1 Navratil," Tobold,3 Fraenkel,4 and Mandl,6—or rupture of the vessels may be produced by an intense venous stasis, as not infrequently happens in whooping-cough. I Symptoms and Course.—The laryngeal hemorrhages, which are not of traumatic origin, are generally unimportant. The blood extravasated into the tissue of the mucous membrane and upon its surface is slight in amount; it generally appears only in the form of streaks upon the catarrhal secretion, and soon disappears. In most cases the laryngoscope reveals only a small bleeding point. In Navratil's case, the vocal cord was covered with a dark-brown layer of blood, which re-formed several times after being wiped off. The mucous mem- brane underneath was swollen and injected. Similar to this—only more extensive, and present also in the trachea—was the hemorrhage in the case of laryngitis hemorrhagica reported by B. Fraenkel. Here also the amount of blood was small, the color dark-brownish, almost blackish, and the consistence that of a viscous crust. Previous to the hemorrhage the patient had suffered from catarrhal laryngitis, and this had become much worse in consequence of the very stormy weather and the frequent vomiting due to pregnancy. Tobold also reports two cases of hemorrhage from catarrhal laryngitis; in one instance the blood came from the border of the epiglottis, in the other from the right vocal cord. Mandl observed a hemorrhage from one of the ventricles of Morgagni. 1 Laryngoskopie, 1863. 5 Laryngologische Beitrage. Leipzig, 1871, S. 18. 3 Lehrbuch, S. 143. 4 Berliner klinische Wochenschrift, 1874, No. 2. 6 Maladies du larynx, p. 644. 192 VON ZIEMSSEN.—DISEASES OF THE LARYNX. Severe hemorrhage has hitherto been observed only in rare cases. Tiirck * describes a case of laryngeal syphilis in which fatal hemorrhage oc- curred from an eroded lingual artery, in consequence of an ulceration of the right sinus pyriformis with denudation and necrosis of the great cornu of the hyoid bone. onsiderable hemorrhages into the submucous connective tissue—if we except those cases where the larjmx has been wounded by cuts, stabs, shot, etc., as inappropriate to our sub- ject—are just as rare as severe hemorrhages upon the surface of the mucous membrane. Cases of this nature are described by Bogros2 and Pfeufer.3 In Bogros' case symptoms of oedema of the larynx suddenly occurred in a patient, twenty-two years of age, ill with variola hsemorrhagica. The autopsy revealed infiltration of the ary-epiglottidean folds from blood, and not from oedema. In Pfeufer's case, the patient, forty-five years of age, who had incurred mercu- rial stomatitis from using inunction with mercurial ointment as a parasiticide, became ill with cough and symptoms of laryngeal stenosis, as was supposed from exposure to cold, and five hours afterwards died from suffocation. The autopsy showed a submucous extravasation of blood beneath the right ventricle of Mor- gagni, from one to three lines in thickness and a square inch in extent, and at the corresponding part on the left side a superficial extravasation. Hemorrhagic infiltrations of this kind have, according to Ruehle,4 been observed also in scorbutic conditions. According to these observations, the symptoms of hemor- rhagic infiltration of the submucous connective tissue are those of urgent laryngeal oedema, from which they are probably to be distinguished with certainty only by means of larjmgoscopical examination; although, of course, the antecedent existence of a blood-disease will make it more probable that the case is one of hemorrhagic submucous infiltration rather than oedema of the larynx. The symptoms of hemorrhage from an acutely inflamed or 1 Klinik der Kehlkopf krankheiten, S. 402. 2 In Sestier, Traite de l'angine laryngee cedemateuse. Paris, 1852, pp. 63 and 114. 8 Henle and Pfeufer's Zeitschrift fiir rat. Medicin, Neue Folge., Bd. III. 4 Kehlkopf krankheiten, S. 172. CYANOSIS AND ICTERUS. 193 ulcerating mucous membrane are, on the other hand, usually very unimportant, and are limited to the occurrence of streaks of blood in the expectoration, and the lesions discovered by the laryngoscope. Still, the case of B. Fraenkel, referred to above, shows that even with superficial hemorrhage of the mucous membrane quite alarming attacks of stenosis of the glottis may occur, and may disappear upon expectoration of solid coagula of blood. The prognosis, like the diagnosis, depends essentially upon the intensity and duration of the stenosis, as well as upon the laryngoscopical condition. In the trifling hemorrhages which occur in laryngitis and ulcerations, the treatment may be limited to the local use of styptics (alum, liquor ferri perchloridi, etc., and, if necessary, the external and internal application of ice), measures which are generally found to be sufficient, while in hemorrhagic infiltra- tions of the submucous tissue experience has shown that trache- otomy is the main reliance as soon as symptoms of stenosis of the glottis manifest themselves (see infra the sections on Laryn- gitis Hsemorrhagica and (Edema Laryngis). Abnormal Color of the Mucous Membrane. Two varieties only will be here considered : 1. Cyanosis of the mucous membrane of the larynx, with a general bluish lustre, and development of numerous varicosities, a condition which was first recognized by Gerhardt in emphy- sema of the lungs, and which I have seen in an exquisite degree in patients with congenital cyanosis. 2. Icterus of the mucous membrane of the larynx. I have repeatedly seen this even in moderate jaundice, and to a very marked degree where the jaundice has been intense. The white color of the vocal cords enables us to estimate the amount of icteric color, just as in the case of the sclerotic, but the observa- tion, to be satisfactory, must be made by sunlight, because in artificial light even a high degree of yellow color may be entirely overlooked. VOL. rv.—13 194 VON ZIEMSSEN.—DISEASES OF THE LARYNX. INFLAMMATIONS OF THE MUCOUS MEMBRANE OF THE LARYNX. Bretonneau, Des inflammations speciales du tissu muquex. Paris, 1826.—Guersant, Dictionnaire des sciences medicales, Art. " Croup."—Piedvache, Revue de The- rapeut. medic.-chirurg., 1857, Nos. 6-8.—Kerli, Deutsche Klinik, 1858, Nos. 5-7.—Gilewski, Wiener med. Wochenschrift, 1861, Nos. 39 u. 40.—Lewin, Vir- chow's Archiv, Bd. 24, S. 429, 1862.—#"^ Salter, Brit. Med. Journ., Sept. 13, 1862.— Ruhle, Kehlkopfkrankheiten, S. 41 ft.—Tiirck, Klinik der Kehlkopf- krankheiten, 1866, S. 145.—Gerhardt, Kinderkrankheiten, 11. Auft, S. 257, und Wiirzburger med. Zeitung, 1862, S. 10.—Sherwood, Acute Laryngitis, treated by Nitrate of Silver Injections into the Larynx and Trachea, New York Med. Journal, June, 1868.—Cordes, Die Recidive der chron. Laryngotracheitis, Berliner klinische Wochenschrift, 1870, 2, S. 19.—M. Mackenzie, On the Differ- ential Diagnosis of Chronic Inflammations of the Larynx, Lancet, 1872, Jan. 6.—Lefferts, A New Instrument for the Insufflation of Powders into the Larynx. Med. Record, Nov. 15, 1873.—Burow, Laryngologische Mittheilungen, v. Lan- genbeck's Archiv fiir Chirurgie XVIII., 228 ff., 1875.—Robinson, A Case of Chronic Laryngitis, American Journal of the Medical Sciences, October, 1875. The bibliography of croup is prefixed to the article on that disease. LARYNGITIS CATARRHALIS ACUTA. ACUTE CATARRH OF THE LARYNX. Etiology. The causes of acute catarrh of the larynx are very numerous, but none of them is so frequently effective as catching cold.1 This is particularly the case in persons who are predisposed to catarrhal inflammations of the air-passages, and especially of the larynx. Such a predisposition is, of course, most apt to exist 1 In regard to the nature of the process " catching cold," see the explanation by Seitz, in his article On Certain Slight Disorders Occasioned by Catching Cold, in a later volume of this Cyclopaedia. ACUTE CATARRH. 195 in persons who have had frequent attacks of laryngitis, and whose laryngeal mucous membrane has consequently become a locus minoris resistentie. In sensitive individuals this irrita- bility of the mucous membrane frequently dates from the earli- est youth, and owes its origin to an attack of croup, or whoop- ing-cough, or to the remains of an obstinate scrofulous affection of the mucous membrane. The predisposition is increased by the habitual straining of the vocal organs, to which teachers, preachers, singers, and other professional persons are exposed; by delicacy of the skin, and a tendency to perspire ; by wearing an excess of clothing so that the secretion of sweat is promoted ; and especially by the habit, induced by professional ardor, of neglecting slight catarrhs. Frequently, however, no explana- tion can be given for the tendency to laryngeal and tracheo- bronchial catarrh. In many persons a primary catarrh of the nasal mucous membrane always extends to the throat, larynx, and trachea, while in most men it remains limited to the nose. The cold seems to originate sometimes in the skin immediately adjacent to the larynx, and at other times in distant parts of the skin. Thus, the laryngeal catarrh may be produced by leaving off a customary neckerchief, or by having the hair cut, as well as by getting the feet chilled and wet. Catarrh may be excited also by all those injurious influences which have been mentioned as etiological factors of hypersemia, when their action is more intense and longer continued, or when they attack a membrane already congested ; such as mechanical irritations from prolonged loud speaking or singing, from foreign bodies—if they be not immediately removed ; also from thermal influences, such as rude changes in the temperature of the respired air, too hot drinks, etc. ; as well as from chemical sub- stances, especially strong alcoholics, spices, particles of tobacco snuff which have passed into the larynx, and acrid gases and vapors, such as iodine, bromine, chlorine, etc. The certainty of laryngitis being produced by these deleterious agents is all the greater when several of them co-operate in their action upon an already predisposed laryngeal mucous membrane, as is the case with loquacious frequenters of public-houses, who carry their drinking, talking, and singing to excess, and after leaving the 196 VON ZIEMSSEN.—DISEASES OF THE LARYNX. heated room, filled with tobacco smoke, often expose themselves for a long time to the cold night air. Certain atmospheric influences also undoubtedly produce catarrh. In the spring and autumn, catarrh of the larynx, as well as of the rest of the respiratory passages, not infrequently prevails endemically. In general, rude changes in the tempera- ture and moisture of the air, as well as sudden shifting in the direction of the wind, are regarded as the most important causes. In the case of the catarrhal fever known as the influenza or grippe, which occurs epidemically, and implicates the laryngeal mucous membrane, it is necessary to assume the existence of a specific irritant or infective matter, although the intimate nature of this substance is still concealed from us (see article on Influenza, Vol. II., p. 515 et seq.). The laryngeal catarrh, which is developed in summer catarrh or hay cold, has been shown by the investigations of Blackley,' to depend solely upon the action of the pollen of certain flowering grasses and meadow herbs (see article on Hay Fever, in Vol. II., p. 539 et seq.). Acute laryngitis very commonly occurs also in connection with many infective diseases, especially measles, and, less fre- quently, scarlatina, small-pox, and typhoid fever. Finally, it may be also mentioned that the local treatment of the laryngeal mucous membrane with caustics or strong astrin- gents, on account of small neoplasms, ulcerations, etc., some- times excites a very active laryngitis, although, of course, in most persons the reaction to such treatment is inconsiderable, and disappears after a few days. PATHOLOGY. General Description of the Disease. The general character of the disease varies extremely accord- ing to the severity and extent of the inflammatory process, as well as according to the age of the patient and the susceptibility of the larynx. 1 Charles Blackley, Experim. Researches on the Causes and Nature of Catarrhus 33stivus (Hay Fever, Hay Asthma). London, 1873. ACUTE CATARRH. 197 A. In the mildest cases the only symptoms are slight irrita- tion and tickling in the larynx, a trifling impairment of the voice, increasing to hoarseness only when the voice is strained, and the secretion of a little tough mucus, which induces a frequent clear- ing of the throat. By this means the voice may, for a time, become clear again, but continuous talking is fatiguing. As there is no cough or constitutional disturbance, the patient is not pre- vented from attending to his business. Inspection reveals a rosy injection of some portions of the mucous membrane, especially the posterior ends of the vocal cords, where they terminate in the vocal processes, the mucous membrane covering the inter-arytenoid region, the arytenoid cartilages and the ventricular bands.1 The anterior parts of the vocal cords are either perfectly normal in appearance, or are stained of a faint rosy hue. With proper care, especially in regard to sparing the voice, this form of the disease is recoved from in a few days, while neglect, constant talking, fresh colds, etc., develop it into a more serious affection. B. In moderately severe cases—whether they have assumed this form from the start or have developed out of the milder variety in consequence of new exposures—the functional distur- bance is more considerable ; indeed in small children it may even be dangerous. The hoarseness becomes more marked, and may increase to aphonia. The patient experiences a burning pain, itching, or dryness in the larynx, and an inclination to clear the throat without being able to raise any considerable amount of mucus, and without the voice becoming any clearer. External pressure upon the sides of the larynx, or pressure backwards against the spine, is sometimes accompanied by painful sensa- tions. The laryngoscopical examination shows that the mucous membrane, especially upon the ventricular bands, is much congested and swollen ; the vocal cords, which are thus partially 'The term "ventricular bands" (Taschenbander) is preferable to " false vocal cords," because, as Morell Mackenzie has suggested, the latter phrase "• not only per- petuates the memory of a physiological error, but makes it necessary to qualify the real vocal cords by the term ' true.' "—Translator. 198 YON ZIEMSSEN.—DISEASES OF TIIE LARYNX. concealed from view, have a slender appearance and a rosy hue, with here and there darker islands of injection or ecchymosis. The mucous membrane between and upon the arytenoid carti- lages, upon the epiglottis, and in the trachea, together with that of the ary-epiglottidean folds, is much swollen, and is sometimes of a uniform dark color, sometimes of a spotted redness, and occasionally its surface has a faint grayish hue, as if it had been brushed over with a solution of nitrate of silver (Tiirck), an appearance which is probably wholly due to cloudiness of the epithelium. In adults dyspnoea does not occur, because, notwithstanding the considerable swelling of the mucous membrane on the ven- tricular bands, the inter-arytenoid region, etc., the width of the glottis is amply sufficient for respiratory purposes. In children, however, even these moderate inflammations of the laryngeal mucous membrane may, although only tempora- rih', produce symptoms of the most severe inspiratory stenosis of the glottis. It was on account of these peculiarities of catarrhal laryngitis in young children, peculiarities which are dependent upon the anatomical and physiological relations of the larynx in childhood, that Guersant proposed for this variety of laryngeal catarrh the name Pseudo- Croup, which has also been adopted by most recent writers, Bouchut, Friedreich, Ruehle, Duchek, etc.1 The paroxysmal occurrence of laryngeal stenosis at night, while during the day the symptoms are merely those of laryn- geal catarrh, is characteristic. The first attack usually occurs suddenly on the second or third night after the patient has mani- fested the usual signs of a cold, such as cough and nasal catarrh. 1 I am willing to admit that the introduction of a name, which has only a semeiotic, or rather only a differential, diagnostic value, is opposed to the simplification of medical nomenclature ; nor is there any reason why here, as in all cases where it is possible, we should not be governed by the anatomical principle of classification. The other names recommended by former writers, such as laryngitis spasmodica (Barthez and Rilliet), laryngitis and angina stridula (Bretonneau), asthma acutum (Millar), and asthma Mil- lari (Wichmann) might better be committed to oblivion, in order to put an end to the constantly recurring confusion. ACUTE CATARRH. 199 The child awakes from sleep with a sense of suffocation, loud stridor in inspiration, a dull, barking, dry cough, alternating with a doleful cry, the voice hoarse and toneless, active move- ments of the accessory muscles of respiration, inspiratory sink- ing inwards of the epigastrium and false ribs, slight cyanosis, great restlessness, and anxiety. Examination of the throat shows the presence of simple catarrh without any croupous- diphtheritic membrane. The temperature is either normal or only slightly elevated. With proper treatment the attack of laryngeal stenosis gener- ally lasts but a few hours ; the stridor gradually diminishes, and with it the dyspnoea; the breathing becomes more quiet; moist rales make their appearance in the chest; the patient perspires, and passes water more abundantly ; and the drowsiness soon passes into a quiet slumber, interrupted from time to time only by a hoarse barking cough, which alarms the parents anew. On the following morning the child is usually almost entirely well, and presents no symptoms except simple catarrh and slight hoarseness. In many cases the attack is not repeated; but not infrequently it returns the next night, without the course of the disease being thereby rendered more unfavorable. The so-called attacks of croup are very apt to recur with every acute catarrh of the upper respiratory passages, and it is not uncommon to find children who are said by their parents to have had "croup" half-a-dozen times. It is hardly necessary to say that in all such cases the affec- tion was merely catarrhal, since recurrences of true croup are extremely rare. These attacks are merely an evidence of un- usual vulnerability of the respiratory mucous membrane in chil- dren who have an hereditary predisposition to scrofula and phthisis, or who have been reared effeminately, and such attacks are therefore to be regarded as important indications for subse- quent medical treatment. C. The severest form of catarrhal laryngitis, which even in adults may induce symptoms of stenosis of the glottis and death, is very rare. The intensity of the process may manifest itself in several ways : 1. As very acute laryngitis terminating in edema of the 200 VON ZIEMSSEN.—DISEASES OF THE LARYNX. larynx. The rapidity and the great amount of swelling of the macous membrane, together with the inflammatory oedema of the submucous connective tissue, produce a serious obstruction to the entrance of air. Under the influence of a fresh exposure to cold, a wetting of the perspiring skin, or some other cause, a laryngeal catarrh, which at the outset is of a simple character, becomes aggravated, with a rapid increase of the catarrhal symptoms, burning pain in the larynx, dysphagia, etc., to the development of severe steno- sis of the glottis, so that within a few hours life is seriously endangered, and death from asphyxia ensues if relief be not speedily afforded. As long ago as Morgagni,' cases of this kind were described by him with the words, "Ingens ab hoc morbo periculum, utpote paucis nonnunquam horis hominem jugular," Porter (1. c), Ruehle (1. c, S. 50 et seq.), and Tobold (1. c, S. 101) men- tion cases of acute laryngeal catarrh which proved rapidly fatal by suffocation from oedema glottidis setting in at night, or even in the daytime; other cases are also recorded in which the fatal result was prevented only by energetic antiphlogistic treatment or by tracheotomy, as in Nos. 3 and 4 of Tobold's cases. 2. As laryngitis hemorrhagica. The injection of the swollen mucous membrane is moderate in amount, and results either in extravasation of blood upon the free surface, with temporary amelioration of the symptoms of stenosis of the glottis, or in hemorrhagic infiltration of the mucous membrane and sub- mucous connective tissue. These cases are extremely rare. Reference has already been made in the section on laryngeal hemorrhage, p. 191, to the few cases of this kind on record. It may, however, be mentioned here once more, that the symptoms of laryngitis ha3morrhagica may be so insignificant as to make a diagnosis possible only by a laryngoscopical examination in connection with the presence of streaks of blood attached to the expectorated mucus; also that alarming stenosis may be pro- duced either by the formation of a tolerably firm clot on the surface of the vocal cords—which is especially apt to happen when the extravasation is very gradual and occurs during the night—or by a considerable tumefaction of the soft parts from 1 De sedibus et causis morborum, Epist. XVIII. ACUTE CATARRH. 201 hemorrhagic infiltration of the mucous and submucous tissues, giving rise to all the symptoms and results of cedema glottidis. The diagnosis will depend mainly upon the inspection ; and when this is impossible, upon the presence of blood in the expectoration, and the decline of the symptoms of stenosis con- currently with the extravasation of blood. 3. As laryngitis exanthematica, or laryngitis secondary to the acute eruptive diseases. This form is very often met with during the course of acute infective diseases, especially the exanthemata. It is most common in measles, in which laryn- gitis is rarely entirely absent; but it also occurs in small-pox, typltus, and typhoid fevers, scarlatina, and erys'vpelas. In these diseases the laryngitis usually presents a catarrhal char- acter ; but the croupous-diphtheritic form of inflammation is by no means rare, especially in measles. In some epidemics of measles I have seen the laryngeal affection much more frequent and severe than in others; in such cases delicate diphtheritic exudations upon the mucous membrane, and secondary super- ficial ulcerations have been comparatively common. Hitherto a true eruption upon the mucous membrane has been noticed only in small-pox, in which genuine variolous pustules and ulcera- tions may occasionally form, and extend from the throat to the larynx (Tiirck). I have made an autopsy upon one such case. In measles a deep uniform redness of the mucous membrane of the laryngeal mucous membrane, with a yellow-reddish color of the vocal cords, has been observed with the laryngoscope by Stoffella,1 and repeatedly also by myself. Whether the redness begins in a spotted form—as many authors suppose—or as a diffuse injection, cannot be determined in most cases. The symptoms of stenosis in the simple laryngitis of measles are frequently by no means inconsiderable, and if superficial diph- theritic exudations take place, quite common. Still the stenosis rarely reaches such a height as to require laryngo-tracheotomy; at least in some twenty cases of laryngeal diphtheria from measles I have never found the operation necessary. In erysipelas, especially when it affects the head, laryngeal 1 Wochenblatt d. Ges. d. Wiener Aerzte, 1862, S. 154. 202 VON ZIEMSSEN.—DISEASES OF THE LARYNX. catarrh is not uncommon. This complication has been spoken of by English physicians, who have paid particular attention to this question (Gibson, Ryland, Gibb, Hinckes, Bird), as being very frequent, and as generally preceding the outbreaks of the erysipelas (sixty per cent, according to Bird). The catarrh starts from the throat, and extends thence to the larynx. There is nothing peculiar about the complication, except that not very infrequently the ary-epiglottidean folds become slightly cedema- tous. In this way a rapidly increasing stenosis may be devel- oped, which may prove fatal within a few hours ; but there are very few recorded cases of the kind. Among several hundred cases of erysipelas of the face and head I have not seen a single instance in which the laryngeal stenosis was at all alarming. In the chapter on (Edema of the Larynx will be found a description of a mild case of oedema occurring during erysipelas under the observation of Tiirck. Laryngeal catarrh is a frequent complication also in both typhus and typhoid fevers. In the latter it is not uncommonly accompanied or followed by more or less deep ulcerations, and by perichondritis with laryngeal oedema, which runs its course with extreme rapidity; while in typhus it is rare for a simple inflammation of the mucous membrane to result in oedema. Moreover, the frequency of laryngeal affections in typhoid fever has been very much diminished by the modern antipyretic treat- ment, showing that the vulnerability of the laryngeal mucous membrane is chiefly owing to the fever, and that the typhoid ulcerations on the posterior commissure are pathogenetically allied to bed-sores. Analysis of Individual Symptoms. The derangement of vocalization, which in slight cases is the most noticeable symptom, varies, according to its anatomical cause, from a simple huskiness or veiling of the voice to com- plete aphonia. Not infrequently the voice, without losing its force, acquires an abnormal timbre, or an abnormally low or high pitch. These functional disturbances are produced by a variety of ACUTE CATARRH. 203 Fig. 1. Gaping of the Glottis in Phona- tion, from Incomplete Tension. Acute Laryngitis. acoustic conditions. A common cause, and one to which Ger- hardt was the first to call attention, is that during phonation the inter-arytenoid mucous membrane protrudes as a fold between the vocal processes, so as to prevent not only their proper approximation but also that of the vocal cords. This mechanical interference with the movements of the arytenoid cartilages and vocal cords is, however, rather unusual. Still less fre- quent is a considerable degree of swelling of the mucous membrane lying between the anterior points of attachment of the vocal cords. Much more commonly the hoarseness depends upon a derangement, as yet unsatisfactorily explained, in the innervation of the laryn- geal muscles, or upon an alteration in the muscular substance itself. The de- gree of hoarseness is by no means always in direct proportion to the inflammatory injection and swelling of the soft parts concerned in phonation. In many cases, besides a partial injection and swelling of the mucous membrane, there is to be noticed in phonation only a consider- able gaping of the glottis, or a slight concaveness of the borders of the vocal cords (see Figs. 1 and 2). The longitudinal (and perhaps also the transverse) tension of the vocal cords is incomplete, and probably also unequal. This hypothesis of an inequality of tension would enable us to explain the fre- quent huskiness, jarring, and shrillness of the voice, for which in so many cases no satisfac- tory cause can be discovered by the laryngo- scope ; these qualities being produced by the vibrations of unequally tense membranes. Considerable swell- ing of the ventricular bands may also be an important impedi- ment' to the free movements of the vocal cords (see Fig. 3). This swelling may be so great that the ventricular bands almost com- pletely cover the vocal cords, and approximate so nearly to each Fig. 2. Gaping of the Cartilages of the Glot- tis in Phonation. Acute Exacerba- tion of a Chronic Catarrh. Fig. 3. Swelling of the Ventricular Bands, and slight Gaping of the Glottis in Phonation. Acute Laryngitis. 204 VON ZIEMSSEN.—DISEASES OF TIIE LARYNX. other in attempts at phonation, that the vibrations produced in them by the forcible impulses of air give rise to a deep husky sound. Dyspnea is very rare in adults, and in simple laryngitis without implication of the perichondrium it occurs only in consequence of very considerable inflammatory swelling, and a simultaneous functional derangement in the action of the mus- cles which open the glottis (the posterior cricoarytenoid mus- cles). In children, the symptoms of laryngeal stenosis may occur even when the inflammation is only moderately intense. These attacks of stenosis are due partly to the relatively great amount of swelling of the mucous membrane in comparison with the narrowness of the true and false glottis, and partly to the secretion, which dries upon the parts during sleep, and increases the obstruction. The stridor is solely inspiratory, and the expi- ration takes place noiselessly. When the secretion is liquefied, and removed by the use of warm drinks or emetics, or by cough- ing, etc., the inspiratory stridor disappears rapidly, and almost entirely, and there are left only the loud bass cough and hoarse- ness. It is possible, nay probable, that in many cases the symptoms may be partly due to reflex spasms of the muscles which close the glottis ; still, the instances in which spasm of the glottis takes a prominent part are rare, and the symptoms of spastic stenosis, when they do occur, last but a very short time. The cough is usually active and of a spasmodic character. Especially in young children it often occurs in paroxysms, which resemble those of whooping-cough, and are composed of several series of forcible expirations in rapid succession, fol- lowed by stridulous inspiration. In children—less frequently in adults—the cough has often a peculiar, deep, humming tone, which, according to some laryngoscopical examinations, which I have had the opportunity of making in these patients, is pro- duced not by vibrations of the vocal cords themselves, which on account of their shortness are quite incapable of such large vibrations, even when completely relaxed, but rather by the movements of the swollen ary-epiglottidean folds, and of the arytenoid and Santorinian cartilages which are not properly fixed in position by the relaxed muscles. In adults the cough ACUTE CATARRH. 205 during the early days of the attack has an impure timbre, and, when the swelling of the vocal cords is more considerable, it becomes entirely toneless. As soon as the muco-purulent secre- tion increases in quantity the cough becomes moist, and has the ring of a cough that is loosening, in consequence of the vibra- tions of the masses of mucus. The secretion of the mucous membrane is at first very scanty, almost entirely mucous, clear, transparent, watery, and deficient in mucus cells. It contains a few formed epithelial cells, and sometimes red blood-corpuscles. Not infrequently blood may be seen by the naked eye in the form of small streaks. The amount of secretion is often so small that no sputum can be obtained for examination. After a few days the secretion be- comes more abundant and consistent, and more yellow from the increasing number of pus-cells. In general its quantity is incon- siderable in consequence of the small extent of surface affected by the catarrh. Dysphagia occurs only when the epiglottis and the posterior surfaces of the arytenoid cartilages and ary-epiglottidean folds are considerably implicated in the inflammation. The 'amount of pain and disagreeable feeling of dryness, or irritation, as if from a foreign body, varies considerably, being sometimes very slight even when the inflammatory symptoms are quite severe, and in other persons very annoying, although the inflammation is but trifling. As Tobold suggests, the greater or less sensitiveness of the individual has undoubtedly much to do with this difference. The general malaise also varies much in different individuals. While nervous sensitive persons are much alarmed, and have to keep to then rooms and to their beds, we often see those who are more robust attending to all the details of their business. Moreover, the pain appears to be produced, not so much by the direct contact of food with the inflamed parts, as by the mechanism of the closure of the glottis in the act of deglutition, that is, by the firm pressure of the under surface of the epiglot- tis, especially of the cushion (tubercle) of the epiglottis, upon the inflamed mucous membrane of the upper aperture of the larynx (Semeleder). 206 VON ZIEMSSEN.—DISEASES OF THE LARYNX. Diagnosis. The diagnosis of acute laryngitis, as a rule, presents no diffi- culties. The history of the case, the subjective and objective symptoms, and especially the changes discoverable by laryngo- scopical examination, usually make a certain and exhaustive diag- nosis practicable from the outset. In many cases, to be sure, the diagnosis of acute catarrh of the larynx may be made with- out the laryngoscope, but such a diagnosis cannot be exhaustive. The special localization of the inflammatory changes, as well as the rarer sequelae and complications, such as muscular pareses, ulcerations, small neoplasms, and cedemas, cannot be recognized without a laryngoscopical examination. I cannot, therefore, too urgently recommend that, as a matter of principle, every laryn- geal affection, even those which appear to be the most trifling, should be followed up laryngoscopically. Only by observing this rule can we obtain an insight into the great variety of lesions, which enter into the picture of a disease apparently so simple as acute laryngeal catarrh, and only in this way can we obtain certain and speedy curative results. In childhood the awkwardness, and frequently, also, the obstinate resistance of the little patient, and the excessive sym- pathetic tenderness of the mother, render the diagnosis more diffi- cult ; but with sufficient practice, dexterity, and patience, one can very often succeed, even in young children, in obtaining a full view of the changes in the larynx. Such, at least, has been my own experience in many instances,1 and it is confirmed by the recent reports of Klemm.5 Laryngoscopy is especially serviceable in the differential diagnosis between pseudo-croup and true croup. I have re- peatedly succeeded in making the diagnosis at once by inspec- tion with the mirror—a point of very great importance in obscure cases, in reference to the prognosis and treatment, and especially for the purpose of quieting the fears of the parents. 1 See Ziemssen: "Ein laryngoskopirter Croupfall," Greifswalder medic. Beitrage, Bd. II., S. 123, 1864. 2 Klemm, Laryngologisches aus der Kinderpraxis, Jahrbuch fiir Kinderheilkunde, N. F., Bd. VIII., S. 360 et seq. ACUTE CATARRH. 207 When the inflammatory stenosis has made rapid progress, an accurate diagnosis is difficult, and, in fact, often impossible, on account of the urgent dyspnoea interfering with the la^ngo- scopical examination. In this case the question must be de- cided by the history of the case, the subjective and objective symptoms, and especially by digital exploration of the entrance to the larynx for oedema or foreign bodies. Course, Duration, Results, and Prognosis. The course of acute laryngitis under proper treatment is fav- orable and rapid. Its duration extends in the mildest forms from five to eight days ; in the moderately severe, from eight to fourteen days ; and in the most severe, from two to three weeks or longer. Under injudicious treatment, especially if the vocal organs be not spared, and the patient contract fresh colds, or be exposed to other injurious influences, the disease may last for a much longer time and assume the character of a chronic laryn- geal catarrh. In children with a vulnerable laryngeal mucous membrane—whether the disposition to respiratory affections be transmitted from phthisical parents, or be acquired in conse- quence of effeminate rearing—even the mildest catarrhs of the larynx frequently take on the form of pseudo-croup, but they almost always terminate favorably. A fatal result in pseudo- croup is extremely rare. It must be borne in mind, also, that a simple catarrhal laryn- gitis may be converted into the croupous-diphtheritic form in otherwise healthy children, and in patients with measles or small-pox : this possibility of course materially affects the prog- nosis. In the severest form of inflammation its termination in oedema of the larynx is to be inferred, if symptoms of stenosis of the glottis supervene upon those of a simple catarrh, and if the asphyxia reach a dangerous height in the course of a few hours. The prognosis in such cases depends essentially upon the efficiency and promptness of the treatment, and especially upon the employment of tracheotomy. 208 VON ZIEMSSEN.—DISEASES OF THE LARYNX. Treatment. Both in adults and children, when there is a marked predis- position to catarrhs, the prophylaxis against acute laryngeal catarrh becomes a matter of importance. Above all, care should be taken to diminish the sensitiveness of the respiratory mucous membrane, as well as that of the skin, to the influences of the weather, and this all the more because the frequent recurrence of catarrhs leads to an excessive timidity and caution in regard to clothing and enjoyment of fresh air. In such cases it is well to have the whole body rubbed every morning with a large sheet, which has been previously dipped in cold water, and carefully wrung out. As the patient gets out of bed his night linen is removed, and the sheet, which is held spread out, is thrown around him from behind so as to cover the head, but not the face, and the whole body down to the feet. A gentle rapid friction of the skin by rubbing with the sheet will diminish the unpleasant impression from the cold moisture. After one or two minutes of this friction the wet sheet is removed, a warm dry one is thrown about the body in the same way, and the body is dried. The patient then puts on his clothes, and immediately takes out-door exercise, whatever the weather. If the skin be very delicate I modify the treatment by at first giving the water, into which the sheet is dipped, a lukewarm temperature (about 86° F.), and then lowering the temperature two degrees daily until it reaches that of spring water (50° to 56°). This treatment I have adopted for several years, with the best results for children as well as adults, and the patients never catch cold, if the rubbing be done in a warm room with the feet resting upon a woollen rug. After using this treatment for eight days the patient may be allowed to wear less clothing. During the winter he may continue to use a fine woollen underjacket, notwithstanding the frictions, but in the spring this garment must by all means be discarded, and about this time the cold frictions are to be resumed—if they are not employed both winter and summer, as is advisable in the case of children. In the course of the summer it is very desirable that the ACUTE CATARRH. 209 patient should spend five or six weeks at the sea-side in order to obtain the hardening effects of sea-bathing. This plan should, however, be preceded by a course of friction treatment at home, so that the bathing and out-door exercise may be resorted to immediately without restriction and without anxiety on the part of the relatives. The moisture and motion of the air on the sea- coast not only diminish the sensitiveness of the skin and respira- tory mucous membrane, and enable the patient to remain out of doors all day without the danger of catching cold, but, in con- nection with the bathing, they also aid the general health by improving the appetite and increasing the metamorphic changes in the body. If sea-bathing be impracticable, tepid salt-water baths (77° to 88°) of from ten to fifteen minutes' duration, with gentle friction, may be recommended. It is important also to avoid wearing very thick neck-ker- chiefs at night, or thick shawls by day. Persons who are obliged by their occupations to talk or sing much, and in a loud tone, as, for instance, teachers, clergymen, and vocalists, should be urgently advised to spare their vocal organs as much as possible during the practice of their profes- sions, and also to abstain entirely from speaking or singing for a certain length of time during the year. Many vocalists would be able to preserve their voices longer, if, during their vacation, they rested the larynx, instead of straining it excessively by being obliged to entertain their hosts. Treatment of laryngitis during the attack. Among the injurious influences whose prevention is the first condition for the treatment of laryngitis, those of a mechanical and atmos- pheric-thermal character occupy the first rank. In particular the detrimental effect of the mechanical irritation of the glottis and the neighboring parts induced by talking has been much underestimated. The more the vocalizing power of the vocal cords is diminished by the swelling of the mucous membrane and by the other anatomical changes previously mentioned, and the louder the tone which the catarrh renders necessary, the more considerable become the compression and irritation of the mucous membrane, because an excessive action of some of the VOL. IV—14 210 VON ZIEMSSEN.—DISEASES OF THE LARYNX. laryngeal muscles is required to compensate for the mechanical impediments. Any one who has had much experience with laryngeal disease can often, during the course of treatment of a laryngeal catarrh, at once discover by the mirror that the patient has the day before strained his vocal organs, and it is my con- viction that some of the paralyses of the vocal cords are due solely to this cause. Moreover, the mechanical irritation of the mucous membrane thus induced favors not only the aggravation of the catarrh and the production of muscular pareses and paralyses, but also the chronicity of the catarrh and the development of local prolifera- tions upon the mucous membrane, however judicious the treat- ment in other respects. The prohibition of all talking and sing- ing cannot be too urgently insisted upon, nor carried out with too much strictness. When the catarrh is accompanied by high fever the inju- rious influences of changes in the temperature of the air should be avoided by keeping the patient in bed, and by maintaining a uniform temperature in the room (63° to 66° F.). In the milder cases the patient should at least keep to his room in unfavorable weather. When fever is present, and the mucous membrane of the nose, throat, trachea, and bronchi are also affected, mild diapho- retic treatment is advisable, such as elderberry tea, or an infu- sion of jaborandi, six drachms to the pint. Wadding or a Preissnitz compress may be used around the neck. There is generally no occasion for any special antiphlo- gistic treatment. For the relief of the irritable cough and the uncomfortable feeling of dryness in the throat, an infusion of marsh-mallow or expectorant herbs, warm sugar and water, or hot milk and Selters water in equal parts are generally sufficient. Small doses of morphine have also an excellent effect, as one-thirtieth of a grain of muriate of morphia given every hour or two in a mixture of the emulsion and the syrup of almonds. For chil- dren the dose is to be correspondingly diminished. Very happy results are also to be obtained by spraying the throat several times daily with a solution of morphine in bitter ACUTE CATARRH. 211 almond water, or with a solution of bromide of potassium, twenty grains to the ounce, or of chloride of sodium, twenty-five grains to the ounce, for the purpose of liquefying the tough secretion and relieving the feeling of dryness and irritation. As the case progresses expectorants may be used, such as muriate of ammonia, water of ammonia, or, if necessary, nar- cotics in small doses, as one-fortieth of a grain of muriate of morphia every three hours in a mixture containing liquorice and spirit of ammonia. This treatment is sufficient in most of the mild and mode- rately severe cases of idiopathic laryngitis, and also in the catarrhs which accompany measles and other infective diseases. In severe cases antiphlogistic treatment may be necessary in the form of cold compresses, an ice bag about the neck, or the frequent swallowing of ice-water or pieces of ice. Leeches to the larynx in adults, or to the manubrium sterni in children, are generally undesirable. If cold water cannot be borne, poultices may be used, or hot-water compresses (Ruehle), or large sponges dipped in hot-water. To prevent evaporation and rapid cooling these applications should be covered with rubber cloth. The treatment of acute laryngitis by strong counter-irritants, especially by the blisters, which are highly recommended by French and Russian writers, has met with no approval in Ger- many. The rapid counter-irritation from mustard plasters is, however, unobjectionable. For the direct local treatment of the mucous membrane solutions of morphine, bromide of potassium, or chloride of sodium may be used by inhalation, as previously recommended, or the parts may be painted with the wine or tincture of opium, or with a solution of morphine, bromide of potassium, etc. Astringents (nitrate of silver, tannin, alum) are unadvisable in the acute stage ; still more objectionable is the attempt to abort the disease by local applications of strong solutions of nitrate of silver, etc. Internally, narcotics in mucilaginous vehicles are to be pre- ferred. Very happy results are also often obtained—and on this point I agree entirely with Ruehle—by derivation to the intestines, especially in full-blooded adults, by means of castor- 212 VON ZIEMSSEN.—DISEASES OF THE LARYNX. oil, croton-oil, the confection of senna, or "bitter water.'' In children caution is necessary, and as a rule calomel is to be preferred. If paresis of the muscles is developed, the electric current may be used in both forms percutaneously, in addition to the remedies mentioned above. When symptoms of marked stenosis occur—in children under the form of pseudo- croup—an emetic is also indicated, such as pulv. ipecac with tart, emetic, apomorphia or sulphate of copper. By this means the paroxysms of severe dyspnoea are usually speedily relieved. If the laryngeal stenosis still con- tinue to be alarming, and the laryngoscopical inspection, as well as the digital exploration, show the presence of oedema glot- tidis, the attempt should be made to scarify the cedematous parts (with the aid of the mirror), and if this operation be not followed by rapid relief of the stenosis, tracheotomy should be performed without delay. LARYNGITIS CATARRHALIS CHRONICA. CHRONIC CATARRH OP THE LARYNX. ETIOLOGY. Chronic laryngeal catarrh generally proceeds from an acute attack, as a result of neglect or of exposure to those injuri- ous influences which have been referred to above as prolonging the inflammatory process. Among these causes none is more prejudicial than the mechanical irritation of the laryngeal mu- cous membrane by speaking or singing, especially in a loud voice, as is so frequently the case with over-zealous professional speakers, teachers, clergymen, singers, popular orators, land- lords, and other professional persons. Many persons sin to an incredible extent against their vocal organs, as if they were inde- structible, and, even when the voice is quite gone, try to make themselves understood by severely straining the larynx. Another extremely frequent cause of chronic laryngeal ca- CHRONIC CATARRH. 213 tarrh is chronic pharyngitis, which is especially apt to extend to the larynx when several causes co-operate, such as straining the voice by loud talking, the abuse of tobacco, and alcoholic stimulants, etc. Inveterate topers almost always suffer from chronic pharyngeal and laryngeal catarrh. Stokes and other writers would give us to understand that chronic catarrh is often due to the mechanical irritation of the epiglottis and entrance to the larynx by the tip of an elongated uvula, which they advise in such cases to be amputated. But no evidence has hitherto been adduced that an elongated uvula can produce such an irritation ; and as Ruehle has remarked, both the uvular enlargement and the laryngeal catarrh are to be regarded as co-effects of the same cause—the chronic pha- ryngitis. The dusty atmosphere which is generated in various occu- pations—millers, weavers, hare-wool cutters, stone-masons, glass- polishers, tobacco-workers, miners, etc.—appears to have but a slight effect upon the laryngeal mucous membrane; at least Sigaud, Ramazzini, Fourcroy, Hirt, Merkel and other writers do not ascribe much importance to this cause. As regards age and sex, primary chronic catarrh of the larynx is more frequent during the middle years of life than in childhood or advanced age, and in men far more frequent than in women. The reason for this probably lies in the greater fre- quency, variety, and intensity of the injurious influences to which men are exposed in the pursuit of their occupations. As a secondary affection chronic catarrh occurs in connec- tion with all the different pathological processes in the larynx which are of long continuance, with the destructive processes in phthisis, typhoid fever, syphilis, lupus, and also with polypi, can- cer, and perichondritis laryngea. The fact that chronic catarrh often develops as an accompaniment of ulcerative changes in the mucous membrane, even from the very beginning of the latter, has given rise to the erroneous opinion that chronic catarrh has a natural tendency to result in ulceration. Simple chronic laryngeal catarrh, however, even when of long standing and con- siderable intensity, does not lead to ulceration, as was formerly supposed by Engel, Ruehle, and other trustworthy writers. 214 ON ZIEMSSEN.—DISEASES OF THE LARYNX. PATHOLOGY. Symptoms, Anatomical Changes, and Terminations. Primary chronic catarrh of the larynx exhibits all the pecu- liarities which are seen in chronic catarrh of the throat and other portions of the respiratory mucous membrane : especially the tendency to hyperplasia of the mucosa and submucosa when the disease lasts a long time, with but a very slight disposition to superficial ulceration ; the tendency to extend along the sur- face ; and finally, the same tedious course and obstinacy to treatment. It begins either as an acute catarrh, which from continued exposure and neglect assumes a chronic character, and is con- tinually being rekindled into acute exacerbations; or in an insidious form, with insignificant symptoms, which are chiefly subjective and then gradually developing more marked objec- tive disturbances in phonation, in the tone of the cough, and in rare cases also in the respiration. The subjective symptoms, which so frequently mark the beginning of the disease, consist in a feeling of dryness in the throat, itching and an uncomfortable irritation, which compels the patient to clear his throat, to cough, and to swallow fre- quently. These abnormal sensations are aggravated by talking, singing, and smoking, and are relieved by resting the vocal organ, by drinking warm fluids containing sugar and mucilagi- nous substances, or by the use of cough syrups, cough candy, etc. Actual pain in the throat, or a feeling of excoriation, is not complained of except after long-continued talking, and disap- pears when the voice is rested. In acute exacerbations pain of some severity may occur spontaneously, or may be produced by attempts at phonation, and by external pressure. The objective disturbances consist chiefly of alterations in the voice in various degrees, according to the intensity of the catarrh. In the lightest cases the voice is generally clear, and of normal timbre and force, but easily becomes altered by talking, or by masses of mucus, which are either situated on or near the vocal cords, or extend from one vocal cord to the other in the form of CHRONIC CATARRH. 215 whitish threads. Such patients, on long talking, are usually obliged to repeatedly clear their throats, and also to drink fre- quently. In severer cases the voice is clear only in the morning after the night's rest, and after the removal of secretion by hawk- ing ; but as soon as the voice begins to be used it becomes husky, and the patient is obliged to be continually clearing his throat, and to strain the expiratory and vocal muscles. In the evening, especially if the voice have not been used excessively, and if beer or tea have been taken freely, all these derangements are reduced to a minimum, but only to return the next morning with the first word spoken. In the severest forms of the uncomplicated chronic catarrh the voice is quite hoarse, deep, and rough, or abnormally high, and easily changes to a falsetto (vox anserina). Talking is pos- sible only with great muscular exertion, because, as the vocal cords are no longer able to close and vibrate with their usual facility, the expiratory current of air must be urged forward under very high pressure in order to excite the vibrations of the glottis ; in general a pure tone can no longer be produced. The patient is obliged to hawk and cough for hours every morning to relieve the troublesome irritation in the larynx. The secretion, in its total amount, is scanty, but relatively to the small size of the secreting surface it is considerable. The mucus is whitish gray, frothy with minute bubbles, viscid and thread-spinning (fadenspinnend), often clear and vitriform, and in cases of long standing contains numerous pus-cells, which give it a rather yellowish color. It rarely contains blood, and then generally in small streaks during acute exacerbations. The irritation which excites cough is urgent, and the tone of the cough deep, hoarse, and of an unusual timbre. The anatomical changes, as seen by laryngoscopical examina- tion, present the most varied appearances, according to the sever- ity of the disease, from a slight swelling and injection of the mucous membrane, limited in many cases to certain parts, such as the vocal processes, the inter-arytenoid region, the edges of the vocal cords or the ventricular bands, up to the deepest uniform redness, with a bluish or brownish lustre, diffused over the whole organ, a velvety sponginess of the mucous membrane and swell- 216 VON ZIEMSSEN.—DISEASES OF THE LARYNX. ing of the submucosa, with diffuse uniform thickening of the epiglottis, ventricular bands, and inter-arytenoid region. The tumefaction of tliese different parts interferes seriously with vocalization. Thus the hypertrophied inter-arytenoid fold may, by its interposition between the arytenoid cartilages during phonation, prevent the normal approximation of the same, and that of the vocal cords. So also the swollen ventricular bands not only obliterate the ventricles of Morgagni, and cover over a large part of the vocal cords, but also materially lessen the excursions of the latter during phonation. Moreover, the swell- ing of the mucous membrane of the epiglottis, and the imperfect mobility of this organ, which is thus produced, have much to do with the abnormal timbre. The redness from congestion is usually less noticeable upon the vocal cords than upon other portions of the mucous mem- brane. The swelling and thickening of the vocal cords may be recognized by the granular condition of their surfaces, the uneven- ness of their edges, and the magnitude of their vibrations. Very generally motor derangements can be detected by the laryngoscope. These consist either in a mechanical interference with the movements of the arytenoid cartilages and vocal cords from thickening of the mucous membrane and submucosa, or in true muscular pareses, which are more frequently unilateral than bilateral, and which can be recognized by the fact that the two arytenoid cartilages and vocal cords move less freely than usual in phonation, and probably also in respiration. The vicarious activity of the healthy vocal cord frequently obviates the diffi- culty in the closure of the glottis in phonation by carrying the cord over beyond the median line, thus giving the glottis the necessary narrowness, though at the same time an oblique direction (see infra, "Diseases of the Laryngeal Nerves and Muscles"). Erosions are of rather rare occurrence, and true ulcerations in simple chronic catarrh are extremely uncommon. Among the rarer lesions may be noted partial thickenings of the mucous membrane and submucosa on the epiglottis, ary-epi- glottidean folds, ventricular bands, arytenoid cartilages and vocal cords. In these cases one is struck, on the first glance into the CHRONIC CATARRH. 217 larynx, by the great tumefaction of the several parts, sometimes amounting to distortion. This appearance is more frequent on the epiglottis, ventricular bands, and ary-epiglottidean folds than elsewhere. The epiglottis is irregularly thickened, very much bent, and covered with dilated veins. The ventricular bands overlie the vocal cords almost completely, and usually allow only the internal border and cartilaginous portions of the latter to be seen. Lewin has called special attention to the thickening of the ary-epiglottidean folds, and has pointed it out as a fre- quent peculiarity of preachers. These persons, he says, pro- duce the deep, hollow tones, which express pathos, by forcibly depressing the epiglottis through contraction of the muscular bundles running in the ary-epiglottidean ligaments ; and the habitual tension of these folds, by interfering with the circu- lation, is said to lead to their thickening, and, according to Lewin, perhaps also to the atrophy of the epiglottis, which is sometimes noticed. The marked development of veins, above alluded to as com- mon on the epiglottis, occurs also in rare cases upon the vocal cords along their borders, upon the ventricular bands, and else- where. Morell Mackenzie regards this "phlebectasis laryngea" as the result of a constitutional anomaly, and the hoarseness as the result of the phlebectasis—a supposition with which I can- not agree. Duchek has opposed this view, and is probably correct in his statement that the dilatation of the veins and the aphonia are both caused by the chronic catarrh. The alterations produced in the vocal cords by chronic catarrh may be very varied. Usually the only changes noticed are an irregular dirty-red injection, a fine, dark-red edge on the border of the cord, and in very protracted cases a roughness of the surface, which seems to be due to a partial dermoid meta- morphosis of the mucous membrane. This latter lesion has been called by Tiirck sometimes chorditis tuberosa, sometimes tra- choma of the vocal cords. Wedl examined such a trachoma microscopically, but could find nothing except hypertrophied connective tissue and heaps of nuclei. At other parts of the mucous membrane where there are numerous glands, the hypertrophy of the glands may produce a 218 VON ZIEMSSEN.—DISEASES OF THE LARYNX. granular condition, known to the older writers as laryngitis granulosa, and analogous to the pharyngitis granulosa, with which it is often found associated. In very protracted and maltreated catarrhs the affection frequently results in the formation of papillary proliferations and polypi, which will be considered more fully hereafter under the head of Neoplasms. The favorite situation of catarrhal erosions is on those parts where the mucous membrane is most exposed to injury, viz., between the arytenoid cartilages, and upon the so-called glottis cartilaginea. In very rare cases the chronic catarrh leads to hypertrophy of the connective tissue of the under surface of the vocal cords, a condition known as chorditis vocalis inferior hypertrophica. This consists in a true induration of the mucosa and submucosa on the under surface of the vocal cords, from hyperplasia of the connective tissue, whose contraction may, and in fact usually does produce, after a time, a high degree of laryngeal stenosis. Rokitanskyx refers to this result of inflammation as an indura- tive degeneration (callosity), and says that this degeneration of the mucosa and submucosa into a callosity occurs in a particu- larly massive form in the neighborhood of the glottis, and gives rise to an ultimately fatal stenosis. Shortly after this statement was made, Czermaka published a case of this kind, the first in which the diagnosis was made by the use of the laryngoscope. The patient was a scrofulous girl, eighteen years of age, who had previously had enlargement of the cervical lymphatic glands, and of the entire anterior region about the larynx. Hoarseness occurred with dyspnoea, and the latter gradually increased to such a degree as to necessitate tracheotomy. After the operation, and notwithstanding the use of bougies, etc., the stenosis produced by the subchordal hypertrophy became more and more severe, and ultimately the lumen of the larynx was hermetically closed. Gibb3 has published one, and Tiirck4 two cases of this kind. 1 Lehrbuch der patholog. Anatomie, III. Aufl., Bd. III., S. 16. 2 Der Kehlkopfspiegel, II. Aufl., I860, S. 163. 3 On Diseases of the Throat and Windpipe. London, 1864, p. 119* 4 Klinik der Kehlkopfkrankheiten, S. 204 ff. CHRONIC CATARRH. 219 The second one of Tiirck's cases is especially important on account of the spontaneous retrogression of the process. Chronic Swelling of the Under Portions of the Vocal Cords—Tracheotomy—Sub- sequent Reduction of the Swelling.—Girl fourteen years of age. Without apparent cause, difficulty in breathing occurred, which in the course of six months gradu- ally increased, and finally was attended by aphonia, cough, and suffocative attacks. The fissure of the glottis appeared to be narrowed, and at the same time shortened, by pads which projected beneath the vocal cords (see Fig. 4). Tracheotomy was performed for relief of the long-continued suffocative attacks. Eight months after- wards, when the breathing with the tracheal canula closed had become much improved, the laryngoscopical examination showed that the lumen of the stenosed part between the longitudinal pads, which projected beneath the vocal cords, had been considerably widened. When the stenosed part was examined with the mirror in an oblique position, and the larynx at the same time pushed to one side, it was found that the borders projected very distinctly above, but became more and more flattened towards the bottom, and that consequently the stenosis proceeded, not from a membrane, but from a rolling of the internal surfaces and part of the anterior surface of the posterior wall of the larynx into the form of pads. At the last examination the fissure was about 4'" long, and 1-J-'" broad at the widest part. Below could be clearly seen the canula (see Fig. 5, in which the canula appears below as a white hemispherical projection). Fig. 4. Fi«. 5. Scheff1 has also published a case, but the final result is unknown. Gerhardt2 has recently published a very interesting case, in which also life was saved by laryngo-tracheotomy. The patient was a female operative, thirty years of age. The affection began in the summer of 1870, with hoarseness, unaccompanied by cough or dysphagia. No cause could be discovered, but syphilis could be eliminated with certainty. During the winter the occurrence of pregnancy aggravated the hoarseness, and dyspnoea supervened. By the middle of March, 1871, the dyspnoea had increased so much as to prevent sleep. She was received into the Jena Clinique much emaciated, com- 1 Wiener med. Presse, No. 51, 1871. 8 Deutsches Archiv f. klin. Med., Bd. XL, S. 584 ff., 1873. 220 VON ZIEMSSEN.—DISEASES OF TIIE LARYNX. pletely aphonic, and suffering from intense laryngeal dyspnoea, with noisy respira- tion. The vital capacity was 1400 c. cm. Swallowing and talking were very diffi- cult on account of the dyspnoea; there was little or no fever. On laryngoscopical examination, there was seen lying by the side of each vocal cord, and projecting downwards from its internal border, a pale-red, slightly roughened pad, more promi- nently developed anteriorly, which on quiet breathing closed the glottis at all points, except posteriorly, where a fissure was left about one-half a ctm. in length, and three mm. in breadth. Four days after admission, a suffocative attack, with convulsions, made it neces- sary to resort to laryngo-tracheotomy. On July 1 she was discharged, and after- wards had an attack of varioloid, so that the cavity of the larynx was not again examined until November. The movement of the vocal cords for closing the glottis was strong and complete, but for dilatation—feeble and unsatisfactory. The longi- tudinal pad, which projected downwards and inwards from each vocal cord, and narrowed the glottis, appeared to be separated from the yellowish white upper surface of the cord by a very shallow longitudinal furrow, but was covered with an unchanged pale, red, mucous membrane. It extended also to some extent over the anterior and posterior commissures, so that the glottis seemed not only nar- rowed, but shortened. Repeated scarifications of the pad gradually diminished the swelling so much that the tracheotomy canula could be closed as long as five hours at a time, and the voice was restored, but still remained hoarse. Burow, Jun.,1 not long ago stated that he had seen in all six cases of chorditis vocalis inferior hypertrophica. In each trache- otomy became necessary on account of the urgent stenosis. Here, therefore, although rarely, we find chronic laryngitis resulting in hypertrophy of the connective tissue on the under surface of the vocal cords, a condition of great clinical import- ance, on account of the stenosis to which it leads in the course of a few months. The diagnosis in these cases is to be based chiefly upon the laryngoscopical examination, but also upon the history of the case and other symptoms. Ulcerations, perichondritis, and edema are very rare results of chronic laryngitis (see infra in the section on these affections). The chronic secondary laryngitis, which is dependent upon syphilis, ulcerative processes, neoplasms, traumatic irritations, perichondritis laryngea, or upon the compression or displace- ment of the larynx by a goitre, does not differ essentially in its symptoms from the primary chronic catarrh of the larynx, but, 1 Langenbeck's Archiv, Bd. XVIII., S. 228. CHRONIC CATARRH. 221 as a matter of course, the clinical picture is frequently much altered by the primary affection. Course and Prognosis. The course of chronic laryngeal catarrh is always very varia- ble and tedious. Improvements and aggravations may rapidly follow each other according as the affection is modified by external circumstances, the habits of life, and the medical treat- ment. Care in using the vocal organ, as regards talking, singing, smoking, and drinking, favorable atmospheric influences, local treatment of the mucous membrane with astringents, etc., may speedily produce such an amelioration of all the symptoms that the patient thinks himself entirely rid of his complaint. But when he resumes his customary mode of life he discovers his mistake. Even the slightest excess rekindles the inflammation, which soon becomes as severe as ever. Hence, the common experience that, in patients who do not possess the energy neces- sary for a long course of medical treatment, and precaution for the sake of an apparently unimportant and innocuous affection, the catarrh often continues to vacillate between better and worse for years together. The absence of all constitutional symptoms, and the conviction of the harmlessness of the disease naturally make the patient indifferent to the representations of the physi- cian. The extreme solicitude and pertinacity of consumptives in visiting the laryngeal specialist are strikingly in contrast with the heedlessness of patients with chronic laryngitis, who are otherwise perfectly well. A week or a fortnight's precaution and local treatment they regard as a very great sacrifice, even although such lesions as granular thickenings, papillary excres- cences, polypi, and muscular pareses have already developed. To this rule, however, there is a marked exception in the case of the hypochondriacal patients, with pharyngo-laryngitis, among, clergymen, teachers, and other professional speakers, who are harassed by the fear of consumption, and who actually become a burden to the specialist. When serious anatomical changes have once become estab- lished, these in their turn help to maintain a condition of irrita- 222 VON ZIEMSSEN.—DISEASES OF THE LARYNX. tion. This is the case particularly with polypi, which keep the surrounding mucous membrane in a state of continual irritation ; while in muscular pareses the excessive exertion on the part of the sound muscles during phonation cannot fail to inflict injury upon the mucous membrane and submucosa. Even in favorable cases the larynx remains a locus minoris resistentie, so that acute attacks of laryngitis occur from com- paratively slight causes, and always run a protracted course. A perfect and permanent cure is, however, by no means a rare occurrence, but such a, result presupposes, at least in invet- erate cases, persistent care on the part of the patient and on the part of the physician large experience and dexterity. Death from this cause is extremely rare, and results either from the above-mentioned connective-tissue hypertrophy of the under surface of the vocal cords, producing stenosis, or from the equally rare lesions, perichondritis and oedema. Many writers, and recently again Tobold,1 have supposed that simple chronic laryngeal catarrh may, if neglected, lead to phthisis of the larynx and lungs, but this conclusion rests upon false premises. Chronic laryngitis produces as little disposition to phthisis of the larynx as simple chronic bron- chitis does to phthisis of the bronchi and lungs. Tobold states that " the mild form of simple chronic laryngitis, even in robust persons, if it last for several years, or be continually renewed by fresh exposures, may terminate in ulcerative and tuberculous laryngitis, with a general phthisical infection of the hitherto sound lungs." This opinion he regards as confirmed by the experiments of Sommerbrodt; but erroneously, because these experiments merely show that ulcerations and suppurations artificially produced in the larynx may give rise to purulent peribronchitis and pulmonary phthisis, but furnish no evidence in regard to the results of simple chronic catarrh. Sommerbrodt in his work has nowhere anything to say in favor of pulmonary phthisis originating in simple catarrh. That chronic catarrhs do accompany destructive processes in the larynx is undeniable ; we are not concerned however, with these secondary affections at present, but rather with those of a simple idiopathic character. As to which of these two forms is 1L. a, p. 179. CHRONIC CATARRH. 223 present in any given case, it is, of course, in many cases exceed- ing^ difficult to decide (see infra in the article on Destructive Processes). TREATMENT. In the first place all those injurious influences are to be avoided which are apt to produce or protract a laryngeal catarrh. Accordingly, every mechanical irritation of the mucous membrane, by speaking or singing, is to be specially guarded against. Teachers, clergymen, singers, actors, and other persons who are obliged by their occupation to use their voices to excess, should at once take a vacation for several months, because absolute rest of the vocal organ is indispensable for a complete cure. In many cases it will require the whole of one's profes- sional authority to enforce so stringent a regulation. But it is not sufficient that the patient be condemned for a time to silence ; he must also avoid smoking, or staying in rooms filled with tobacco smoke ; and he must give up using snuff, spirituous liquors, or highly seasoned food, because any irritation of the mucous membrane of the pharynx always revenges itself upon that of the larynx. The treatment is mainly local. The application of the stronger astringents should always be made by the physician himself, and with the aid of the laryngoscope, as the e}Te is the only safe guide for the instrument. The weaker astringents are generally ordered in solution, and inhaled by the patient in the form of spray generated by one of the numerous inhaling appa- ratus. I prefer Siegle's spray apparatus, which works uniformly and safely. The patient should be personally instructed how to use it, how to hold the head and mouth properly, and how long the inhalations should last. These I never allow to be continued for more than four or five minutes, and usually only twice daily. When a tannin solution is used, the minute opening at the end of the glass tube may easily become occluded by flakes of tannin. This may be remedied by placing the glass tube for some time in warm water or in alcohol, in order to dissolve the hardened tannin. Drilling with needles, wires, etc., is almost certain to break the fine glass tube. Among the astringents which may be used by inhalation tannin is probably the best. Solutions of five grains to the 224 VON ZIEMSSEN.—DISEASES OF THE LARYNX. ounce may be employed. If there is much irritability of the mucous membrane of the larynx and throat, it is well to begin with solutions of potassium or sodium salts, for the purpose of first relieving the hypersesthesia, and of increasing and lique- fying the secretion. These indications are best fulfilled by inha- lations of solutions containing from twenty to twenty-five grains of bromide of potassium to the ounce, and also by solutions of common salt. In general, however, too much must not be expected from the use of inhalations in chronic catarrh of the larynx and throat; they are adapted, when used alone, only to the mildest cases, and in the moderately severe and severe cases they should be regarded merely as an aid to the rest of the treatment. Among the stronger astringents I give a decided preference to nitrate of silver, because it can be locally applied in sub- stance with perfect ease and safety, and because it can be kept in solution in any degree of concentration. In very inveterate catarrh of the larynx and throat I always use the remedy in substance. Every time the application is to be made I cover the grooved knob of the curved caustic-holder with the melted caustic, in the way first recommended, if I am not mistaken, by Lewin. The caustic is melted in a small porcelain saucer over a moderate flame; the knob of the caustic-holder is then quickly dipped in, and becomes coated, if the liquid be not too thick nor too thin, with a thin layer, just sufficient for one application. Then, guided by the mirror, I pass the instrument into the larynx, and rapidly and superficially touch the parts most congested and thickened. The spasmodic contraction which immediately ensues in the muscles, closing the entrance to the larynx, spreads the caustic action, and for several minutes there is a very active spasm of the glottis, which is soon relieved, however, by drinking a little cold water. If the parts be examined immediately afterwards, the upper surface of the vocal cords and ventricular bands will be seen to be skimmed over by a tolerably uniform gray layer, from the action of the caustic. On the upper soft parts of the entrance to the larynx, e.g., the mucous membrane of the arytenoid cartilages, or the ary-epiglottidean folds, the caustic effect can, of course, be localized much more exactly and to a smaller surface. This energetic local treatment may be repeated as often as once a week or fortnight, according to circumstances. The nitrate of silver solutions, which it is well to keep pre- pared of various strengths (16, 24, 48, 96, 240 grains to the CHRONIC CATARRH. 225 ounce), I apply by means of a well-made thick brush, or with a small piece of soft sponge fastened to a slender metallic rod, which can be screwed on to a bent handle made of strong wire. I usually prefer the brush, because with the strong solutions which I employ I in this way avoid introducing too much fluid, and succeed better in making a uniform application to the interior of the larynx. These objects can be more easily accomplished by a very thick brush with a good point than by the sponges so strongly recommended by Tobold. Still, it cannot be denied that the latter are useful in the application of weak solutions. Among the other astringents strong solutions of tannin and alum are also worthy of mention, but their effect is less certain and pleasant than that of nitrate of silver. In cases of long standing the tincture of iodine may also be tried, at first diluted, or the iodine in glycerine (Lewin). The injection of astringent remedies by means of a small syringe is generally unadvisable, because the fluid easily runs down into the trachea, even if injected during phonation. The application of astringents in a powdered form is likewise objectionable, because its operation is uncertain and disagreeable to the patient. Now and then during the course of the astringent treatment intervals should be allowed, during which inhalations of bro- mide of potassium or chlorate of potassa solutions are to be used. In plethoric persons saline cathartics, such as the Ofen bitter-water or the Carlsbad Sprudel salts, may be taken every morning fasting. If at the same time the diet be regulated by limiting the amount of food, especially in regard to nitrogenous articles, and if spirituous liquors be entirely proscribed, quite a rapid improvement may usually be effected even in the very old chronic catarrhs of plethoric and hemorrhoidal patients, par- ticularly if energetic local treatment with nitrate of silver or at tincture of iodine be used at the same time. The removal of the remaining infiltration and the hyper- plastic thickening presents great difficulties, and all the more because the endurance of the patient is apt to become exhausted as soon as he notices any considerable improvement. In these cases I have seen much benefit from the employment of the electrical current in both forms, applied percutaneously vol. rv.—15 226 VON ZIEMSSEN.—DISEASES OF THE LARYNX. as well as to the pharynx. This treatment is adapted not only to relieve the secondary muscular pareses, which are so com- mon, but also to remove the exudation and hyperemia. External counter-irritation to the neck by means of blisters, tartar-emetic ointment, and croton oil, as was formerly the general practice, has more and more gone out of use since the introduction of laryngoscopical local treatment. Priessnitz's compresses, however, and the application of tincture of iodine and strong iodine ointment to the skin of the neck, justly retain a certain amount of confidence. Little is to be hoped for from baths and the use of mineral waters when they are employed alone without proper local treatment. The patient generally finds himself much better during the course of this method of cure, in fact, often quite free from his complaint ; but as soon as he returns to his usual habits of life, and is again exposed to the former injurious influences, the catarrh soon resumes its former intensity. These remedies are, however, very valuable when used in connection with a rational local and dietetic treatment, and whenever it becomes necessary to intermit the local treatment for a time, for the sake of rest to the larynx, they are a very good temporary substitute. The cold sulphur springs of Weilbach, Nenndorf, Eilsen, etc., have long enjoyed a reputation in the chronic catarrhs of plethoric and hemorrhoidal patients, and no doubt many of these cases, in which a torpid chronic catarrh is associated with the so-called hemorrhoidal and other abdominal derangements, are much improved by such a course of treatment. Unfortu- nately we have at present almost no accurate knowledge of the effects of the sulphur waters, and consequently their prescrip- tion must be entirely empirical. The stronger Glauber's salt waters, especially the Kreuz- brunnen in Marienbad, and the cooler springs in Carlsbad, act very favorably in the chronic catarrhs of plethoric persons, who are capable of but little physical exertion although they take an abundance of food, and who, from lack of exercise, etc., usually suffer from all sorts of abdominal complaints, such as dyspepsia, constipation, etc. CHRONIC CATARRH. 227 The warm soda and chloride of sodium springs of Ems, and the salt-water springs of Reichenhall, Ischl, etc., are better adapted to delicate constitutions with great irritability of the respiratory mucous membrane, and where there seems to be a predisposition to phthisis either from hereditary causes or from antecedent scrofula. CROUP. STEINER. CROUP—LARYNGITIS CROUPOSA ET DIPHTHERITICA. MEMBRANOUS CROUP. Descriptions of a disease similar to the laryngeal croup of the present day are to be found even in the works of Hippocrates, Celsus, Galen, and C. Aurelianus.—.. Montanus, Consultat. med. Venitiis, 1859, Curt. II., p. 51.—Baillau in 1576 described croup, and even at that time insisted upon the formation of a pseudo- membrane.— Villa Real, De signis, causis, essentia, prognostica et curatione morbi suffocantis. Compluti, 1611.—Fontecha, Disput. med. supra ea, qua? Hippocrates, Galenus, Avicenna, etc., de anginarum naturis etc., scripsere, et circa affcctionem vocatam Garotillo. Compluti, 1611.— Ch. Bennet, Theatr. tabid. London, 1656, noticed the expectoration of membranes.—Nic. Tulpius, Observat. med. Amstelod., 1685.—Harris, 1691.—Martin Ghisi, Lettere med., Tom. II. Cremona, 1749.—Malouine, Histoire de maladies epidemiques 1747- 1751.—Starr, .An Account of Morbus Strangulatorius, in Philoso2->h. Transact., Vol. 46. London, 1752.—Langhans, Beschreibung verschiedener Merkwiirdig- keiten des Siementhales nebst genauerem Berichte liber eine neue ansteckende Krankheit. Zurich, 1753.—van Bergen, Nova acta naturae curios. Lipsiae, 1764.—Francis Home, An Inquiry into the Nature, Cause, and Cure of the Croup. Edinb., 1705.—Samuel Bard, Transactions of the American Philosoph. Society. Philadelphia, 1771.—Heinrich Callisen, Acta societ. med. Havniensis, 1778.—Michael is, De angina polyposa. Gottingen, 1778. This author first describes croup and angina gangrenosa as two distinct diseases.—Johnstone, Of the Malignant Angina. Worcest., 1779.—Lenlin, Hufeland's Jour., 1796. —Marker, Geschichte einer epidemischen Braune, in Hufel, Bd. XIX.— Vieusseux, Observations sur le croup. Paris, 1806.—J. II. T. Autenrieth, VcTsuche fiir die praktische Heilkunde aus der klin. Anstalt von Tiibingen, 1807.—Caron, Traite du croup aigu. Paris, 1808.—Des Essartz, Mem. s. 1. croup. Paris, 1808.—Friedldnder, Sammlungen und Beobachtungen die hiiutige Braune betreffend. Tubingen, 1808.— Cheyne, The Pathol, of the Membrane of the Larynx and Bronch. Edinb., 1809.—Sachse, Das wissenswerthe fiber die hiiutige Braune. Lfibeck, 1810.—Lbbenstein-Lobe, Erkenntniss und Heilung der hautigen Bn'iune. Bamberg, 1810.—Royer- Collard, Rapport sur les ouvrages de concours. Paris, 1812.—Goelis, Tract. de rite cognosc. et san. angina memb. Viennae, 1831.—Senff, Ueber die Wir- kung der Schwefelleber in der hautigen Briiune. Leipzig, 1813.—Albers, Comm. de tracheit. inf. vulgo Croup vocat. Lipsiae, 1816.—Jurine, Abhand- lung fiber den Croup. Leipzig, 1816.—Lobstein, Observat. et recherches sur le 232 STEINER. —CROUP. croup. Paris, 1817.—Desruelles, Traite" theoret. et pratiq. de croup. Paris, 1821.—Bretonneau, Des inflammat. speciales du tissu muqueux et en part, de la Diphtherit. Paris, 1826.—Bricheteau, Precis analytique du croup et de l'an- gine couenn. Paris, 1826.—Guersant, Revue medicale, Octob., 1829.— Corne- liani, Due storie razionali di angina croupale. Pav., 1835.—F. W. Ileiden- reich, Revision der neueren Ansichten und Behandlung von Croup. Erlangen, 1841.—Hirtz, Gaz. med. de Strasb., No. 12, 1841.— Boudet, Histoire de l'epidem. du Croup en 1840-1841. Paris, 1842.— Rilliet et Barthez, Traite theoretique et prat, de malad. des enfans. Paris, 1843.— Valleix, Bull, de thgrap., Oct., 1843.—C. A. Wunderlich, Handbuch der Pathologie und The- rapie. Stuttgart, 1846.—Virchow, Handbuch der Pathologie, 1847.— Weber, Der Croup und seine Behandlung. Erlangen, 1847.— Beau, Arch. gen. de Med., 1848.—Gaillard, Sur 1. diagn. du vrai croup. Paris, 1849. — Crisp, Lond. Med. Exam., May-July, 1850.—Hauner, Journal fiir Kinderkrank- heiten, 1850.— John Ware, Contributions to the History, Diagnosis, and Treat- ment of Croup, Reprint from Boston Med. and Surgical Journal. Boston, 1850.—Honertyrf, Schwefels. Kupferoxyd gegen Croup. Leipzig, 1852.— Valleix, Guide du med. prat. Paris, 1853.— Schaible, Ueber Croup und Tracheotomie. Basel, 1853.— Magnus Huss, Schmidt's Jahrbficher, 78. Bd., 1853.—Emerich, Abhandlung fiber die hautige Braune. Neustadt a. H., 1854. —Heymann, Krankheiten der Tropenlander. Wfirzburg, 1855.—Kuttner, Journ. fiir Kinderkrankh., 1855.—Schlantmann, De causa dyspnceae et suffoc. in laryng. crouposa. Gryphiae, 1856.— Olshausen, Disput. de laryngit. memb. epid. Regiom, 1857.—Loschner, Jahrb. fiir Kinderheilkunde, 1857.—Bohn, Konigsb. Jahrb., 1858.—Samuelson, Konigsb. med. Jahrb., 1858.—Bouchut, Journ. de med. et de chir., Nov., 1858.—M. Peter, Quelques recherches sur la diphth. et sur le croup. Paris, 1859.— Fock, Deutsche Klinik, Nos. 23, 25, 1859. —Luzinsky, Berl. Journal fiir Kinderkrankheiten, Heft 9 und 10, 1859.— Lebert, Handbuch der praktischen Medicin. Tubingen, 1859.—Gerhardt, Der Kehlkopfcroup. Tubingen, 1859.—Porges, Versuch einer Deutung des Croup- processes. "Wiener med. Wochenschr., No. 31, 1859.—Guillot, De la nature et du traitem. du Croup. Paris, 1859.—Silva, Presse med. beige, 1859.—Duhome, Sur le Croup. Paris, 1859.—Bouchut, Gaz. des hop., 1860.— W. Zimmermann, L'angine couenn. et le croup. Valencien, 1860.— Charnaux, Wiener med. "Wochenschrift, 1860.—Gamier, These sur la tracheotom. Paris, I860.— Anlrun, Gazette hebdom., I860.—A M. Barbosa, 1861.—Barthez, Med. chir. Monatshefte, 1861.—Clar, Wiener med. "Wochenschrift, No. 45, 1861.—Roser, Archiv fur Heilkunde, 1861.—Lissard, Anleitung zur Tracheotomie bei Croup, 1861.—Hirsch, Handbuch der hist.-geogr. Pathologie, 1862.—Fieber, Mecliz. Halle, 1862.—C. Miquel, Correspondenzblatt des Vereines fiir gemeinschaftl. Arbeiten, No. 55, 1862.—Schuller, Oest. Zeitschrift f. prakt. Medicin, 1862, No. 4,0.—H. Wulf, Ueber Tracheotomie bei Croup. Dorpat, 1862.— Steiner, Zur Tracheotomie bei Croup, Jahrb. fiir Kinderheilkunde, 1863, 2. Heft.— Widerhofer und Salzer, Wochenblatt der Gesellschaft der Aerzte in Wien, BIBLIOGRAPHY. 233 1863, p. 271.—Dougherty, American Med. Times, 1863.— Crace Calvert, Lancet, Sept. 26, 1863.—Kiichenmeister, Zeitschrift fur Med., Chir. und Geburtshilfe, 1863, 2. Heft,—A. Millet, Traite de la diphther. du Larynx. Paris, 1863.— Ozanam. Journ. fiir Kinderkrankheiten, 1863, No. 3.—Mailer, Deutsche Klinik, 1863, 42.—Fischer et Brichetau, Traitement du Croup. Paris, 1863.—Pouquet, De la tracheot. dans le cas de Croup. Paris, 1863.—31. Peter, Gazette hebd. de medec. Paris, 1863.—C. V. A. Anderson, American Med. Times, Jan. 13 and 27, 1863.—Xotta de Lisieux, Journ. de med. et de chir. pratiq., Sept., 1864.— H Rohlfs, Deutsche Klinik, 1864.—Jaksch, Prager med. Wochenschrift, 6 u. 7, 1864.—Fbrster, Prager Vierteljahrschrift, 1864, 3 u. 4. — Trousseau, Gaz. des hopit, 1864, 20.—Balassa, Wien. med. Wochenschrift, 1864, 1.—Steiner, Reise- bericht, Prager Vierteljahrschrift, 1865, Bd. I.—Fried. Pauli, Der Croup. Wurzburg, 1865 ; a work in which the historical literature of this subject has been most industriously elaborated.—E. Wagner, Die Diphtheritis und der Croup des Rachens und der Luftwege in anatomischer Beziehung, Archiv fiir Heilkunde, VII., 1866; a very valuable contribution to the doctrine of croup. —Clatter, Jahrbuch der Kinderheilkunde, VII. Jahrg., 1. Heft.—Luzinsky, Journal fiir Kinderkrankheiten, 1866, 3 u. 4.—Steffen, Zeitschr. fiir rat. Medicin, XXVIII.—Moreth, Sitzungsbericht des Vereins der Aerzte in Stcier- mark, 1868.—A. Jacobi, Pathology and Treatment of Croup, Amer. Jour, of Obstet, May, 1868.—Steiner, Zur Tracheotomie beim Croup, Jahrbuch fiir Kin- derheilkunde, 1868, Heft I.—Bai'bosa, Gaz. med. de Lisboa, 1868.—Abeille, Gaz. med.; und Jahrb. fiir Kinderheilkunde, 1868, p. 450.—Bregaut, Gaz. med., 1808, No. Q.—Crighton, Edinb. Medic. Journ., Vol. XIII., 1868.—H. Fabius und v. d. Busch, Journ. fur Kinderkrankheiten, 1868.—.1. Weber, Centralblatt No. 22, 1869.—L. F. Zielke, Beobachtungen fiber den Rachen- und Kehlkopf- croup, Virchow's Archiv, Bd. XLIV.—Hueter, Zur Lehre der Tracheotomie bei Diphtheritis, Berl. klin. Wochenschrift, 1869.—Oehlschlager, Zur Tracheo- tomie, Archiv fiir klin. Chir., Bd. XL—Hartmann, Ueber Croup und Diph- theritis der Rachenhohle, Virchow's Archiv, Bd. LII., p. 520.—Daguillon, Note sur le traitem. du croup, Gaz. hebd., 1870, No. 30.—Max Midler, Bei- trag zur Statistik der Tracheotomie beim Croup, Archiv f. klin. Chir., XII. —v. Ziemssen, Ein laryngoskopirter Croupfall, in Greifswalder med. Bei- tragen, Bd. II., p. 123.—Kieffer, Bromide of Potassium in Croup, Med. Times and Gaz., 1871, No. 12.—F. Steudener, Zur Histologic des Croup im Larynx und der Trachea, Virchow's Archiv, Bd. LIV.—Boldyrew, Ein Beitrag zur Histologic des crouposen Processes, Centralblatt f. d. med. Wissenschaften, 1872.— Veneschi, Zur Frage fiber die Tracheotomie bei Laryngitis diphth., Berliner klin. Wochenschrift, 1872.—Bouchut et Labadie Lagrave, Sur Fana- tomie pathologique de l'angine gangr. ou couen. et du croup, Gaz. med., 1872, No. 33.—L. v. Rndnicki, Einige Bemerkungen fiber die klinische Theorie der hautigen Braune, Wien. med. Wochenschrift, Nos. 23, 24, 25. Jahrg., 1873. —J. Soils Cohen, Diseases of the Throat, etc., New York, 1872; Croup in its relations to Tracheotomy, Philadelphia, 1874. (These contain copious refer- 234 STEINER.—CROUP. ences to recent periodical literature on this subject.)—Monti, Ueber Croup im Kindesalter, Wiener Klinik, 1. und 2. Heft, 1875.—Richardson, Diphtheritic Croup; Tracheotomy; Artificial Respiration; Recovery, Med. Times and Gaz., July 17, 1875.—R. and R. J. McCready, Two Cases of Recovery from Diph- theritic Croup, one with, the other without, Tracheotomy, Amer. Journal Medi- cal Sciences, Oct., 1875. See also the works on Diseases of Children by Rilliet and Barthez, Bouchut, West, Hennig, Vogel, Gerhardt, Steiner, and those on Special Pathology and Thera- peutics by Niemeyer, Oppolzer, Duchek, and others. General Considerations and Etiology. Croupous laryngitis is that form of inflammation of the larynx in which a fibrinous, yellow-white exudation takes place upon the mucous surface in the form of membranous coagula, which are loosely attached, are readily and frequently regener- ated, produce no loss of substance, and leave behind no cica- trices. The word croup is of English-Scotch origin. It was first used by Vatrick Blair, in 1713, and originally signified strangu- lation. Cook derives the name croup from the white membrane, which occurs on the tongue of young fowls, and which we call the pip. As laryngeal croup is frequently associated with croupous inflammation of the mucous membrane of the throat, it has also been called, although incorrectly, membranous, or pseudo-mem- branous angina. In diphtheria the lesion is similar to that of croup, only with this difference, that in croup the exudation takes place upon the free surface of the mucous membrane, while in diphtheria it occurs at the same time within the tissue, and thus produces necrosis and loss of substance of the mucous membrane. The attempt to distinguish croup and diphtheria as two entirely distinct diseases has been unsuccessful, both from an anatomical and from a clinical standpoint; indeed there are many good reasons for supposing that these two affections are only varieties. and modifications of one and the same process, which, in consequence of special influences and collateral causes, as yet imperfectly understood, makes its appearance at one time ETIOLOGY. 235 as croup, at another as diphtheria, now in a sporadic form, now as a wide-spread epidemic, now as a primary, and now, again, as a secondary affection. Every one who has observed many cases of croup and diph- theria must admit that these two affections often occur together, or successively, in the same person; that the throat not infre- quently presents the signs of typical diphtheria at the same time that true croup is found upon the mucosa of the larynx and lower air-passages; that in the larynx itself croup and diph- theria are observed to shade into each other; and that, finally, constitutional symptoms, fever, glandular enlargements, and albuminuria are met with during the course of croup, as well as in diphtheria. Notwithstanding these points of contact the relationship between the two affections is far from being satisfactorily eluci- dated, and yet it is necessary that their connection should be premised here, because the diphtheritic throat affection is an important factor in the etiology of croup. Croup may be divided into a primary, or idiopathic, and a secondary, or symptomatic form. The primary or true croup of the larynx is, especially, a disease of childhood, and is rarely seen in adults. It generally occurs in children between two and seven years of age, much less frequently in newly born infants and nurslings, and very rarely in children over seven years of age. Among 501 deaths from croup in Vienna, during 1868, 92 were in the first year (30 were 12 months old, and 12 were 11 months), 128 in the second, 87 in the third, 71 in the fourth, 50 in the fifth, 34 in the sixth, 17 in the seventh, 7 in the eighth, 6 in the ninth, 2 in the tenth and eleventh respectively, 3 in the twelfth, 1 in the thir- teenth, and 1 in the sixty-second. Among the Christian population, the mortality was 2.6 per cent. Among the Israelitish, 4.2 per cent. (Glatter1 This preponderance of the disease among the Israelites accords with my own experience in Prague. The male sex is more frequently affected than the female ; in my own cases, out of 101 children, 77 were boys and only 21 girls. In Bonn's 70 cases, 43 were boys and 27 were girls. Ruehle gives the proportion of boys to girls as 3 to 2. 236 STEINEPw—CROUP. Strong, well fed, hearty children are no more liable to croup than those who are feeble, delicate, or affected with other diseases. To be sure, croup does occur among rachitic, scrofu- lous, tuberculous, and hydrocephalic children, but there is no evidence that scrofula specially predisposes to it. Notwithstanding the views of some writers to the contrary, it must be admitted that there is a, certain hereditary and family disposition to croupous inflammation in general, and to laryn- geal croup in particular. In some families membranous croup is comparatively frequent, while in others it is unknown. I have quite recently become acquainted with two unfortunate families, in one of which all four, and in the other all three children died of membranous croup, within five years in the one case, and within four years in the other. There is no reason to suppose that this hereditary predisposition is specially noticeable in children whose parents have been subject to tonsillar enlarge- ments, or that it originates in scrofula. This individual predisposition appears to be weakened by the occurrence of one attack, and in my experience of more than 100,000 cases of disease among children, I have never yet met with a single recurrence of true croup. In the literature of this disease only a few instances of this kind are recorded. Guersant states that he has opened the windpipe twice for two attacks of croup in the same child. All reports of the disease recurring three, five, and ten times are fabulous, and refer only to pseucVp- croup, which we all know usually attacks a child frequently. Even Honerkopf says that his own child, three years of age, had seven (!) attacks of croup within a year and nine months. Numerous mistakes of this kind have crept into the literature of croup, and only show that the distinction between croup and pseudo-croup is still unrecognized even by many physicians. Notwithstanding the obscurity which, it must be admitted, still surrounds the etiology of croup, it has been proved that the occurrence of the disease is favored by certain conditions, such as the season of the year, the weather, and the nature of the soil. Croup is observed during every season of the year, and at temperatures from 90° above to 31° below zero F. It has been ETIOLOGY. 237 found to be most prevalent during moist, cold, changeable weather, and in many cases the attack seems to be immediately due to exposure to sudden changes of temperature or to cutting north and north-east winds. According to general experience more cases of croup occur in January, February, March, April, October, November, and December, than in May, June, July, August, and September. Out of 467 epidemics of croup, collected by A. Hirsch, 159 belonged to winter (December 56, January 48, February 33) ; 130 to spring (March 51, April 42, May 37); 72 to summer (June 21, July 23, August 38); and 106 to autumn (September 22, October 41, November 42). Croup extends over the whole earth, but strikingly diminishes in frequency, according to A. Hirsch, as we pass from the higher latitudes to the tropics. The same writer says that the disease prevails especially in a moist, cold climate, in narrow valleys swept by cutting winds, on plains exposed to cold winds, and in localities where the temperatures are low, or violent changes occur. The deleterious influence of moisture is shown by Craw- ford's observation, that in Scotland croup, which had hitherto been a common disease, became rarer after the drying of marshy districts (Pauli). Primary croup occurs sometimes sporadically, sometimes, though less frequently, as an epidemic. AVhen several children in a family, or a large number in a neighborhood, are affected with the disease, most of such instances belong generally to the epidemic form ; but this distinction has not been sufficiently observed in the literature of croup to make it available for sta- tistical purposes. Primary true croup is not a contagious disease, although it is so regarded by Bohn, Gerhardt, and others. Diphtheritic croup, however, possesses this quality in a marked degree. By secondary or symptomatic croup is meant that form which occurs in the course of acute infective or general constitutional diseases, p}rffimic processes and other acute or chronic affections. Of the acute exanthemata, measles is the one most frequently complicated with laryngeal croup. This complication generally occurs during the stage of desquamation, more rarely during the 238 STEIXER. —CROUP. height of the eruption, and in very exceptional instances simul- taneously with the outset of the measles ; while, on the other hand, pseudo-croup during measles usually occurs as a prodro- mal symptom. Scarlatina, especially when complicated with throat-diphtheria, also manifests a predilection for croup ; the same thing is true of small-pox, but less frequently. Another secondary form of croup, and one which is justly to be feared, is that which often accompanies epidemic diphtheria. Secondary croup has also been observed during the height of whooping- cough (Vauthier, Steiner, twice), in epithelioma laryngis (Steiner), and in the course of typhoid fever, pneumonia (Blache, West), and cholera. Symptoms and Course. In the great majority of cases, but not always, as some writ- ers suppose, the disease begins with slight catarrhal symptoms, which have been improperly regarded as prodromal. The child becomes fretful, appears uneasy, sleeps more restlessly than usual, loses his appetite, asks frequently for water, sneezes one or more times at intervals without there being any discharge from the nose, complains of burning and itching in the throat, talks with a somewhat husky voice, and even now his cough has occa- sionally a shrill tone. These symptoms, which are usually accom- panied hy a slight fever, gradually become more marked, and if the throat be now examined—as it always should be on the first occurrence of suspicious laryngeal symptoms—there shall be found in the fauces either more or less congestion and enlarge- ment of the tonsils, or signs of exudation, although the child may not have complained of any pain or difficulty in swallowing. The exudation in the throat consists at first of small, circum- scribed, grayish-yellow spots, which are generally isolated, upon the tonsils, uvula, soft palate, and posterior wall of the pharynx. These spots gradually unite to form a more extensive patch of exudation, and in severe cases it may happen, as I have seen, that not only the fauces, but also the hard palate, the tongue, and the mucous membrane of the cheeks are covered with a croupous membrane. When the pharynx is severely affected, the sub- maxillary glands may often even now be found to be enlarged. SYMPTOMS AND COURSE. 239 Even in this stage of the disease, when the child is still able to go about, and manifests at times his usual sprightliness and love of play, the husky voice, the shrill cough, and the presence of croupous patches in the throat will reveal to the experienced physician the full significance of the perilous nature of the dis- ease. These initial symptoms, which may in some respects be called the first stage of the disease, last from twenty-four to thirty-six hours, or even from two to five days, before the characteristic attack of croup is developed. Laryngeal croup does not, how- ever, always begin with these symptoms, which are entirely simi- lar to those of acute laryngeal catarrh, and are anatomically due to a relaxation and tumefaction of the vocal cords ; in rare cases it happens that the croup occurs suddenly, and from the outset assumes its severe form. This form usualby occurs late in the evening or near midnight (between ten and twelve o'clock); the child, who has gone to bed apparently perfectly well, wakes up suddenly after two or three hours of quiet sleep, crying or coughing with a shrill, hoarse voice, and, in very rapid and intense cases, completely aphonic. Almost always his manner is excited and anxious, the skin hot to the touch, and pulse accelerated. As soon as this period of the disease is reached—whether the development of the attack have been gradual, or sudden, as in the fulminant form—there is now superadded a new and highly characteristic symptom, laryngeal stenosis, with its most im- portant sign dyspnea. With this event begins the second stage. The hoarseness increases and becomes permanent. The cough, which is at first shrill and short, becomes barking, and after a while completely toneless. When the patient cries loudl}7, or has a violent fit of coughing there is still heard, however, a hoarse barking sound, which now and then changes from a bass to a high falsetto note. The respirations are more frequent, between twenty-eight and thirty-two to the minute, rarely more ; the respiratory movements are labored, and effected only by the aid of all the accessory muscles, so that the child, tormented by the besoin de respirer, suddenly sits up in bed, straightens his spinal 240 STEINER.—CROUP. column, throws his head backwards, and, in short, does, instinc- tively, all that he can to expand his chest. As the stenosis increases the inspirations become still more laborious and heav- ing ; the child breathes with open mouth; the alse nasi rise and sink violently; the nasal apertures are broadened, in conse- quence of the contraction of the musculi levatores alee nasi; the scapulae and upper ribs are forcibly elevated; the larynx sinks far down with each inspiration, and the xiphoid appendix and the cartilages of the lower ribs are drawn inwards, and form a deep furrow between the chest and the abdomen. Notwithstanding this labored breathing, which requires the aid of all the accessory muscles, only a little air forces its way through the narrowed glottis; the inspirations are prolonged, rather shuffling in character, and, in consequence of the power- ful suction of the air through the narrowed glottis, accompanied by a whistling, sawing, or snoring sound, which not infre- quently can be clearly heard at some distance, and is a most distressing alarm-signal to the parents and physician. In very severe cases, and under certain circumstances to be mentioned presently, the expiration, as well as the inspiration, is accentu- ated or accompanied by a loud rattle. While the inspiratory sound is chiefly of a sawing character, the expiratory more fre- quently has a snoring quality. From time to time, and at intervals which become shorter as the case progresses, the dyspnoea, which has been permanent since the occurrence of exudation on the laryngeal mucous mem- brane, presents exacerbations—the suffocative attacks. A dis- tressing restlessness seizes the poor child; lying or sitting in bed he impetuously begs to be taken in the arms of his mother or nurse, and then immediately to be put back into bed again ; he tosses his hands and feet about; springs up in the bed, or con- vulsively grasps the side of his crib; frequently clutches his neck, as if to remove the obstacle to his breathing, and throws off the bed-clothes; the face expresses great anxiety, and not infrequently is even distorted; the eyes protrude; the frontal veins are swollen, and the respiratory muscles taxed to their utmost capacity—in a word, we have before us the heartrending picture of a child nearly suffocated, tortured with the death- SYMPTOMS AND COURSE. 241 pang ; a picture which draws out all our compassion, and brings home to us, as few other diseases do, the painful side of our calling. These suffocative attacks sometimes last only a few minutes, at other times a quarter of an hour or even more, and usually end in the child's sinking back upon the pillow, and falling into a short, gentle slumber. If now we seek for a satisfactory explanation of these symp- toms, we shall find that the views hitherto prevalent are by no means harmonious, but in many cases are glaringly opposed to pathological and physiological facts. According to Schlautmann and Niemeyer, the dyspnoea in croup is caused and kept up, not only by the narrowing of the glottis from swelling and pseudo-membranous deposit, but also and mainly by the paralysis of the laryngeal muscles. Univer- sally, says Niemeyer, when we have to do with a severe inflam- mation of mucous or serous membranes, we find not only the submucous and subserous cellular tissue, but also the muscles covered by the inflamed membranes, saturated, infiltrated with serum, and pallid. In croupous inflammations these changes in the muscles produce paralysis, and when the muscles which open the glottis are thus affected, dyspnoea ensues, because the entrance of air is more or less impeded. This theory, continues Niemeyer, is supported by the consideration of the anatomy of the glottis in childhood. In children, the triangular space known as the pars respiratoria of Longet, included between the bases of the arytenoid cartilages as they extend forwards and inwards to the vocal processes, is absent; the glottis is in them a rectilinear fissure, and the dyspnoea, when the muscles of the larynx are paralyzed, must therefore be disproportionately greater than in adults, in whom some, if but little, air can at least pass in during respiration through the pars respiratoria glottidis. In paralysis of the laryngeal muscles it is only the inspiration, however, which is prolonged and laborious; the expiration is free and easy. According to Niemeyer, therefore, laborious and lohistling inspiration, with gentle expiration, points especially to a paralysis of the laryngeal muscles; while difficulty in both inspiration and expiration indicates VOL. IV—16 242 STEINER.—CROUP. narrowing of the glottis by false membranes, or an interference with both the entrance and exit of the air. Other writers advocate an entirely different view, and explain the dyspnoea of croup as a purely nervous disturbance in the co-ordination of the respiratory movements. It is supposed by v. Rudnicky' that there is in croup a special irritation of the nerves, and that the focus of this excitation may be situated in different parts. According to the reliable investigations of Ver- son, says Rudnicky, it appears that the branches of the supe- rior laryngeal and recurrent nerves are provided, immediately before they divide into their muscular subdivisions, with numer- ous ganglionic cells. In the posterior fibrous layer of the trachea he found true ganglia, from which distinct bands of nerve-fibres proceeded to the muscular layer of the organ. Hence it is conceivable that the irritation produced in the peripheral nerves by the exudation extends also to the gangli- onic cells, or that the respiratory centres are directly irritated through an altered composition of the blood, or, finally, that both of these causes may act together. Rudnicky, moreover, seeks to break the force of the theory for which Niemeyer con- tends, by showing that explanations, which, like this one, are based upon a misrepresentation of the normal condition of the glottis in childhood, must be fanciful and altogether groundless, and that some laryngoscopical observations made by himself and others (Munk), by demonstrating the mobility of the vocal cords in croup, have proved the existence of the very opposite condition of things to that upon which Niemeyer supports his paralysis theory. Bretonneau, Gerhardt, and others, explain the dyspnoic attacks by the difficulty with which the catarrhal secretion of the bronchi is forced through the narrowed glottis, and thereby transfer the explanation once more to a mechanical cause. Finally, Billard and some other writers still adhere to the hypothesis of a spasm of the glottis. I regard the dyspnoea of croup as the combined result of several causes acting together or in succession. The most 1 Wiener med. Wochenschrift, Nos. 23, 24, 25, 1873. SYMPTOMS AND COURSE. 243 important of these is undoubtedly the mechanical one, viz., the swelling, relaxation, and intense congestion of the mucous mem- brane of the larynx on the one hand, and the false membranes and muco-purulent secretion on the other. To every one who has had frequent opportunities for observing after death the anatomical changes in the larynx of children, and who considers how little is needed to block up the glottis in such patients, it must appear justifiable to infer an intimate causal connec- tion between the dyspnoea of croup and the changes referred to. But, some one will object that the most marked dyspnoea is observed in children during life, without any croupous membranes being found after death, and that the anatomical changes are out of proportion to the symptoms of stenosis. In more than one hundred cases of fatal croup among children, I have always been able to find false membranes in the larynx, though of course more intensely and more widely developed in some cases than in others; but, aside from this fact, it would still be entirely illogical to talk, as Niemeyer does, of a catarrhal cedema and a resultant paralysis of the laryngeal muscles in those cases where no false membranes were found, and where, consequently, no inflammation could have occurred.1 Indeed, every practitioner is aware that an inflammatory swelling of the mucous membrane, whether accompanied by a croupous exuda- tion or not, presents at the autopsy an appearance entirely dif- ferent from its appearance during life. Moreover, there is prob- ably no doubt that the suffocative attacks in croup are caused, and kept up, chiefly by the already narrowed glottis being still further obstructed by loosened shreds of membrane, or by masses of muco-pus. But a part of the dyspnoea, at least in many cases, is due also to the false membranes and to accumu- lations of muco-pus situated in the lower air-passages. In this way, and by the swelling of the mucosa, the respiratory surface is considerably diminished, so as to impede and accelerate the breathing. The correctness of this conclusion is shown by the fact that after tracheotomy the dyspnoea sometimes continues 1 " Wo keine Pseudomembranen vorgefunden wurden, somit keine Entziindung vor- handen sein konnte."— Original Text. 244 STEINER. —CROUP. to be as urgent as before, although the larynx no longer takes part in the respiratory process. To these purely mechanical causes of the dyspnoea of croup may be added another of subordinate importance—the paralysis of the laryngeal muscles; at least some laryngoscopical exami- nations made during the height of the disease favor this view. And yet I cannot agree with Schlautmann and Niemeyer in regarding the dyspnoea as almost exclusively due to this cause. As regards the hypothesis of a spasm of the glottis—a direct or reflected irritation of the respiratory centres (Rudnicky)—it at least has the advantage of stimulating us to farther investiga- tion of the nature of the dyspnoea of croup. The change in the voice can, of course, be explained only by a more or less altered vibratility of the vocal cords. How much of this is due to the swelling and thickening of the vocal cords, and how much to the croupous membranes themselves, it is impossible to decide with certainty; but we know, however, that the swelling is sufficient by itself to produce the so-called croupy voice, because the same symptom occurs in pseudo- croup. The same explanation applies also to the tone of the cough, which, according to the degree of mobility of the vocal cords, is at first sharp, rough, and dry, later, barking or crowing, and, finally, quite toneless. In many cases of croup, especially those which do not run a very violent course, distinct remissions are noticed during the second stage of the disease; the dyspnoea decreases, without disappearing entirely ; the voice regains some of its natural quality, or only shows a crowing impurity of tone ; the cough is less distressing, and the general condition of the child is, on the whole, evidently improved. The fever subsides; the child is able to get a little quiet sleep; even asks again for food, and manifests an interest in the objects about him. These remis- sions, which usually, though not regularly, take place during the morning hours, and are welcomed by the parents with the greatest joy and extravagant hopes, are unfortunately in most cases very delusive, and soon give place to the former, if not to a still more severe dyspnoea. SYMPTOMS AND COURSE. 245 Now and then the remissions occur coincidently with the discharge, by coughing or vomiting, of false membranes mixed with masses of muco-pus, and then the breathing for a time becomes freer. The portions of membrane discharged consist either of irregular shreds of variable size, thickness, and consis- tence, or of tubular casts of the parts, according to the locality from which they are derived (see infra). Frequently it happens that a piece of membrane of some size becomes partially or wholly detached from the mucous mem- brane, and is carried by the expiratory current against the under surface of the vocal cord; in this case both the breathing and the sound accompanying it may be suddenly arrested; then, after a few desperate efforts at inspiration, violent coughing sets in, until the membrane is either discharged or is drawn down into the trachea in inspiration. The movements of these loosened pieces of false membrane produce a flapping sound, which may be heard by the stethoscope placed over the larynx or trachea. In fulminant cases of croup the remissions are entirely absent, and the disease develops so rapidly from the start, with a steady increase of the dyspncea, that death ensues in from twenty to thirty-six hours. If the attack runs a favorable course, as unfortunately hap- pens but rarely, the suffocative attacks become less frequent and violent; the remissions last longer ; the dyspncea visibly dimin- ishes ; the cough becomes softer and loose; the child expecto- rates a large quantity of muco-pus mixed with coagulated flakes and shreds; the aphonia or hoarseness is replaced by a slight huskiness, and afterwards by a louder tone to the voice; the face wears a quieter expression ; the fever ceases; the skin becomes soft and moist; sneezing occurs more frequently, and the nasal mucous membrane, which has hitherto been dry, now begins to discharge ; in short, we have the picture of a laryngeal catarrh gradually progressing to recovery. In the great majority of cases, however, the patient becomes steadily worse, and another group of symptoms is developed, which forms the third stage, or stage of asphyxia. To the signs of laryngeal stenosis are now superadded those of 246 STEINER. —CROUP. carbonic-acid poisoning. The hitherto flushed face and the skin of the child become blanched, pallid, and of an earthy color, afterwards bluish-gray and bluish; the anxious and agitated physiognomy becomes indifferent and dull; the eye is drowsy, languid, and generally half closed; the lips, cheeks, and visible mucous membranes become slightly cyanotic; the dyspncea probably still continues, but the respiratory movements are superficial, and no longer accompanied by the loud stridor ; now and then, however, the child still springs up in a desperate struggle for breath, but only to quickly sink back again ex- hausted into his former comatose condition ; the pulse loses in volume, and becomes very rapid and intermittent; the cuta- neous veins of the extremities become dilated; the forehead is covered with a cold clammy sweat; the extremities grow cold; the skin loses its sensibility ; the consciousness is obtunded, and convulsive movements, or, as I have often seen, carpo-pedal spasms and trismus occur ; in short, both the mental and bodily power of resistance against the deadly disease is broken, and death, if the patient have survived the danger of suffocation, takes place with the symptoms of complete exhaustion. That this train of symptoms is due chiefly to the overloading of the blood with carbonic acid, in consequence of the impedi- ment, and finally, almost complete obstruction, to the admission of air, is amply proved by the previous explanation of the mechanism of croup. Bartels has found in the expired air as much as 3.27 per cent, of carbonic acid. For a long time it was supposed that the cerebral symptoms at least ought to be ascribed to an engorgement of the cerebral and meningeal ves- sels ; but to this view Niemeyer has opposed the consideration that when the air is prevented from entering the glottis, the suction-force of the lungs, which draws the blood from the veins outside the chest into those within it, becomes increased on each deep inspiration, so as to diminish rather than to increase the amount of blood in the brain. That this condition of the circulation does not, however, obtain towards the end of the disease, is shown by the fact that at the autopsy the meningeal and cerebral vessels are very generally found distended with blood. The striking paleness of SYMPTOMS AND COURSE. 247 the skin, however, may be due to the aspiration of blood into the intra-thoracic veins. As regards the febrile movement, it may be said in general that the number of accurate registrations is yet too small to establish any definite laws, and that the curves of the tempera- ture and pulse present different appearances according as the disease runs a rapid or a protracted course. Thus we find cases in which the temperature during the whole course of the disease scarcely reaches or exceeds 101.3° F.; and again others, with a violent onset, where the temperature is as high as from 104° to 1<)5.8°. The latter elevation is common, if the case be compli- cated with extensive bronchitis or pneumonia. Should the inflammation of the respiratory mucous membrane advance slowly, and with clearly marked aggravations, the fever curve will present corresponding irregularities. The highest temperature usually occurs in the second and at the beginning of the third stage, but exceptions to this rule, it should be remembered, are frequently met with where compli- cations or an extension of the disease occur. The pulse at the outset of the disease is moderately accel- erated (between 120 and 130), and at the same time full and hard. During the second stage it maintains this frequency, but often rises twenty or thirty beats on the occurrence of aggrava- tions, and during the remissions falls by as many beats or even more. In rare cases only is the pulse retarded. In the stage of asphyxia it is always very rapid (from 140 to 160 cr even 180), and at the same time small, very compressible and intermittent. Any considerable extension of the membrane to the bronchi, or the intercurrence of croupous pneumonia, is sure to increase the frequency of the pulse. Among the other symptoms, which are of greater or less fre- quency in croup, should be mentioned the enlargement of the submaxillary and lateral cervical glands, a sign which is always found when the pharynx is implicated in the croupous- diphtheritic deposit. Albuminuria is also noticed, more fre- quently in diphtheritic, but also in true croup. Digestive derangements are uncommon, if we except the diarrhoea which is occasioned by the still frequent use of tartar- 248 STEIXEK.—CROUr. ized antimony as an emetic, and which in many children sets in even after the first doses, and often continues until death. Croup of the stomach, which I have sometimes seen as a com- plication, produces repeated vomiting, and severe colicky pains, but when emetics are used it is difficult to say how much this symptom is to be reckoned to their account. Choleraic gastro-enteritis, which, in my experience, occa- sionally complicates croup, gives rise to the symptoms character- istic of this affection, such as vomiting and repeated flatulent, watery evacuations from the bowels. Another symptom, which should probably also be regarded as an effect of carbonic-acid poisoning, is the paralysis of the vagus nerve, in consequence of which even the strongest emetics fail, during the latter part of the disease, to produce any effect, or only very slight vomiting ; while, immediately after tracheotomy, when the air enters more freely, and the blood is rid of its excess of carbonic acid, repeated vomiting occurs as a result of the emetics still retained in the stomach. In regard to the presence or absence of special pain in the region of the larynx, opinions differ. If I can trust the state- ments of some of the older children, the croupous inflammation in the larynx does produce a stabbing, squeezing pain, which occurs spontaneously, but is felt more particularly when the larynx is touched or compressed. The laryngoscopical examination in children with croup is very difficult, especially when the throat is also affected, and in the majority of cases, particularly if the child be quite young, almost impossible. The difficulty arises chiefly from the stenosis and the great restlessness of the patient. Munch gives us a minute description of his laryngoscopical examination of a boy ten years of age. The mucous membrane of the larynx was much reddened; a marked membranous deposit covered the ary-epiglottidean ligaments, and still more copiously the vocal cords; the glottis was narrowed, partly by the deposit upon the vocal cords, and partly by the paresis of the dilator muscles—the posterior crico-arytenoid. Later the whole larynx appeared to be covered with membrane; at the same time it was noticed that the edges of the vocal cords were apparently agglutinated to each other at various points by a layer of fluid exudation. Subse- quently the deposit disappeared under the continued use of caustics, but was SYMPTOMS AND COURSE. 249 renewed daily, until finally only a thin, gauzy layer of membrane was noticed, which returned again and again with great obstinacy, especially upon the vocal cords. The vocal cords ultimately resumed their function, and manifested con- siderable vibratility, even while some of the membrane remained. By the sixteenth or eighteenth day the normal white color of the vocal cords was restored, and here and there a reddish streak was all that could be noticed. Ziemssen found the entrance to the larynx abnormally reddened, and covered with a layer of exudation, with swelling of the vocal cords, which were coated with a grayish-white substance, and immovable. Anteriorly their borders were in contact, but posteriorly they were separated by a narrow slit, which was broadest at the posterior commissure. Jaksch, in a boy thirteen years of age, found the vocal cords separated by a distance of four mm. Similar appearances are recorded also by Tiirck, Semeleder, Levin, Tobold, Benecke, and R. Forster. In only a very few cases is the exudation limited to the larynx. Usually, as has already been mentioned, and as we shall again insist (see infra), pseudo-membranous deposits occur also in the throat and cavity of the mouth. Moreover, the mucous membrane of the trachea and bronchi is often impli- cated in the croupous inflammation, and then we have the laryn- geal croup complicated with a tracheo-bronchitis crouposa, which not infrequently extends into the bronchioles, and thus seriously increases the danger to life. When the case runs a rapid course this complication frequently arises quite early in the disease, but in other cases, with a slower progress, not until later; and, when tracheotomy has been performed, I have often satisfied myself that there were no signs of bronchitis until two or three days after the operation. During the continuance of the stormy manifestations of laryngeal stenosis, the symptoms of bronchial croup are by no means sharply and clearly defined, and, in my opinion, it is impossible to recognize them with certainty at this period. Some writers—Peter and others—hold that feebleness of the respiratory murmur, urgent dyspncea, and marked depression of the epigastrium are pathognomonic of bronchial croup, but I have no faith in these signs, at least before tracheotomy. The loud, whistling, sawing sounds in the larynx usually overpower the pulmonary vesicular murmur so completely that the latter 250 STEINER.—CROUP. cannot be heard at all, or only feebly; how could it be other- wise in view of the small quantity of air, which is only with dif- ficulty drawn into the lungs? After tracheotomy, however, the case is different. The larynx is, for the time being, no longer a part of the respiratory tube ; a new air-passage has been formed, and now the state of the lungs and bronchi can be determined by a physical examination. If, after tracheotomy, the breathing becomes more difficult and rapid ; if, on auscultation, the vesicu- lar murmur is feeble and uncertain, and crackling rales are to be heard here and there, then there can be no doubt that the bron- chi have taken part in the croupous exudation. How cautious one ought to be in diagnosticating this complication, I have often experienced. Not infrequently just before tracheotomy I have found, over a whole lung, very feeble breathing, or at a particu- lar spot the percussion note evidently shortened, or the breath- ing uncertain, so that I have been apprehensive of incipient pneumonia, and yet, after the windpipe was opened, the respira- tion over that part became loud and clear, and the dulness on percussion entirely disappeared. Peter has recorded similar experiences, and has called attention to this possible source of error. Of course the most certain sign of bronchial croup is the expectoration of false membranes in the form of tubes, varying in length and thickness, and in rare cases even representing the branchings of the bronchi. If the bronchitis is already present when the laryngeal steno- sis is at its height, the relief afforded by opening the windpipe will be but slight, and generally only temporary. When the bronchial croup does not occur until after the operation, the symptoms above described may not set in for several hours, or even days. Croupous bronchitis is unquestionably more frequent in cer- tain localities and at certain times than at others; hence the differences of statistics. Bronchial catarrh is another almost constant accompaniment of croupous laryngitis. Niemeyer says, that "the compara- tively insignificant results of tracheotomy in protracted croup are due solely to this complication, whose frequency can easily be shown to be a necessary result. When the thorax expands, SYMPTOMS AND COURSE. 251 and the pulmonary alveoli enlarge, without admitting a propor- tionate quantity of air, the air in the bronchi and alveoli must become rarefied, and must act upon the bronchial mucous mem- brane and inner wall of the alveoli in the same way as a cupping- glass does upon the skin, producing hyperaemia and increased transudation from the vessels in consequence of the diminished pressure upon the walls of the vessels." In this explanation of the bronchial catarrh in croup—an explanation the force of which cannot be denied—Niemeyer has, it seems to me, laid too little stress upon the inflammatory element, and too much upon the physical cause of the catarrh. I shall refer to this point again in the section on the pathology. Pneumonia is a much rarer complication of croup than is commonly supposed. Sometimes it occurs in a lobular, less frequently, in a lobar form. In seventy-two autopsies I found the former variety only eight times, the lobar diffuse pneu- monia only six times ; hence I am surprised that some writers regard pneumonia as one of the most frequent complications of croup. Difficult as is the diagnosis of croupous bronchitis during the height of croup, and especially before the windpipe is opened, the signs of pneumonia are equally uncertain. The lobular form presents no symptoms, either of an objective or of a subjective character, which are at all characteristic, and what symptoms there are, as has already been mentioned, are almost completely masked by the laiyngeal stenosis. If the pneumonic infiltration be very extensive, perhaps it may be recognized by more or less dulness on percussion; still even here the experience of Peter and mj^self shows that mistakes may easily occur. In my own opinion, the physical signs of pneumonia are to be relied upon only when they continue, or are more distinctly pronounced, after tracheotomy. If pneumonia, especially the lobar form, first develops some time after tracheotomy, the usual symptoms are a renewed frequency of the pulse, an elevated temperature, increased dyspncea up to fifty or sixty respirations per minute, and in older children sometimes a marked initial chill. Some writers have supposed that laryngotomy favors the occurrence of pneumonia, but this supposition is based neither upon theory 252 STEINER.—CROUP. nor experience. Pneumonia, like other complications of croup, usually runs quite an acute, and generally an unfavorable course. The previous remarks in regard to lobular pneumonia will apply almost entirely to the atelectases, which are frequently found in children dying of croup. These lesions are most com- monly situated in the lower and posterior parts of the lungs, and vary both in number and size. Unless they are of considerable extent, auscultation and percussion are of but little avail for diagnosis. Pulmonary apoplexy, with pulmonary hemorrhages, and pulmonary gangrene, are rarer complications. The latter affec- tion, which I once saw in connection with diffuse pneumonia in a child five years of age, can of course be detected by the charac- teristic fetor of the breath and expectoration ; but it should be borne in mind that, especially in diphtheritic croup, even the bronchial secretion may be ichorous, and of an offensive odor, without the presence of pulmonary gangrene. Secondary croup, which develops in the course of various acute and chronic diseases, occasionally presents the same symp- toms as the primary affection, but in the great majority of cases its course is milder, and less marked by those severe and stormy disturbances which characterize primary croup. As a rule, the exudation in secondary croup is less copious, and the symptoms of stenosis are but slightly marked or entirely absent; in fact, I have seen cases in which there were no indications of laryngeal disease during life except more or less hoarseness. The severity of secondary croup seems to diminish also with the age of the patient; hence the more favorable reports from those whose experience has been with patients of a more mature age. Among children it is not at all uncommon to see secondary croup present the same malignancy as the idiopathic form of the disease. I can recall such cases in my own experience, occurring during the course of measles, scarlet fever, whooping-cough, etc. And yet it must be admitted that when the secondary croup occurs as an expression of a pyaemic process, or during the course of an exhausting chronic disease, it usually assumes a mild form. To state, however, as many text books do, that this SYMPTOMS AND COURSE. 253 is universally the case, and to compare secondary croup merely with acute laryngeal catarrh, is obviously an error. The older writers have divided croup, according to its mode of development, into a descending (C. descendens) and an ascend- ing form (C. ascendens). The former include those cases in which the membrane usually begins in the throat, and gradually extends downwards into the larynx, trachea, and bronchi, and in rare instances to the mucous membrane of the oesophagus and stomach. This mode of development is by far the most frequent. As ascending croup were described those cases in which shreds or tubes of false membrane were expectorated or vom- ited, even before there were any symptoms of laryngitis, the laryngeal affection making its appearance subsequently, and membrane forming finally in the fauces ; the inflammation also pursuing the same reverse course from the air-passages to the cavity of the throat. Cases of this kind have been described by Jurine, Nonet, Hirtz, Salomon, and others, but recently there has been a disposition to doubt or to entirely reject the existence of such a form of croup. In support of the old opinion I can cite from my own prac- tice four well-marked cases of ascending croup. In each case the disease began with slight febrile symptoms, more or less cough of a painful character, and dyspncea. After from four to six days, while the voice was still completely sonorous and without any indication whatever of laryngeal obstruction, croup- ous membranes were expectorated. Towards the end of the first week, and in two of the cases on the fourteenth day—the fever still continuing—hoarseness occurred, followed by laryn- geal stenosis in its full intensity, and, shortly before death, by the deposit of false membrane upon the faucial mucous mem- brane. In each case the disease was ascribed to a severe chill; three died, and one, a girl five years of age, recovered. Rare as such cases certainly are, their occurrence is unques- tionable. As a rule croup is an acute disease, generally terminating within a few days, but occasionally running a more tedious course. In a child five years of age I have seen false membranes upon the mucous membrane of the bronchi even forty-nine days 254 STEINER. —CROUP. after tracheotomy. In many very rapid—the so-called fulmi- nant—cases, the whole course of the disease is not longer than from thirty-two to forty hours; on an average the attack lasts from four to six days, but exceptionally as long as even three, four, or more weeks. The usual method, and the one adopted in this article, is to divide the course of the disease into three stages. The first, which is also called the catarrhal or prodromal stage, embraces the signs of pharyngitis and the early manifestations of disease on the part of the larynx; it usually lasts from one to three days, but in the very rare fulminant cases this stage may be absent. The second stage begins with the occurrence of laryn- geal stenosis, and continues sometimes only one, sometimes several, and occasionally even fourteen days. The third stage, or the stage of asphyxia, with its symptoms of carbonic-acid poisoning, is ordinarily the shortest, and usually lasts only from thirty-six to forty-eight hours. The duration of the disease is furthermore influenced by the age of the patient, as has already been mentioned, by the operation of tracheotomy, and also by the genius epidemicus. If the disease terminates favorably, the recovery is generally complete, and the hoarseness, which sometimes remains, entirely disappears after a time. In rare instances, however, the case results in cicatricial narrowing of the larynx, with aphonia and difficulty in breathing, or—as Schindler and myself found at one autopsy—in complete occlusion of the cavity. The child was obliged to wear a canula for more than a year, when death resulted from the supervention of hydrocephalus. Paralysis of the vocal cords, continuing for a longer or shorter time, is another occasional sequel. For anatomical as well as clinical reasons the conditions in adults are on the whole much more favorable. The cavity of the larynx is much wider, while the muscular and cartilaginous structures are better able to withstand the force of the disease- considerations which serve to explain in part the superior endur- ance of adults over children. In the majority of cases, especially where there has been no operation, death is caused by general paralysis from carbonic- PATHOLOGICAL ANATOMY. 255 acid poisoning ; more rarely by suffocation from complete occlu- sion of the glottis by a piece of loosened membrane. Among the other causes of death are croupous bronchitis, diffuse catarrh of the air-passages, pneumonia, oedema glottidis, and acute oedema of the lungs. The latter complication is specially to be apprehended when the stenosis is severe, because then the suction-force of the lungs is considerably increased in conse- quence of the partial exhaustion of the contained air, and pul- monary engorgement is more readily produced. Hemorrhages from ulceration of the trachea or perforation of the innominate artery—accidents which have several times been observed after operations in children—laceration of the air-passages, uraemia, and diphtheritic septicaemia are also occasional causes of death. The greatest mortality occurs during the first five years of life; after this age recovery is far more frequent. Pathological Anatomy. The pathologico-anatomical changes which belong to laryn- geal croup vary according to the stage, extent, and complica- tions of the disease. The first alteration at the outset of the disease is a more or less intense hyperemia ; the mucous membrane of the larynx is of a bright red color, swollen, and sometimes dotted with minute ecchymoses, but at the autopsy the hyperaemia may have entirely disappeared, or be scarcely noticeable. Soon after this, along with relaxation and swelling of the submucous cel- lular tissue, there forms upon the free surface of the mucous membrane an exudation, which is sometimes merely a mode- rately thick pellicle, but more frequently a thin, gauzy, or a firm, tenacious false membrane several lines in thickness. The color is sometimes whitish 3-ellow, at other times gray, brownish, or even blackish yellow, from admixture of blood, etc. Upon the external surface of many membranes may be found here and there red points or streaks of adherent blood. The thinner and softer false membranes are but loosely attached to the mucous membrane and may be easily removed, but those which are firm and solid are more intimately adherent. It has been repeatedly asserted that in rare instances no 256 STEINER. —CROUP. croupous membrane is to be found at the autopsy of children, who have died of croup. The exudation may, it should be remembered, have been present during life in a fluid or coagu- lated form, but have been expectorated before death; and in general it may be said that the post-mortem lesions in croup present a different appearance at different times, according to the stage of development of the disease, and can be judged of only in connection with the clinical picture. The croupous exudation, in the form of thinner or thick shreds and flakes, or even casts, sometimes fills up the laryngeal cavity completely, but its favorite situation is upon the vocal cords, which are usually covered uniformly, and sometimes so thickly, by the deposit, that the glottis is narrowed considera- bly, or even entirely occluded. The ventricles of Morgagni are also more or less coated and obliterated. The external surface of the epiglottis and arytenoid cartilages usually remains free, while on the inner surface traces or larger quantities of croupous exudation are almost always present. Sooner or later the false membranes become loosened by the exudation of serum on the underlying mucous membrane, after a while separate entirely, and are expectorated in the form of larger or smaller irregular jagged shreds, or of connected mem- branes or tubes. After the first membrane is exfoliated a second soon forms, then a third, and so on until death ensues from one of the above- mentioned causes, or recovery takes place from the membranes ceasing to form again, and the epithelium is renewed on all parts of the mucous membrane which had been occupied by the exu- dation. Examined microscopically, the croupous membrane, which may occasionally be as much as three or four millimetres in thickness, is found to be composed of amorphous or fibrillated fibrine, in which numerous young cells are entangled. As to its chemical composition, the membrane resembles most closely coagulated fibrine, and is soluble in alkalies, and especially in lime-water—a property which has been known for some time, but was never utilized therapeutically until recently by Kuchenmeister. PATHOLOGICAL ANATOMY. 257 Opinions still differ on some points in the histology of the croupous exudation in general and of that of the air-passages in particular. According to E. Wagner—whose numerous and thorough investigations have shown that there is no sharp divid- ing line between diphtheria and croup, an opinion with which I must entirely agree—the croupous membrane, as it begins to form, is composed of a thick network of delicate, very fine threads, whose interstices are occupied by numerous bodies essentially like ordinary pus-corpuscles. This network is pro- duced in croup, just as in diphtheria, by a peculiar metamor- phosis of the epithelial cells, which consists in the cells at first becoming enlarged, and then developing long prolongations, by the coalescence of which a network is formed, which acts as a matrix for the newly-formed cells. In most cases the croupous membrane lies so loosely upon the mucous surface as to be readily detached, being separated from it by a thin layer of muco-purulent fluid, which contains ordinary pus-corpuscles, isolated cylindrical epithelial cells, sometimes ciliated epithelium, and a few blood-corpuscles. Ac- cording to E. Wagner true croup, as well as true diphtheria, may occur on the gums and throat, as well as in the large air- passages ; but most frequently the two diseases seem to shade into each other; i.e., the affection appears on the gums and throat as diphtheria, in the upper part of the larynx as diph- theritic croup, and in the lower part of the larynx, in the trachea and large bronchi as croup. In opposition to these views of E. Wagner, F. Steudener regards the croupous membrane as an exudation produced by the migration of numerous white blood-corpuscles from the vessels of the mucous membrane, and the direct formation of fibrine from the transuded blood-plasma. He denies that the epithelium takes any such part in the formation of the matrix of the croupous membrane as was supposed by E. Wagner, and says that he has succeeded in observing the first stages of this kind of transformation in cylindrical epithelium, as Wagner has described it, for the pavement epithelium of the pharynx. An exclusively endogenous origin of the cellular elements of the croupous membrane seems to him improbable ; indeed he is VOL. IV.—17 258 STEINER.—CROUP. sceptical whether pus-cells are ever formed in epithelium by endogenous growth. Boldyrew has also been led by some investigations of his own to reject the epithelial origin, of false membranes, and supposes that the latter are produced by the coagulation, in successive layers, of a fibrinous fluid which exudes upon the surface. He calls special attention to the parallel stratification of the mem- brane so often observed in croup, and to the occurrence of peculiar spherical bodies, presenting a concentric stratification with a cloudy mass at the centre composed of minute granules. Hallier, Jaden, Laycock, Wade, Oertel, and Klebs believe that they have discovered the nature of the croupous diphtheritic exudation in the generation of fungi. In opposition to this view it is only necessary to say that if vegetable parasites are found upon such exudations, they are probably merely accidental, and are not an essential part of the disease. Karsten' has recently very properly again pointed out that the bacteria, vibriones, micrococcus, etc., which are found in the interior of organs during disease or after death, and which are supposed to be the carriers of contagion, are merely pathological cellular structures like pus and yeast cells, because one can in fact satisfy himself by careful examination that they originate within the cells of animals and vegetables, and do not grow into them after the manner of parasites. The extent of the croupous exudation is modified in various ways by the age and idiosyncrasy of the patient, by the charac- ter of the epidemic, and probably also by certain conditions of soil and climate. In the majority of cases of croupous laryn- gitis the organs of the throat are involved in the exudation, and form the starting-point of the inflammation (croup descendens). Occasionally, however, the deposit is entirely absent from the fauces, but in such instances more or less intense redness can always be discovered. The exudation occurs sometimes in the form of true croup, and sometimes in a diphtheritic form, but the wretched confusion and uncertainty which still prevail among physicians in regard to the theory and nomenclature of these two processes, would make it difficult to collect statistics 1 Wiener med. Wochenschrift, No. 39, 1873. PATHOLOGICAL ANATOMY. 259 showing their relative frequency; moreover, it must be frankly confessed that it is not always easy during life to make a clear diagnosis. Among twenty-one carefully recorded cases, recently under my observation, I found the throat covered with a croup- ous diphtheritic exudation in twenty; in the other case it was markedly congested. In laryngeal croup not only the pharynx, but also the trachea, and the large, medium-sized, and small bronchi are frequently affected in the same way. Thus, in the trachea and larger bronchi we often find firmly coherent, even dendriform tubes, and in the finer bronchi croupous cylinders, or a shreddy, flaky exu- dation. As regards the structure of the false membranes in the different parts of the air-passages I can confirm the statement of E. Wagner, that there is no essential difference between them, except that in general, as we proceed downwards, the number of cells becomes greater, and the fine network more scanty and delicate, until finally the croupous bronchitis has changed into a purulent or muco-purulent one. The implication of the trachea and bronchi is, at least with us, very common; in fifty-five autopsies of children I found that in thirty-one the croup had extended to the larynx, trachea, and bronchi, with casts even in the smaller tubes ; in nineteen the false membranes were limited to the larynx and trachea, with purulent or muco-purulent secre- tion on the mucous membrane of the bronchi, especially those of the first and second order; in the other five cases croupous deposits were present only in the throat and larynx, with muco- pus in the trachea and bronchi. It is to be particularly noticed that in all these cases false membrane was demonstrated in the laryngeal cavity, and it is safe to say that the absence of exuda- tion, to which some are so ready to appeal, is unquestionably the very rare exception. During an epidemic of croup in Konigs- berg, Bohn found in twenty autopsies the trachea affected six- teen times, and the bronchi only thrice. In one hundred and forty-four autopsies Peter observed catarrh forty-four times, croup thirty-two times, and in only eleven an absence of lesions in the bronchi, but in fourteen of the cases no attention was paid to their condition. Bretonneau in thirty-two cases found the air- passages unaffected only once. Rilliet and Barthez state that 260 STEINER.—CROUP. the croupous membrane extended as far as the bronchi in only one-third of their patients. Houssenot also found the same result in one hundred and forty-two autopsies. In North America the implication of the bronchi seems to have been noticed very frequently; while in England during recent epidemics it has been strikingly rare. The extension of the croupous exudation to the oesophagus and stomach is certainly exceptional; I have noticed it only twice. The condition of the lungs varies; but certain changes, which are the necessary results of the croup, are almost always ob- served, more particularly a usually considerable degree of hyper- emia, and more or less extensive emphysematous dilatation of the lungs resulting from the extraordinary exertions of the respiratory muscles and the expansion of the thoracic cavity. The latter condition, as Peter has observed, may even result in laceration of the pulmonary vesicles, and the production of inter- lobular and cutaneous emphysema. More or less numerous atelectases, especially in the posterior inferior portions of the lungs, are also frequent, either from the plugging of the bronchi by membranes or by an abundant muco-purulent secretion, or from paralysis of the respiratory muscles. The development of such atelectases is particularly favored by the rachitic chest. Pneumonia occurs sometimes in a lobar, sometimes in a lobular form. Its frequency has been variously stated. While I, in the seventy-two autopsies previously referred to, was able to discover lobular pneumonia only eight times, the lobar form only six times, and either form in only about one-fifth of all the cases; Peter found pneumonia in three-fourths, and Rilliet and Barthez in five-sixths of their cases. The bronchial and pulmonary glands in croup are also, as a rule, in a condition of hyperemia and hyperplasia. In many cases I have found pleuritic adhesions. They have always been upon the same side as the affected lung, and have generally been soft and easily detached. In two boys, one three and a half and the other five and a half years old, I found ecchy- mosis of the pleura. The heart is occasionally distinctly hypertrophied, and in DIAGNOSIS. 261 rare instances the muscular substance has become fatty. J. Bridges states that in the majority (!) of his cases he found endocarditis of the auriculo-ventricular valves, but this expe- rience must be regarded as unique. Grerhardt and myself have repeatedly seen acute enlargement of the spleen not only in diphtheritic but also in true croup. The kidneys are either normal, or present the early lesions of Bright's disease. I have several times met with fatty liver. Enlargement of the solitary glands in the intestinal canal, especially in the small intestine, has been observed by R. Maier and myself in all children dying of croup, whether they have been operated on or not. In many cases the brain is much congested; the menin- geal vessels, even to their minutest ramifications, are engorged, and the cut surface of the brain is dotted with numerous points of blood of various sizes; in three instances I also found con- siderable serous effusion in the ventricles, and once marked cedema of the brain. Diagnosis. When croupous laryngitis has once become fully established, the diagnosis usually presents no important difficulties. It rests chiefly upon the sudden occurrence of hoarseness or aphonia, the barking cough, the signs of stenosis of the larynx—par- ticularly the constantly increasing dyspncea—the suffocative attacks, the continuous fever, the enlargement of the submax- illary glands, and—what is most significant in connection with these disturbances—the discovery of croupous membranes. While in the throat the presence of these membranes coinciding with hoarseness is a symptom pointing with considerable prob- ability to true croup, their detection in the expectoration and vomited matters may be regarded as an unfailing indication of the disease. In order to be sure of finding the false membranes in the expectoration, it is advisable to examine the sputa in water so as to set the membranes free. The absence of false membrane from the fauces does not always, however, contraindicate the existence of croupous laryngitis, because, as has already been pointed out, the throat may remain unaffected even in true croup. 262 STEINER.—CROUP. The most certain diagnosis is, of course, to be obtained by a laryngoscopical examination ; but unfortunately this is possible only in a very few cases, and then only in older children. At the height of the disease, and in very young children, even phy- sicians of much experience in laryngoscopy fail to accomplish their object, and Pauli is not far from right when he says, that for the diagnosis of croup the laryngeal mirror is not only inefficient but superfluous. True croup, especially at its outset, is most readily con- founded with catarrhal laryngitis, the so-called pseudo-croup. The careful consideration of certain points will clear up any doubt, although in many cases not until the second or third day. Thus in pseudo-croup the morbid symptoms are upon the whole never so intense and continuous as in the genuine form. The fever in false croup is either entirely absent, or only very slight and transient. The tone of the cough may be hard, rough, and barking, but the voice is never so hoarse, or so completely extinct, as in true croup. In pseudo-croup the dyspncea is never so severe and obstinate, the suffocative attacks are less frequent and weaker, and usually occur at the very beginning of the disease, but in true croup not until a later period. Croup- ous membranes in the fauces, and symptoms of permanent stenosis and asphyxia indicate croupous laryngitis, while fre- - quent sneezing and coryza, a soft moist cough alternating with shrill, rough tones to the cough, quiet sleep, and gentle inspira- tions unaccompanied by a loud stridor, are symptomatic of laryngeal catarrh. Experience shows that children who are subject to attacks of hoarseness and barking cough after catching cold, almost never suffer from genuine, but often from false croup. In families where one or more children have already been ill with or have died of true croup, every attack of hoarseness should be regarded with alarm, and as probably indicating true croup. At the beginning of measles or whooping-cough, hoarseness and a barking cough generally signify only a laryngeal catarrh ; but when the same symptoms occur at the height of these diseases, or during convalescence, true croup may often be suspected. Croup can be confounded with edema of the glottis only PROGNOSIS. 263 when the individual symptoms are superficially considered. The history of the case, and a careful examination, will always put one on the right track. The symptoms of retro-pharyngeal abscess present a remote resemblance to those of croup, particularly the gradually in- creasing difficulty in breathing, the great restlessness on lying down, and the snoring respiration. When the abscess is of idio- pathic origin it occurs most frequently in nursing children, in whom croup is almost never observed. If the abscess be s}^mp- tomatic, and dependent upon spinal disease, the latter will decide the diagnosis. Moreover, retro-pharyngeal abscess always develops more insidiously than croup, and without its acute stormy symptoms. Prognosis. Croup is, under all circumstances, a deadly disease, and the prognosis is in general extremely doubtful. If certain phy- sicians—generally homoeopathists or hydropathists—boast of brilliant cures, while practitioners of known ability and honesty confess to the most dreadful losses, the explanation lies simply in the fact that none but swindlers or ignoramuses indulge in such vaunts. Healthy, robust children succumb just as certainly as the feeble, or as those wbo are suffering from chronic diseases. Diphtheritic croup is fully as dangerous as the true idiopathic form. The prognosis varies also with the age of the patient, being much more serious in early life, and somewhat more favor- able with increasing years. Sporadic cases of croup are gener- ally found to run a less dangerous course than those which occur during an epidemic. If the exudation is confined to the larynx and trachea the prospect of recovery is much better than if the membrane has extended far down into the bronchi. Ful- minant cases run a more malignant course than the more gradual cases. Croupous bronchitis and pneumonia seriously increase the danger. A speedily fatal termination is to be expected from the presence of the following symptoms : severe and continued dyspnoea, frequent suffocative attacks, high fever, pallor, and a steel-gray color of the face, impaired consciousness, great fre- 264 STEINER.—CROUP. quency and intermittence of the pulse, spontaneous vomiting, and a frequent desire to go to stool. On the other hand, pro- longed remissions, the easy separation and expectoration of the false membranes, a steady fall in the pulse, decrease in the dyspncea, and less shrillness of the cough, with the presence of mucous rales, justify the hope of a favorable termination. If, after tracheotomy, the dyspncea continues, the child still remains somnolent and feverish, and the canula is dry, a fatal result may be expected; but if the operation be immediately followed by relief to the dyspnoea, and by a disappearance of the symptoms of carbonic-acid poisoning, with a moderately abundant, non-offensive discharge from the canula, the prog- nosis is more favorable. The proportion of recoveries is stated by all writers of honesty and diagnostic skill as lamentably small. Out of quite a large number of cases occurring in my practice, before I had adopted the operation of tracheotomy, I saw but three recoveries ; since 1863, however, this discouraging rate has been so much improved by the employment of trache- otomy that the mortality has at different times amounted only to sixty, sixty-five, and seventy per cent. Bricheteau states it at sixty-nine, Franque at sixty-eight, Trousseau at fifty, and G-reve in Sweden at twenty-three per cent. Treatment. In view of the general facts—which seem to be now well established—that many families exhibit either a hereditary or an acquired predisposition to croup ; that the disease is favored by certain conditions of weather, especially sudden changes of temperature, and by the prevalence of north and north-east winds, and that the diphtheritic form is unquestion- ably contagious, it is proper to consider here the importance of certain prophylactic measures. When such a predisposition exists the child should be cautiously subjected to a process of hardening, for which purpose nothing is better than cold ablu- tions of the neck and chest, begun early in life and persistently and systematically carried out, together with the use of cold- water gargles several times daily. If the clothing be adapted to TREATMENT. 265 the age of the child and to the season, it is unnecessary to be too anxious about exposure to fresh air. If the family, on the father's or mother's side, have exhibited a tendency to croup, the parents should be admonished of the risk of sending the child out of doors during the prevalence of cold dry winds. When an epidemic of diphtheria is raging, the frequent inspection of the throat should not be neglected, in order to discover the first indications of the disease, and when they have made their appearance the patient should be isolated without delay. As soon as a membranous exudation in the throat is detected it should be treated energetically. If the patient be old enough to know how to use gargles, these may be employed: such as lime-water with equal parts of distilled water, or chlorate of potassa, from twelve to sixteen grains to the ounce for children, and fifty for adults. If the patient be too young, or do not possess the knack of gargling, the above-mentioned fluids may be injected into the throat, or the parts maj^ be touched with lunar caustic. In the case of restless or refractory children the stick caustic is dangerous, and should be replaced by a strong solu- tion (two drachms to the ounce), applied by means of a thick camel's hair-pencil, or a small piece of sponge attached to a whalebone rod. The latter instrument is especially useful, when it is intended to apply the caustic solution as far as the entrance of the larynx or to its interior. Besides these, other local remedies are recommended, some of which act as caustics, while others are said to affect the solu- tion of the false membranes ; they may be used either for brush- ing the throat or for inhalation in the form of spray—for exam- ple, chromic acid (twenty-four grains to the ounce of distilled water) by Lewin, the tincture of iodine, hydrochloric acid, by Rilliet and Barthez, lactic acid by A. Weber, sublimed sulphur by Barbosa, chloride of iron (from nine to twelve grains to the ounce of water) and alcohol (two parts with one of water). I have tried them all, but have found none so efficacious as the remedies previously mentioned, especially the lime-water. As far as the special treatment of laryngeal croup is con- cerned, it must unfortunately be admitted that, notwithstanding 266 STEINER.—CROUP. the great number of external and internal remedies which have from time to time been used and recommended, we do not at present possess any which directly influence the morbid process and upon which we can rely with full confidence. I hope, therefore, that I shall be permitted, without incurring the charge of ignorance in regard to the literature of the subject, to pass over in silence most of these remedies which have come to us from known and unknown sources. Literature has, to be sure, been inundated with them, but the real object has not in the least been advanced. To follow the indications of the disease itself, let us first consider the antiphlogistic method, although no brilliant results can be claimed for it. The abstraction of blood, especially locally by means of leeches, is even at the present day practised and defended by many. I have never used this mode of treat- ment in croup, because I cannot satisfy myself that it is possible for bleeding to check or abort the inflammatory process, or to prevent the formation and spread of false membranes ; nor have I ever seen any benefit derived from leeches in those children who were treated in this way without my consent. In case, however, it be decided to try leeching—which would be excusable only with strong, full-blooded children, but never with the feeble, anaemic, or scrofulous, or with those who have diphtheria—from two to six leeches, according to the age of the child, are to be applied to the manubrium sterni, but never to the laryngeal region, because in the latter locality it is difficult to control the hemorrhage which is apt to occur, and because, moreover, the leech-bites would probably be an annoyance if tracheotomy had to be performed. Far more entitled to be considered a true antiphlogistic is the rational use of cold, preferably in the form of frequently changed cold compresses about the neck. These applications should be kept up without interruption, so long as the disease presents the character of an inflammation, or the exudation con- tinues to spread. As soon as the symptoms of carbonic-acid poisoning or depression occur, this treatment should be discon- tinued. Many writers, especially the professional hydropath- ists, are not satisfied with the merely local use of cold water, TREATMENT. 267 but employ also the wet-cold sheet until a general perspiration is induced. Cold baths are also recommended (Bartels). In the present hopeless condition of the therapeutics of croup, no objection can be made to this treatment, but no more is to be expected from it than from the local application of cold. It should be mentioned, however, that many families have an unconquerable prejudice against cold water, but—to the praise of the laity be it said—the fear of this mode of treatment is gradually disappearing. Certain authorities—among whom are some whose opinion is entitled to weight—ascribe to calomel a beneficial action in croup. Even Niemeyer advocates its use in doses of a quarter or half grain every two hours. On this point I agree entirely with Oppolzer, who is not only doubtful of the advantages of the treatment, but even deprecates its use on the ground of its tendency to salivate, to excite profuse diarrhoea, and to increase the exhaustion of the child. Next to the use of cold water, emetics are, under certain cir- cumstances, the most useful. It would be wrong to expect from an emetic anything more than a mechanical effect; it is not a specific, an unfailing panacea in croup ; nor has it any revulsive, diaphoretic, or antiphlogistic influence upon the course of the disease. And yet, when the glottis is occluded or narrowed by false membranes or muco-pus, which cannot be removed by coughing, how often do we see a strong emetic remove the obstruction and produce a relief which is apparent even to the attendants ? Emetics are to be used early in the disease, and continued every ten or fifteen minutes until they operate. Dur- ing remissions they should be discontinued, to be resumed when the dyspncea again increases. The emetics most used are ipecac, tartar emetic, sulphate of copper, and the sulphate of zinc. Each has its panegyrist. Tartar emetic is recommended by Rilliet and Barthez, Bouchut, Ruehle, and others as very reliable, while others reject it on account of its tendency to paralyze the heart and loosen the bowels. The sulphate of copper (from two to five grains to the ounce of distilled water) was first recom- mended by Hoffmann, of Darmstadt, and has been since warmly endorsed by Hufeland, Zimmermann, Canstatt, Scharlau, Honer- 268 STEINER.—CROUP. kopf, Trousseau, Niemeyer, and others. I have tried them all, and found them efficacious, but I usually prefer ipecac in combi- nation with tartar emetic (a powder containing two grains of ipecac, one-sixth of a grain of tartar emetic, and five grains of sugar to be taken every ten minutes). If diarrhoea be present, or if it follow the administration of this prescription, I select the sulphate of copper. The emetic—whichever one be chosen— should be given in large doses, in order to obtain a certain and rapid effect. In some cases, after emetics administered in water have failed of their effect, I have seen them act by giving them in wine. Many physicians, Clemens and others, have recom- mended the administration of emetics in small doses, at short intervals, but I cannot approve of this method, because the con- tinued use of the drug diminishes its effect, and the only result is to still further exhaust the patient's strength. To relieve the scruples which many persons entertain, I will add that, notwith- standing the large and frequently repeated doses of copper and antimony which I have given, I have never yet seen gastritis produced. The croupous-diphtheritic gastritis, which occurs in very rare instances as a complication of croup, has no connec- tion with the use of emetics. If diphtheria supervene during the course of croup, antisep- tics should also be used internally, preferably the chlorate of potassa in alternation with large doses of quinine. In accordance with his views as to the nature of membranous croup, Rudnicky recommends the hypodermic injection of mor- phine and quinine, with the internal administration of arsenic, and the painting of the exudation with a solution of the perman- ganate of potassa; and it was not until he began to use this treatment, he says, that he became convinced that true croup was a curable disease. Far be it from me to condemn this treat- ment without previous trial, but I must say I am not very sanguine of its success. If the treatment by cold water and emetics fail to improve the condition of the child, if the inflammation continue to advance, and symptoms of carbonic-acid poisoning occur, which are unrelieved by emetics, but one resource is left—tracheotomy. This operation is no more curative of croup than are emetics; TREATMENT. 269 it cannot even arrest the croupous process; its only office is to establish a new provisional air-passage while the danger of death from laryngeal stenosis lasts, and to assist nature in her effort to cure ; and no other means fulfil these indications so certainly and so directly. As to the time when tracheotomy is to be performed, I agree with those writers who urge an early operation, and do not defer it until urgent symptoms of carbonic-acid poisoning have manifested themselves. All the indications are in favor of an early operation ; in fact, I venture to say that, when properly performed, tracheotomy may be a safeguard against the further spread of the croupous process. The beginning of the third stage—the so-called stage of asphyxia—is the moment when the operation becomes necessary. In its performance the opposition of the relatives has usually to be combated, and in too many cases their consent cannot be obtained until the condition of the child has become in the highest degree dangerous. As regards the operation itself— which, when possible, should be done by daylight, and with proper assistance—my own experience has convinced me that the best tracheotome is the knife, aided by the finger, and that the best method of operation is to carefully dissect the individual layers until the trachea is laid bare. While in an early operation great diffi- culty is often met with from the violent rising and falling of the larynx and windpipe, making it necessary to fix the parts by means of sharp-pointed hooks, the later operation—when the asphyxia is far advanced, and the child is already half uncon- scious—is generally unattended by this obstacle. Many writers advise that the necessary quiet on the part of the child should be secured by the administration of chloroform, but I must confess it would be difficult to satisfy me of the advisability of this practice. The apprehension expressed by Roser, Pauli, and others, that secondary pneumonia might readily occur from blood flowing into the opened windpipe, I by no means share. The locality where the windpipe is to be opened must be left to the judgment of the operator. 270 STEINER. —CROUP. In general it may be said that in children, especially the younger ones, tracheotomy is to be perferred to laryngotomy ; furthermore, that high tracheotomy is rendered difficult by a considerable development of the thyroid gland, and by the numerous plexuses of veins; and, on the other hand, the short- ness of the neck in fat children is very unfavorable to the deep operation. Of almost equal importance with the operation itself, so far as the ultimate success is concerned, is a proper after-treatment. During the first few days following the operation it is of urgent importance that the child should have a physician or a well- trained nurse at its bedside; and it is the very difficulty of effecting such an arrangement that makes tracheotomy so much more successful in hospitals—to say nothing of the less expense to the parents. The after-treatment may be divided into a dietetical, a medi- cal, and a surgical portion. As to the first, it is requisite that the bed-chamber should have an abundance of fresh air; the temperature should be between 64° and 68° F., and in order to keep up a certain degree of moisture in the air it is well to place several vessels filled with water in the room. The nourishment should be adapted to the strength of the patient, the height of the fever, and the appetite. In most cases milk, strong beef-broths, eggs, coffee, light kinds of meat, and wheat bread form an appropriate diet; but if symptoms of ex- haustion are present, wine, rum punch, etc., should be given. In general, caution in the selection of the food is unnecessary, and if the patient have an appetite, articles may be allowed which do not strictly belong to the dietary of invalids. The medical after-treatment must be modified by the course of the croupous process ; if this be checked by the operation, and no new aggravations occur, all further medication may be omit- ted. If, however, the fever continue, or increase—as always happens when a croupous bronchitis or a pneumonia sets in— wet cold compresses or sinapisms may be applied to the breast, and digitalis, the tincture of veratrum viride, or quinine given internally. If the expectoration cease, or if the secretion from the air-passages be very profuse, ipecac in connection with TREATMENT. 271 ammoniacal solutions, or benzoin, etc., may be used. If the dis- charge be offensive, preparations of bark with chlorate of potassa may be given, or the muriated tincture of iron or Bestuscheff's tincture of the same. As to the surgical treatment, it is especially important that as broad a canula should be used as possible, and that it should be cleansed of the false membrane and bronchial secretion, which force then* way into it, as often as any obstruction occurs. The amount of secretion from the air-passages is not always equally abundant; a moderate quantity may be regarded as a good sign, but when the discharge is very profuse and at the same time offensive, or when it is entirely absent and the canula is dry, especially during the first few days, the prognosis is more unfa- vorable. In order to keep the respired air moist it is well to place before the canula a light cravat or sponge wet with water. Should severe reaction occur in the neighborhood of the wound, or the soft parts become infiltrated, the wet cravat, frequently changed, will act as a cold compress. If the edges of the wound have an unhealthy color, or are covered with a diphtheritic deposit, they should be treated with nitrate of silver, or a solu- tion of chlorate of potassa, permanganate of potassa, or carbolic acid. The time for removing the canula depends chiefly upon the rapidity with which the laryngeal inflammation disappears. Sometimes this result takes place by the third or fourth day after the operation; in other cases, however, the canula may have to remain for two or three weeks. I have seen some cases where it had to be worn for ten, twelve, fourteen, and once even fifteen months. This delay in its removal—in some cases it may have to be worn permanently—may be caused by chronic swelling of the laryngeal mucous membrane, by ulcerations resulting in stenosis, or, as Schindler and myself have seen, by complete obliteration of the laryngeal cavity in consequence of adhesions, as well as by paralysis of the glottis. As far as I know there are, in general, no contra-indications to the operation ; if nothing more can be accomplished, at least the death of the poor child may be made somewhat easier. It is the universal testimony that the result of the operation is usu- 272 STEIN EII. —C RO U P. ally very doubtful in children under two years of age, and some surgeons, for this reason, refuse to operate at this tender age. I have myself seen two recoveries in such children. The proportion of recoveries varies according to the character of the epidemic, the age of the patients, and the period of the disease when the operation is performed. In the hospital for children at Prague, there were thirty recoveries out of one hun- dred operations. Among the 1,698 cases of tracheotomy col- lected by Duchek, a favorable result occurred in 428, a propor- tion of 1 to 3.9 (25.2 per cent.), which is probably the correct average. Loiseau and Bouchut have tried catheterism of the larynx by passing a tube through the glottis (tubage de la glotte). This plan has recently been recommended again by Weinlechner for the introduction of medicaments into the windpipe, as well as for the relief of the stenosis ; but judging by the trials thus far made it cannot and will not take the place of tracheotomy. If tracheotomy be not permitted by the relatives, the treat- ment in the last stage of the disease can be only symptomatic. The carbonic-acid poisoning and the gradually developing symp- toms of paralysis demand the rapid and energetic use of stimu- lants, in the form of cold affusions in a warm bath, mustard plasters to the breast and calves, frictions with warm vinegar, and internally wine, camphor, musk, or ammoniacal prepara- tions. These are all generally useless, and are recommended only in the absence of anything more efficacious. DISEASES OF THE TRACHEA AND BRONCHI. RIEGEL. VOL. IV.—18 TRACHEA AND BRONCHI. Prefatory Remarks. While the larynx has to display its activity in two directions —in one as the organ of voice, and in the other as an organ for respiratory purposes—the trachea and bronchi, on the contrary, play a relatively subordinate role. Interposed as they are between the larynx and the pulmonary parenchyma, where the • interchange of gases is effected, their first and most important function is to serve as conducting-tubes for/the passage in and out of the air. The greater calibre of the trachea, in proportion to that of the larynx, is such, that even severe diseases of the trachea often progress without essential disturbance of the mechanism of respiration. On the other hand, however, dis- eases of the trachea present so many analogies and relations to those of the larynx, that the separation of tracheal and laryn- geal diseases is not altogether thoroughly practicable. In the following description, therefore, we will only undertake the special description of those forms which are not in direct asso- ciation with analogous diseases of the larynx. Many affections of the larynx, however—croup more than all others—are charac- terized by the frequency with which the trachea participates in the malady. This point must, therefore, have already received proper consideration in the description of the analogous diseases of the larynx; so that a separate description of these diseases, often secondarily extended upon the trachea, appears to be unnecessary. While the diseases of the larynx, in correspondence with the functional significance of the organ, are sometimes associated with alterations of voice and sometimes with dyspnoea, the 276 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. majority of diseases of the trachea and bronchi do not produce any important disturbance in either of these two directions. Even in severe grades of tracheal stenosis the voice shows hardly any important modification. It is somewhat different with reference to the respiration, which, however, also presents no important deviations from the normal condition in the more simple affections of the trachea, so long as they do not produce any considerable encroachment upon the calibre of the tube. It is different in the higher grades of diminution of the calibre of the trachea, no matter by what cause it may have been pro- duced. The diameter of the trachea as a connecting-tube bears a certain reciprocal relation with the size of the respiratory appa- ratus in general; and the volume of the latter, again, with the size of the entire body. If the relations between the diameter of this connecting-tube and the size of the respiratory organ is dis- turbed, then the admixture of oxygen in the blood must be less t in any given unit of time, and disturbances in the function of respiration must result in consequence. Dyspnea takes the first rank among these disturbances. In just that proportion in which the diminution of the calibre of the trachea becomes greater in degree, will this dyspnoea undergo increase. Here, also, as in affections of the larynx associated with stenosis of a high grade, there is a special form of dyspncea, which has been distinguished as " inspiratory dyspnea.'" The characteristic of this special form of dyspncea lies in the greater impediment to inspiration, in contrast to the relatively unimpeded expira- tion, in most instances. Inspiration is remarkably protracted in the severest grades of this form. It is performed at the greatest expense of muscular force. The vertebral column is stretched, and the head bent backwards ; in consequence of which inspira- tion is effected with a loud whizzing or sipping noise, while expiration follows comparatively easily and noiselessly. A further peculiarity consists in this : that the respiration is not accelerated, as one might be disposed to expect; but, on the contrary, is sometimes even considerably slackened, in a manner analogous to that which is often enough witnessed in croup. That form of dyspncea observed in many bronchial affections PREFATORY REMARKS. 277 is, on the other hand, less characteristic. We encounter here both that form of dyspncea which I have designated as " mixed," on a previous occasion,1 and the so called " expiratory dysp- noea." The peculiarities of these forms of dyspnoea, and the circumstances by which they are occasioned, will be recurred to in describing the individual diseases. Cough must be designated as one of the almost constant symptoms of diseases of the trachea and bronchi. The majority of tracheal and bronchial affections, as is well known, are associated with cough. The intensity of the parox- ysms of cough is in no way immediately dependent upon the extent or intensity of the local alterations, nor upon the consis- tence of the secretions; so that we cannot form any definite conclusions, from the nature and severity of the cough, as to the seat and extent of the pathological alterations. The great importance of the cough in all affections of the . respiratory organs, and especially in those of the trachea and bronchi, renders it desirable to interpolate a short resume of our present knowledge of the subject, and especially of the most important of the experimental investigations which have been made on that point. The results of experimental inquiries are the more deserving of attention, that clinical observations in this direction have been deficient. Physiologico-experimental investigations upon the nature of cough were, until recently, tolerably meagre ; and it is only quite lately that a few very worthy observations have been pub- lished on this subject. The first exact experiments on cough date from Krimer,2 whose investigations led him to the conclusion that cough is originally a nervous affection, principally affecting the pair of pneumogastric nerves. On the other hand, as he found by his experiments, irritations of the recurrent nerve did not induce cough. He proved, further, that even when the recurrent nerves of both sides were divided, hoarse cough still occurred, and that 1 Riegel, Die Athembewegungen; erne Physiologisch-pathologische Studie. "Wurz- burg. 1873. A. Stuber. " Untersuchungeu iiber die nachste Uraache des Hustens, von Dr. Krimer, 1819. 278 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. even after the further division of both pneumogastrics, pinching or bruising of the oesophagus still excited cough. In the second place, the experiments instituted by Budge' are to be taken into consideration. Budge came to the con- clusion, from his experiments, that cough occurred primarily only in the larynx, but not further down; a conclusion with which Blumberg's* experiments are also in accordance, inas- much as he also failed to see cough produced by irritating the tracheal and bronchial mucous membrane. On the other hand, Longet3 found cough excited by irritation of the bronchial mucous membrane; and Cruveilhier,4 Rom- berg, 6 and Budge,6 excited cough by irritating the pneumogas- tric nerve. Then we have to mention the experiments of J. Rosenthal,' who considered the superior laryngeal nerve as the special nerve of cough ; inasmuch as he observed relaxation of the diaphragm, with simultaneous constriction of the glottis and spasmodic contractions of the expiratory muscles ensue on irritating the inner branch of that nerve. We are indebted to Nothnagel8 for an important advance in our knowledge of cough. He was the first to prove with cer- tainty, by actual experiment, that cough can be excited by irri- tation of the tracheal and bronchial mucous membrane; and that not only does the superior laryngeal nerve act as a nerve of cough, but that there are fibres situated still further backwards in the pneumogastric nerve whose terminal extremities in the mucous membrane of the trachea excite the reflex act of cough when suitably irritated. Nothnagel was unable to excite cough by irritation of the pleura, or by irritation of the intact branch, 1 Budge, Allg. Pathologie, p. 232. 2 Dorpater Inaugural Dissertation, 1865. 8 Longet, Anatomie u. Physiologie des Nervensystems, T. II., p. 264, 1849. 4 Nouv. Biblioth. med., 1828. T. II., p. 172. 6 Mailer's Archiv, 1838, p. 311. 6 Lehrbuch der Physiologie d. Menschen, von Dr. Valentin, 1844, Bd. II., p. 757. Budge, Untersuchungen iiber das Nervensystem, Hft. II., p. 75. 7 J. Rosenthal, Die Athembewegungen und ihre Beziehungen zum N. vagus, 1862. B Zur Lehre vom Husten, Virchow's Archiv, Bd. XLIV. PREFATORY REMARKS. 279 or the central stump, of the pneumogastric or superior laryn- geal nerve. Finally, the very recent and commendable work of Kohts' is to be mentioned; from which, by the way, we have extracted the preceding historical remarks. The importance of the sub- ject renders it desirable to present here the most important con- clusions of the numerous experiments of Kohts. While the free borders of the vocal cords were not sensitive to the touch, intense cough set in at once on touching the inter- arytenoid fossa. Irritation of the glosso-epiglottic fold, and of the aryteno-epiglottic fold, also excited cough. On the other hand, Kohts was as little able as Nothnagel had been to deter- mine whether irritation of the alveoli excited cough or not. In accordance with the results of earlier experimenters, Kohts found, in reference to the cough proceeding from the mucous membrane of the trachea and bronchi, that the cough is most lively on irritation of the bifurcation of the trachea, and less active on irritation of the trachea and bronchi. Furthermore, he was the first to furnish experimental evi- dence that cough may also be produced by irritation of the pleura. Supported by the clinical experience that cough is present in most affections of the pharynx, he instituted a series of experi- ments which led to the conclusion that, on irritation of the pos- terior pharyngeal mucous membrane, as well as of the inner sur- face of the soft palate, one or two succussions of cough ensued as a rule, and continuous cough occurred but seldom. Intense cough ensued both upon mechanical and electrical irritation of the pharyngeal nerve ; and the cough following powerful pulling of the nerve amounted to a veritable paroxysm. Pulling and pinching the oesophagus also succeeded in excit- ing cough; while, on the other hand, the experimental inves- tigations concerning irritations applied to the stomach always gave negative results. As far as regards the pneumogastric nerves, the experiments coincided with the results arrived at by earlier authors, viz., that 1 Experimented Untersuchungen iiber den Husten. Virchow's Archiv, Bd. LX., Hft. 2, p. 191. 280 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. cough ensued upon mechanical and electric irritation of the root of the vagus, as well as of the central stump of the nerve. Exquisite cough likewise resulted from irritation of the root of the superior laryngeal and of the pharyngeal nerve. Irritation of the recurrent nerve, on the contrary, always gave negative results. Finally, slight pressure upon the rhomboid groove, immedi- ately under the cerebellum, on both sides of the raphe, repeat- edly excited cough ; and weak electric irritation near the raphe, above the calamus scriptorius, also produced cough on several occasions. It therefore appears certain that there is also a central cough, which may be excited by direct irritation of the medulla oblongata. It may suffice, in this place, to have alluded briefly to the physiological inquiries arising from these results. In describing the individual forms of tracheal and bronchial affections we will have repeated opportunity to return especially to this point. Here the remark need only be made, that clinical experience also favors the admission that reflex cough may proceed not only from the tracheal mucous membrane, but also from other localities, as the pleura and the like. The experimentally ascertained fact, also, that the inter-ary- tenoid incisure is characterized by a peculiar reflex irritability, is in full accord with clinical facts, as can be readily ascertained at any time. The same is true of the irritability of the bronchi. It is to be considered, too, that the experimental facts just nar- rated were substantiated upon normal mucous membrane, and it is, therefore, readily comprehensible that this reflex irritability may undergo considerable increase in cases of severe inflamma- tion. It appears to be otherwise in many cases of chronic inflam- mation of the tracheal, and especially of the bronchial mucous membrane, in which the irritability is sometimes so remarkably blunted that even considerable accumulations of secretory pro- ducts may take place without exciting special cough. It is not to be forgotten, as already advanced by Biermer,1 that very often the source of the cough in bronchitis does not originate in 1 Bronchienkrankheiten, in Virchow's Handbuch der speciellen Pathologie u. Therapie. PREFATORY REMARKS. 281 the bronchi, or at least not in the bronchi alone, but higher up, in the trachea and in the larynx. Pain is less frequently observed in the diseases of the trachea and bronchi than cough. When present it is rarely intense, and is chiefly occasioned by the paroxysms of cough. Not infrequently it is manifested rather as a sensation of tick- ling, or a slight soreness along the trachea and the sternum, or a dull sensation of pressure. Severe pain is not observed in the majority of these affections. The condition of the sputa is exceedingly different in indi- vidual cases. There are no authoritative distinctions of such a nature that simple inspection of the sputa will furnish reliable conclusions as to the locality of production. The special rela- tions of the sputa will be mentioned in describing the individual forms of disease. Precise methods of physical exploration are of special importance in the recognition of the diseases of the trachea and bronchi. Inspection furnishes no specially prominent indica- tions, if we except exploration with the laryngoscopic mirror, soon to be described. Only in the severer forms of tracheal stenosis are important deviations from the normal type of respi- ration observed, similar to those which croup of the larynx fre- quently furnishes opportunity of witnessing. In certain forms of bronchial diseases, however, there are deviations from the normal type and depth of the respirations. The breathing then exhibits the above-mentioned character of expiratory or mixed dyspncea, on the one hand, and, on the other hand, in addition, certain abnormal changes in the part taken by individual por- tions of the thorax; the main burden of the respiratory move- ments being thrown upon the healthy portions, while the dis- eased portions participate in breathing in a correspondingly diminished degree. The inspection of known anomalies is of important service in accurately estimating the degree and extent of morbid disturbances. Exploration with the laryngoscopic mirror is of especial importance in the recognition of diseases of the trachea; but the method, unfortunately, is too little employed for the purpose. And yet it is practicable, with some practice and the observance 2S2 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. of a few precautions, to inspect the entire tracheal tube, as far as the point of bifurcation, with the aid of the laryngoscopic mirror, if not in every case, at least in the greater number of subjects, provided the illumination is sufficiently intense. In the ordi- nary method of laryngoscopy at most only a greater or smaller portion of the anterior wall of the trachea is inspected. The reason of this is to be found chiefly in the different relations of that portion of the larynx situated above the glottis, and that portion beneath it. The two portions, as is well known, form an angle with each other which is much more obtuse when the head is maintained in the erect posture, than when it is strongly bent backwards. In the majority of persons it is easy to render this angle so much more obtuse that a rectilinear track is secured large enough for the rays of light to pass through the larynx and the entire trachea down to the commencement of the bronchi. A more detailed description of the precautions by which we over- come the obstacles opposed to inspection of the trachea, in indi- vidual cases, cannot be entered into here, and the reader is referred, on these points, to the manuals on laryngoscopy, and especially to the excellent manual of Tiirck.1 The significance of tracheoscopy in the recognition of special diseases of the trachea is evident without further explanation. Without direct inspection a great number of tracheal dis- eases cannot be sharply differentiated from each other, while a glimpse in the mirror suffices at once to learn the nature, local- ity, and extent of the affection. Some physiological phenomena, first described by Gerhardt,2 deserve mention in this place. Gerhardt was the first to direct attention to a normal pulsating point in the tracheal wall. In individuals with chronic catarrh of the respiratory mucous membrane, associated with a copious secretion, cardiac systolic rales, as is well known, are often heard from the opened mouth. In such individuals most distinctly, but in most others also, 1 Klinik der Krankheiten des Kehlkopfes und der Luftrohre nebst einer Anleitung zum Gebrauch des Kehlkopfrachenspiegels und zur Localbehandlung der Kehlkopf - krankheiten, von Dr. Tiirck. Wien, 1866. 2 Ueber syphilitische Erkrankung der Luftrohre. Deutsches Archiv f. klin. Med., Bd. II., p. 543. PREFATORY REMARKS. 283 when attention has been once directed to the phenomenon, the lateral walls of the trachea, just above the bifurcation, can be seen to pulsate in the mirror, the pulsation being more strongly marked on the left side. A glance at Luschka's plates shows at once how the trachea, at this point, lies wedged in between the arch of the aorta and the trunk of the innominate artery (Gerhardt). Quite recently, and, as it appears, independently of Gerhardt, Schrotter,' has likewise described this movement of the trachea and primitive bronchi, visible in the laryngoscopic mirror. He has examined a great number of healthy and diseased indi- viduals with reference to this movement of the trachea, and has thereby come to the same conclusion mentioned above, that in very many persons the trachea may be inspected in the laryn- goscopic mirror, as far down as to its bifurcation, if only the precautions alluded to are observed, as already laid down by Tiirck for this purpose. Schrotter describes the movement of the trachea, just briefly sketched, as a spasmodic pulsating displacement of the bifur- cation-spur,—that is to say, of the ridge which projects more or less sharply at the subdivision of the trachea into the two bron- chi,—alone or simultaneously with displacement of contiguous portions of the trachea and bronchi. This movement is especially evident when there are injected vessels coursing over the structures mentioned, presenting a point for observation concerning the nature and extent of the locomotion, the extent often amounting to at least two lines. Out of seventy individuals the manifestation was present in twenty-seven instances, in such a manner that the bifurcation spur, coursing more or less directly from before backwards, was moved backwards from right to left, and exactly in unison with the heart's systole ; in twelve cases the movement was directly the opposite; and in seventeen instances the movement was a complicated one, being not simply lateral, but at the same time from before backwards, or the reverse. 1 Schrotter, Beobachtungen iiber eine Bewegung der Trachea und der grossen Bron- chien mittelst des Kehlkopfspiegels. Aus dem LXVI. Bande d. Sitzb. d. k. k. Akad. d. Wiss , III. Abth. Juliheft. Jahrg. 1872. 284 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. Schrotter conceives that the movement from before back- wards, and the movement from left to right is produced by the ascending portion of the aorta and its arch ; but at the same time an influence from the descending portion upon the left bronchus from behind cannot be entirely disregarded, because this finds attachment and support on the spinal column. In the second place, the two branches of the pulmonary artery are also of great importance, and the movement from before backwards may well depend upon the circumstance that the point of divi- sion of the trachea and the right bronchus lie immediately be- hind the right branch of the pulmonary artery ; in like manner, the movement backwards, and that to the left also, may depend upon the fact that the left bronchus lies behind and below the left branch of the pulmonary artery. In the third place, a com- bination of the first and second movements may well explain the combined oblique movements. When we reflect further that the innominate artery and the common carotid of the left side course over the anterior tracheal wall, we can readily see how the pul- sations of these vessels may also produce movements of portions of the trachea situated higher up (Schrotter). Schrotter believes the cause of the individual differences of the movement to reside in the normal limits of the deviations in the course and topo- graphical relations of the organs concerned. Palpation affords few data, on the whole, for the recognition of diseases of the trachea and bronchi. The same may be said of percussion. Auscultation, on the contrary, is of much greater importance, and constitutes, in diseases of the bronchi especially, the most valuable method of exploration. On the other hand, again, the results accruing from the use of the spirometer and the tape-measure are without great signifi- cance in the diseases in question. Stethography,x introduced by myself, elicits results in many cases not altogether insignificant. We will recur to the details of this procedure in treating of special forms of disease. Pneumatometry,* recently introduced by Waldenburg, as a 1 Deutsches Archiv f. klin. Medicin, Bd. X., p. 124, and Bd. XL, p. 379. 8 Die Manometrie der Lungen oder Pneumatometrie als diagnostische Methode. Berliner klinische Wochenschrift, 1871, No. 45. PREFATORY REMARKS. 285 method of clinical exploration, is also competent to furnish valu- able conclusions in many forms of tracheal and bronchial disease. Before turning from these general remarks to the description of individual forms of disease, we must again premise the remark that in consequence of the intimate relations which diseases of the larynx and trachea, on the one hand, and those of the trachea and bronchi on the other, bear to each other, their frequent concurrence renders their precise separation impracti- cable in many instances. Many diseases of the larynx are asso- ciated with analogous disease of the trachea, while the same disease is not at all confined to the trachea alone, or only in extremely rare cases. In the first class of cases the disease of the trachea is much less significant than' its analogue in the larynx. These relations must have been considered already in treating of the diseases of the larynx, and we refer the reader to the appropriate chapter on laryngeal diseases. On the other hand, many tracheal diseases are almost always complicated with analogous diseases of the bronchi, so that here, also, the separate description of both represents only an artificial division. From this point of view the following division of our subject will find its justification. 286 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. MALFORMATIONS. Congenital Diseases of the Larger Air-Passages (Trachea and Bronchi), C. H. Dzondi, De fistulis tracheae congenitis. Halle, 1829.—Ascherson, De fistulis colli congen. Berlin, 1832.—Fleischmann, Bildungshemrnungen der Menschen und Thiere, 1833.—Harless in Reil's Archiv fiir die Physiologie, Bd. IV., p. 218.—Collomb, CEuvr. med.-chir. Paris, 1798.—Gilibert, Sammlung pract. Beobacht., p. 97.—Klein, Monstr. quorund. descriptio. Stuttgart, p. 23.— Blanchot, Acta nat. curiosa an. IX., p. 350. — Otto, Monstror. acephal. de- scriptio. Francofurt:, 1808.—The same author, Seltene Beobachtungen zur Anatomie u. Physiologie, 1816, Hft. 1.—Brodie, Journ. de medec. Paris, 1810, Octobre, p. 281.— W. Horn's Reise, Berliner medic. Zeitung, Jahrg. 1, No. X., p. 160.—Fleischmann, De chondrogen. asperse arteriae et situ oeso- phagi abnormi nonnulla. Erlangen, 1820.—Schdller, Eigenthiimliche Missbil- dung. der Speiserohre als Ursache einer Verbindung des Athmungsapparates mit dem Verdauungskanale, Neue Zeitschrift f. Geburtskunde von Busch, d'Outrepont und Rittgen, Bd. VI., pp. 264-273, 1838.—Meyer, Rust's Magazin, Bd. 55, Hft. 1. Casper's Wochenschrift, 1873, No. 33.— Albers, Atlas der pathol. Anatomie und Erlauterungen zum Atlas der pathol. Anatomie, Bd. III., p. 506.—Gilibert, Adversaria medica pr. CXXXIL, Lucubr. anath. de fcetu acephalo.—ProscJiaska, Medic. Jahrbticher des osterr. Staats, Bd. V.—The Dub- lin Hospital Reports, Vol. V., Part II., p. 311; see also in Albers.—Ammon, Die angeborenen chirurgischen Krankheiten d. Menschen. Berlin, 1842.—Luschka, Roser's und Wunderlich's Archiv, 1848, VII., 1.—Riecke, Journ. f. Chirurgie u. Augenheilkunde, N. F., 1845, Bd. 34, IV., 4, p. 618.— Bednar, Krank. der Neu- gebornen. Wien, 1850, I.—Leudet, Trois bronches naissant de la trachee, Gaz. mSd. de Paris, No. 27, 1856.—Jenny, Schweiz. Zeitschr., 1854, 1.—Heusinger, Hals-Kiemenfisteln von noch nicht beobachteter Form., Virchow's Archiv, XXIX., p. 558, 1864,.—Rossi, Mem. de Turin, T. 33, p. 168.—Despres, Fistule bronchiale borgue externe chez une fille de dix ans, Gaz. des hop., No. 146, 1866.—Fbrster, Die Missbildungen des Menschen. Jena, 1861, p. 102.— Vrolik, Handboek der Ziektekundige Ontleedkunde, II., 1842, Aangeborene Gebreken. —Angeborene Bildungsfehler, beobachtet von Prof. Lehmann, Nederl. Tijdschr., II. Afd., 1. Aflev., p. 142, 1868.— Voigtel, Handbuch der pathologischen Ana- tomie, Bd. n., p. 289.-2%. Gass, Essai sur les fistules bronchiales, These de Strassburg, 1867, 2 Ser.—Meckel, Handb. d. pathol. Anatomie, No. 1, 1812, p. 481.—Fbrster, Handb. d. pathol. Anatomie, n., 211.—Rokitansky, Handb. d. pathol. Anatomie.—Andral, Prgc. d'anat. pathol. Bruxelles, 1837.—Duchek, Haudb. d. speciellen Pathologie u. Therapie, 1. Bd., III. Liefg. Die Krank- MALFORMATIONS. 287 heiten des Larynx und der Trachea, der Schilddriise und der Thymusdriise. Erlangen, 1873, p. 464.—Perier, Anomalie des Oesophagus; Obliteration seines oberen Endes; Einmiindung des unteren in die Trachea in der Hohe der Bifur- cation derselben. Gaz. des hop., 1874, No. 12. Consult, further, the manuals of surgery of Emmert, Roser, and Bardeleben, as well as especially Pitha and Billroth, Handbuch der allgemeinen und speciellen Chirurgie. Erlangen, 1871, Bd. IH., 1 Abth., 3 Lfg.; die Krankheiten des Halses von Dr. G. Fischer, p. 15. One portion of the congenital malformations of the trachea and the bronchi possess an anatomical interest merely, and not a clinical one, inasmuch as they exclude the viability of the affected individual. For this reason we will not devote any special consideration to them in this place. To this class belongs the complete absence of the trachea, observed in acephalous and other non-viable monsters. This condition is observed most fre- quently in connection with absence of the entire respiratory organ. In other cases absence of the trachea has been observed with presence of the lungs and the larynx; the latter in such in- stances being in immediate connection with the lungs and the bronchi. Such cases have been reported by Blanchot, Gilibert, Klein, and others. Atresia, blind termination of the trachea, and likewise closure of both branches of the trachea, belong, further, to the anoma- lies of form of anatomical, but not of clinical interest. Rossi has reported a case of the latter sort, in which he found a clo- sure of the glottis by a membrane, in addition to closure of both branches of the trachea; Otto has likewise reported a case of occlusion of the trachea. Communication of the oesophagus with the posterior wall of the trachea belongs, further, to this category. This communication, in most instances, occurs in such a manner that the pharynx terminates in a blind extrem- ity, and the portion of oesophagus ascending from the stomach opens into the trachea. Such a case has been reported by Scholer.' In this case it was remarked directly after birth that the breathing was greatly impeded by a large quantity of See, also, Amnion, Die angebornen chirurgischen Krankheiten des Menschen. Berlin, 1842. 288 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. mucus ; the child, in attempts to swallow, was seized with severe suffocative paroxysms, and everything taken in the shape of food was regurgitated through the mouth and nose. On dis- section it was found that, in addition to the termination of the oesophagus in a blind sac, the lower portion of the oesophagus ascending from the stomach opened into the trachea. Simi- lar cases are recorded by Lehmann, Albers, Fleischmann, and Perier. Further malformations to be mentioned are: the absence of individual tracheal cartilages ; the coalescence of several tracheal cartilages into one; an excessive number of cartilages; their abnormal division longitudinally or horizontally; and their ab- normal configuration, size, and texture. Sometimes the trachea is too short, too narrow, undivided below, or unusually curved. Certain of these last-mentioned alterations sometimes implicate also the rings of the bronchi. Among the abnormal formations of the bronchi, the third bronchus is to be mentioned. This malformation is an infre- quent manifestation in the human subject. The trachea, instead of being divided into two large branches, a right and a left bron- chus, is here divided into three, and usually in such a manner that there are two right bronchi instead of one bronchus. Such a division of the trachea into three bronchi was observed by Leudet in the corpse of a man dead from phthisis. The third bronchus, which was of lesser calibre than the two others, but of the same conformation, descended into the upper lobe of the right lung, which was therefore supplied with two bronchi. This anomaly had also been observed previously by Cruveilhier; * and has been introduced by Albers into his Atlas of Pathological Anatomy2 as a very rare malformation, with the remark that usually two right bronchi are found instead of one. Congenital struma (goitre) and congenital hygroma colli cys- ticum (cystic tumor of the neck) come into consideration, in this connection, only in so far as in their severer and severest grades they exert compression upon the trachea. Inasmuch as the symptoms thus produced are like those to be hereafter men- 1 Traite d'Anat. descr., Vol. III., p. 468, 2. edit. ' Band III., p. 506. MALFORMATIONS. 280 tioned in connection with stenosis of the trachea in general, further details will be referred to that subject. Congenital bronchocele (so-called)—partial dilatation or her- nia of the trachea—must also be mentioned as a very rare mal- formation. In reference to this malformation Ammon1 says, "there exists a single and very incompletely described case of congenital bronchocele reported by Gobi; in this instance there was a com- plication with struma ; the increase of the tumor on inspiration and in crying, as well as the unaltered condition of the tumor on expiration without crying, showed the existence of the com- plication with bronchocele." Finally, doubling of the trachea is to be mentioned. In double-headed monsters with a single trunk the trachea is in most instances double, at least at its commencement. Sev- eral observations of the kind are to be found in Voigtel." Congenital fistula of the neck is of much greater interest than all the malformations thus far mentioned. Our knowledge of congenital fistula of the neck, as is well known, owes its founda- tion and earliest scientific consideration to the labors of Dzondi and Ascherson. Fistule colli congenite, however, must be further divided into two principal groups, fistule pharyngis and fistule trachee; the latter of which only comes into consid- eration here. Congenital fistula of the neck depends upon imperfect closure of the third or fourth branchial cleft; or, in median fistula, upon imperfect union of the third or fourth branchial arch in the median line (Forster). Usually the external orifice of the fistula exists on the side of the neck, half an inch or an entire inch above the sterno-clavicular articulation, either between the two heads of the sterno-cleido-mastoid muscle, or at its inner border. Less frequently it exists higher up, as far as the cricoid cartilage, and towards the median line. As a rule there is but one fistulous opening, situated most frequently on the right side, and less frequently in the median line. When, as is rarely the case, there are two openings, they are sj-mmetrically situated 1 Die angeborenen chirurgischen Krankheiten des Menschen. Berlin, 1842. 8 Handbuch der pathol. Anatomie, Bd. II, p. 298. VOL. IV.—19 290 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. on each side of the neck. In a case reported by Ascherson there were as many as three openings observed, situated one above the other. The external orifice is small, as a rule, so that it can be penetrated only by a very delicate probe or a bristle. The borders of the opening usually project somewhat forwards ; and they are tumid, and not infrequently reddened. The fistu- lous tract leads either into the larynx or pharynx, or into the trachea. The last-mentioned variety is exceptionally rare. It much more frequently happens that the fistula terminates blindly in the connective tissue of the neck ; or that, some- times, a small cyst-like pouch is formed behind the orifice (incomplete fistula). The calibre and orifice of the fistulous tract, even in those instances in which the tract opens into the trachea (complete fistule), are usually so small that bubbles of air are but seldom expelled externally. In those cases in which the fistula terminates blindly in the connective tissue, mucus only escapes from the external orifice—as a matter of course only in a minimum quantity. Real tracheal fistulae are much less frequent than incomplete cervical fistulae and the so-called cervico-bronchial fistulae. These fistulae occur in the middle of the neck in most instances. Sometimes there is only one simple very minute orifice ; some- times a tumor extends from the chin down to the region of the manubrium sterni, in the upper or lower portion of which a deli- cate opening, the fistulous orifice, is found. If the fistula is in- complete, it is gradually lost, blindly, in the tissue, and permits merely a yellowish fluid to trickle outwards. The complete tracheal fistula, on the contrary, presents an open communica- tion of the fistulous tract with the trachea, and is usually located in the middle line of the neck. It is further worthy of mention, that up to the present time tracheal fistulae have been observed almost only in females (Bardeleben).1 All the cases of fistule trachee observed and described by Dzondi occurred in females only. The fistulous tract which led to the trachea was oblique in its course in most instances, and barely permitted examination with the probe. The probe was introduced with 1 Lehrbuch der Chirurgie und Operationslehre, Vierte Ausgabe, III. Band, 1864, p. 445. MALFORMATIONS. 291 certainty into the trachea only in a single instance of all the cases observed by Dzondi. In one instance, when the mouth and nose were closed during free and powerful voluntary respi- ration, air-bubbles issued on expiration out of the fistulous orifice (Amnion). The diagnosis of congenital tracheal fistula is chiefly depen- dent upon the evidence of a direct communication of the exter- nal fistulous orifice with the interior of the trachea, whether it be determined by means of the probe or by escape of air through the external orifice on forced blowing and similar manoeuvres. In man}' cases the diagnosis is obscured by obstacles not altogether unimportant, as is shown in a case reported by Fischer,1 which, in 1862, came under observation in Langen- beck's clinic. A child, twelve years old, when in the fifth year of its age, had a tumor form some two inches above the manubrium sterni, and tolerably in the middle line between both sternal portions of the sterno-cleido-mastoid muscle. The tumor had been opened by means of some caustic, which left a small ulcer and a fistula. The probe penetrated about an inch and a quarter upwards, and gave exit to a stringy, tenacious mass, which contained mucus corpuscles. The first impression was that this was a case of congenital fistula of the neck, a diagnosis, however, which was excluded by inquiry into the history of the case. Apparently a lymphatic gland had undergone suppuration, and the abscess formed had descended and become ruptured lower down. The tract was cut open. It appeared clothed with epi- thelium, and could be followed as far as the level of the hyo-thyroid ligament. It was excised, together with the cicatrix of the ulcer. During the union of the wound air-bubbles escaped repeatedly, indicating, therefore, a communication with the air-passages, so that the case was explained as one of congenital fistula of the neck (Fischer). The treatment, which is based on the same principles as that for cervico-bronchial fistula, belongs to the domain of surgery. 1 Pitha und Billroth's Handbuch, Bd. III., 1. Abtb,, 3 Lieferung. 292 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. CATARRH OF THE TRACHEAL AND BRONCHIAL MU- COUS MEMBRANE; TRACHEITIS, BRONCHITIS, CA- TARRHALIS ; BRONCHIAL CATARRH. Literature. In the following lines we will present only the more important literature of our subject. A complete enumeration of all the works that treat of tracheal and bronchial catarrh would carry us too far, on the one hand, and be useless on the other. The older literature of this subject is cited as it is given by Biermer.' In the enumeration of recent literature, on the other hand, we present not only the larger monographs, but also a series of smaller articles of late date, so as to furnish the reader, if not altogether a complete, still a sufficient insight into the literature of our subject. The remark should be premised that the litera- ture of bronchitis begins in our own century, inasmuch as before that time neither the anatomical alterations of bronchial catarrh, nor its exact sympto- matology, were understood. The name " Bronchitis" was first brought into use by P. Frank (Interpretationes clinicse, 1812, I., 110), and Badham (An Essay on Bronchitis, 1814 ; the German translation by Kraus, 1815). While the forms of disease which are to be summed together under the term bronchitis were previously separated from each other under the most different appellations, without anything approaching a clear insight into their anatomical relations, the first accurate studies of bron- chitis, both in anatomical and clinical aspects, commenced after this time. Further progress in the study of bronchitis was paved by the knowledge of its frequent occurrence in children, especially in the form of capillary bronchitis. Regarding the older literature, we refer the reader to the citations by J. Frank, Prax. med., P. II., Vol. II, Sect. I., pp. 795 and 807.—Naumann, Med. Klin., Bd. I., p. 506 et seq.— Copland, Dictionary of Practical Medicine. London, 1858, Vol. I., p. 268, and Vol. II., p. 700.—Eisenmann, Krankheitsfamilie Rheuma, Bd. I., S. 185, and Bd. III., p. 113.—Canstatt, Spec. Pathol, u. Ther., Bd. Ill, Abth. I. Of later and most recent literature we present the following works: Cheyne, On the Pathology of the Larynx and Bronchia. Edinb., 1809.—Cabanis, Observa- tions sur les affections Catarrhales. Paris, 1807.—Broussais, Histoire des phlegmasies ou inflammations chroniques, etc. Paris, 1808.—Badham, On the Inflammatory Affections of the Mucous Membrane of the Bronchia?, 1814; German by Kraus, 1815.—Hastings, A Treatise on Inflammation of the Mucous 1 Bronchienkrankheiten, in Virchow's Handb. d. spec. Path. u. Ther., V. Bd., p. 647. BRONCHIAL CATARRH. 293 Membrane of the Lungs, etc. London, 1820.— Villerme, Article in Diction, des Scienc. M6d., T. XXXII., p. 208.—Gendrin, Hist, anatom. des inflammations, etc., T. I. Paris, 1826. Translated into German by Radius. Leipzig, 1828.— Roche, Diction, de Mgd. et de Chir., T. IV. Paris, 1830.—Horn, Encyclop. Worterbuch, T. VI. Berlin, 1831.— Williams, Cyclopaedia of Practical Medi- cine, Vol. I., 1833.—Alcock, On Inflammation of the Mucous Membrane of the Organs of Respiration, Med. Intelligencer, Nos. 7 and 8, p. 151.— Chomel, Article Catarrhe pulmonaire, in Diet, de Med., in 30 vols., Vol. IV., p. 417.— De la Berge et Monneret, Compendium de med. prat., Art. Bronchite, in Vol. I., pp. 645-681. Paris, 1836.—Laennec, Traite de l'auscultation, etc., 4. £dit., 1837.—Stokes, A Treatise on the Diagnosis and Treatment of Diseases of the Chest; Part I., Diseases of the Lungs and "Windpipe, 1837.—Ph. Seifert, Die Bronchiopneumonie der Neugebornen und Sauglinge; eine nosologisch-thera- peutische Monographic, 1837.—A Treatise on the Diseases and Injuries of the Larynx and Trachea; founded on the essay to which was adjudged the Jack- sonian Prize for 1835, by Fr. Ryland, 1837.—Hodgkin, Lectures on the Morbid Anatomy of the Serous and Mucous Membranes. London, 1836-40, 2 vols.— Rokitansly, Oesterr med. Jahrb., Bd. XVI., St. 3, 1838.—Hasse, Anatom. Be- schreib. d. Krankheiten der Circulations- und Respirationsorgane. Leipzig, 1841.—Cruse, Ueber die acute Bronchitis der Kinder und ihr Verhaltniss zu den verwandten Krankheitsformen. Konigsberg, 1839.—Albers, Atlas der pathol. Anatomie u. Erlauterungen dazu, 1839, 2. Abth., p. 105.—Fauvel, Recherches sur la bronchite capillaire puiulente et pseudomembraneuse. These. Paris, 1840. The same author, Clinique des hop des enfants, Janv., 1843; and MGm. de la soc. m£d. d'observation, 1844, T. II., pp. 432-596.—Foucart, On Capillary Bronchitis, Gaz. des hop., No. 128,1842. —Cheyne, On Bronchial Blennorrhcea, considered in connection with Rheumatism, London Med. Gaz., Sept., 1843.— Loscherer, Ueber einige Krankheiten der Schleimhaute des Rachens, Kehlkopfs und der Luftrohre, Weitenweber's Beitrage zur Medicin, 1842.—Biedermann, Ueber Katarrh der Respirationsorgane, 1843.—Piorry, Traite1 de m£decine pra- tique et de pathologie iatrique ou mSdicale, cours professe" a la faculty de mMe- cine de Paris, 1842.—Bilhlemann, Beitn'ige zur Kenntniss der kranken Schleim- haut der' Respirationsorgane und ihrer Producte durch das Mikroskop. Bern, 1843.—Girard, On the Treatment of Acute Bronchitis with Emetics, Archiv. gen de m£d, Oct., 1843.—Legendre et Bailly, Arch, de m6d., Janv. et Fevr., 1844.— Chambert, Gaz. de Paris, No. 27, 1845.—Kaiser, Pneumonie und Bron- chitis der Kinder, Casper's Wochenschrift, 1846.—Legendre, Recherches anato- mico-pathologiques sur quelques maladies des en fans. Paris, 1846.—Beau, Arch. gen., Sept. et Oct., 1848.—Rilliet et Barthez, M£moire sur quelques parties de Thistoire de la bronchite et de la bronchopneumonie chez les enfants, Arch. gen de mGd, Oct., 1851.—The same authors, Trait6 clin. et prat, des maladies des enfants, T. I., pp. 388-514, 2. ed. Paris, 1853.— Wagstajf, On Diseases of the Mucous Membrane of the Throat, and their Treatment by Topical Medica- tion. London, 1851.—Gairdner, On the Pathological States of the Lung con- 294 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. nected with Bronchitis and Bronchial Obstruction, Monthly Journal of Med. Science, May, July, and Sept., 1851.—R. A. H. Hunter, On Pulmonary Dis- eases in Tropical Climates, London Med. Gaz., N. S., Vol. XL, pp. 367 and 578.—Black, On the Pathology of the Bronchio-pulmonary Mucous Membrane, Edinb. Monthly Journ., Jan., June, 1853.—Billing, Practical Observations on Diseases of the Lungs and Heart. London, 1852.—Gintrac, Journ. de med de Bordeaux, Dec, 1852, p. 705.—Kirkes, Mad. Times and Gazette, Jan., 1853, p. 8.—A Treatise on the Diseases of the Chest, being a Course of Lectures delivered at the New York Hospital by John A. Swett, 1852.— Cohn, Giinsb. Ztschr., V. 5, 1854. — West, Lectures on the Diseases of Infancy and Childhood. London, 1848. — Wunderlich, Handbuch der Pathologie u. Ther., Bd. III., 1850. — Watson, Bull. gen. de therap mSd. et chir., March, 1853.—James Bright, A Clinical Synopsis of Diseases of the Chest and Air-passages, with a Review of the several Climates recommended in these Affections, 2d edition. London, 1854. Walshe, A Practical Treatise on the Diseases of the Lungs, Heart, and Aorta, including the Principles of Physical Diagnosis, 2d edition, 1854.—H. Davies, Lectures on the Physical Diagnosis of the Diseases of the Lungs and Heart, 2d edition, revised and enlarged. London, 1854.—Horace Green, A Treatise on Diseases of the Air-passages, comprising an Inquiry into the History, Pathology, Causes, and Treatment of those Affections of the Throat called Bronchitis, Chronic Laryngitis, etc. New York, 1855.—Teissier, Bull. gen. de ther., Oct., 1855.— Cockle, Association Journal, July 6, 1855.—Biermer, Die Lehre vom Auswurf. Wiirzburg, 1855.—Gunsburg, Klinik der Kreislaufs- und Athmungsorgane. Breslau, 1856.—Hewitt, On the Pathology and Treatment of Bronchial Affections in Infancy and Childhood, Med. Times and Gaz., 1856, No. 336.—Bennett, Edinb. Med. Journ., Nov., 1857.—Laycock, On Fetid Bronchitis, Med. Times and Gaz., May 16, 1857.—Ziemssen, Deutsche Klinik, 1857; Archiv fiir physiologische Heilkunde, 1857; Prager Viertel- jahrschrift, 1858.—Marc d'Espine, Essai de statistique mortuaire comparee. Paris, 1858.—Leubuscher, Handb. der medic. Klinik, 1. Bd., 1858.—Friedreich, Die Krankheiten der Nase, des Kehlkopfs und der Trachea u. s. w., Virchow's Handb. der spec. Path. u. Ther., V. Bd., 1. Abthlg., 1858.—Mercier, De la bron- chite. These. Paris, 1857.—Duncalfe, Brit. Med. Jour., Jan. 7, I860.—Holler, Die Volkskrankheiten in ihrer Abhangigkeit von den Witterungsverhaltnissen. Wien, I860.—Gibb, On Diseases of the Throat, Epiglottis, and Windpipe; their Symptoms, Progress, and Treatment. London, 1860.—Kostlin, Arch. f. wiss. Heilk., VI., 1861.—Copland, The Forms, etc., of Consumption, etc. London, 1861.—Bamberger. Zur Lehre vom Auswurf, Wiirzb. med. Ztschr., II., pp. 333- 348, 1861.—Bartels, Bemerkungen iiber eine im Fruhjahr, 1860, in der Poli- klinik in Kiel beobachtete Masernepidemie, mit besonderer Beriicksichtigung der dabei vorgekommenen Lungenaffectionen, Virchow's Archiv, Bd. XXL, Hft. 1 u. 2, 1861.—Barrier, Traite" pratique des maladies de I'enfance. Paris, 1861, III. Edition.—Hannover, Deutsche Klinik, 1861.— Traube, Ueber putride Bronchitis, Deutsche Klinik, 50-52, 1861; 1-5, 1862.—Schramm, Ueber Bron- BRONCHIAL CATARRH. 295 chitis, Aertztl. Intell.-Blatt., No. 39, 1862.—Tobold, Deutsche Klinik, 1862, No. 22.— Waldenburg, Deutsche Klinik, No. 44, et seq., 1862.—Hyde Salter, Brit. Med. Jour., 1863.—Steiner, Die lobulare Pneum. d. Kinder, Prager Vierteljahr- schrift, Bd. 75, 1862.—Ziemssen, Pleuritis und Pneumonie im Kindesalter. Berlin, 1862—Black, Gaz. mM. de Lyon, 1863, No. 15.—Fetters, Zur Chemie der Sputa, Prager med. Wochenschr., 4, 5, 1864.—Pouchet, Compt. rend., LIX., 1804.—Fischsr, Berlin, klin. Wochenschrift, No. 17, 1864.—Grisolle, Traite de la pneumonie, III. edition. Paris, Bailliere et fils, 1864.—Steffen, Klinik d. Kinderkrankheiten. Berlin, Hirschwald, 1865.— Oesterlen, Handbuch der medic. Statistik. Tubingen, 1864.—Laycock, Notes on Fetid Bronchitis, etc., Edinb. Med. Journal, 1865.—Hirsch, Handbuch der historisch-geographischen Patholo- gie. Erlangen, 1862-1864.—Fbrster, Handbuch der speciellen pathol. Anato- mie, 2. Aufl. Leipzig, 1863.—Durand-FardA, Compendium der Greisenkrank- heiten.—Seitz, Katarrh und Influenza, cine medicinische Studie. Miinchen, 1865.—Biermer, Krankheiten der Bronchien u. des Lungenparenchyn.s, Vir- chow's Handbuch der speciellen Pathologie u. Therapie, V., 1. Abth., 4. Lief. Erlangen, 1865.—Siegle, Die Behandlung und Heilung von Hals- und Lungen- leiden durch Einathmungen mittelst cines neuen Inhalationsapparates, 1865.— Gamgee, On the Characters of the Expectoration in Fetid Bronchitis and Gan- grene of the Lungs, Edinb. Med. Jour., March and June, 1865.—De Smet, Bull. de la soc. de Med. de Gaud., Avril, 1865.—J. Gr. Glover, The Lancet, 1865. —Guibout, L'Union medic, 1865, Nos. 16 and 22.— 0. Naumann, Arch. d. Heilk., 1865.—Tobold, Berlin, klin. Wochenschr., 1865, No. 37'.—Rosenthal, Wien. Zeitschr. XXII, 1, p. 97, 1866.—Meyer, Petersb. med. Zeitsch., X., 2, 1866.— Widal, Rec de Mem. de Med. milit, Fevr., p. 97, Mars, p. 207, I860.— Ihrkes, On Diseases of the Respiratory Passages and Lungs, etc. London, 1866. —Barth, Bull, de l'Acad., Tom. XXXIL—Copland, Forms, Complications, Causes, and Treatment of Bronchitis, new edition. London, 1866.—Tiirck, Klinik der Krankheiten des Kehlkopfs und der Luftrohre nebst einer Einleit- ung zum Gebrauch des Kehlkopfrachenspiegels und zur Localbehandlung der Kehlkopfkrankheiten. Wien, 1866.—Gerhardt, Ueber syphilitische Erkrankung der Luftrohre, Detusches Archiv f. klin. Medicin, Bd. II.— Cooper, Brit. Med. Jour., Sept. 28, 1S67.—AlUnitt, Med. Times and Gaz., Feb. 16, p. 161; March 2, p. 217, 1861,— Gueneau de Mussy, Etudes physiologiques et thgrapeutiques sur la toux. Union Med., Nos. 32 and 35, 1867.—Rosenstein, Zur putriden Bronchitis, Berlin, klin. Wochenschrift, No. 1, 1867.—Greenhow, Clinical Lec- ture on Chronic Bronchitis, The Lancet, Feb. 16 and seq., 1S67.— Austin Flint, Principles and Practice of Medicine, 2d ed. Phila., 18C7.—Meschel, Allg. Wien. med. Zeitung, No. 20, 1868.—Irving, Allg. Wien. mod. Ztg., No. 30, 1868.—Marrotte, Bull, de ther., LXXIL, 1867.—Gregory, The Lancet, Aug. 24, 1867.—Clark, Med. Times and Gazette, 1867.— Weisenthanner, Considerations genendes sur la bronchite chronique. These. Montpellier, 1867.— Valentiner, Berliner klin. Wochenschr., No. 20 et seq., 1867.—Fuller, On Diseases of the Lungs and Air-passages, their Pathology, Physical Diagnosis, Symptoms, and 296 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. Treatment. London, 1867.—Charles Parsons, Edinb. Med. Jour., 1867.__Rhiwen Roberts, Edinb. Med. Jour., Sept., 1867.—Abelin, Om nyttan af inhalationer af vamia vattenan gor vid lidenden inom respirationsorganerna under den spadare barnaaldern. Hygiea, 1868, p. 121.—Steiner, Die Bronchitis catarrhalis sicca der Kinder, Jahrb. f. Kinderheilk., I., p. 209, 1868.—Buchanan, Lectures on the Diagnosis and Management of Lung Diseases in Children, The Lancet, Ian. 25; Feb. 1, 15, 22; March 14, 28, 1868.— Fuller, Brit. Med. Jour., 1869.—Subbotin, Arch. f. klin. Med., Bd. VI., 2 u. 3, p. 285, 1869.—Richardson, St. Andrew's Med. Assoc. Trans., II., p. 231, 1869.—Fleming, Brit. Med. Jour., June 12,1869. —Ducournau, De la bronchite generalisee suffocante. These. Strassburg, 1869. — Charrier, Bull. gen. de therap., Dec. 15, 1869.—Hayem, Des bronchites, patho- logie generale et classification. Paris, 1869.—Greenhow, On Chronic Bron- chitis ; especially as connected with Gout, Emphysema, and Diseases of the Heart; being Clinical Lectures delivered at the Middlesex Hospital. London, 1869.—Loos, Ueber putride Bronchitis. Inauguraldissertation. Berlin, 1869.— Lebert, Beitrage zur Statistik und Aetiologie des Katarrhs der Athmungsorgane, Berliner klin. Wochenschrift, 1869.—Baas, Deutsches Archiv, Bd. VII.—Som- merbrodt, Nachweis einer neuen Ursache fiir Erkrankungen der Athmungsor- gane, Berliner klinische Wochenschrift, No. 7, 1870.—Hbppe, Memorabilien XV, 3, 1870— Raphael, New York Med. Gaz., May 21, 1870.—Charrier, Gaz. des hopitaux, 1870.—Paul et Gubler, Gaz. de Paris, 1870.—Julian, The New York Medical Record, 1871. — Traube, Gesammelte Beitrage z. Pathologie u. Physiologie. Berlin, Hirschwald, 1871.—Hirt, Die Krankheiten der Arbeiter, Beitrage zur Forderung der offentlichen Gesundheitspflege. Breslau, 1871.— Hertel, Mittheilung aus der Klinik von Traube, Berlin klin. Wochenschrift, Nos. 26, 27, 1871.— Ross, Dublin Quart. Jour. Med. Sci., Feb., 1871.— Waldenburg, Die Manometrie der Lungen oder Pneumatometrie als diagnostische Methode, Berlin, klin. Wochenschrift, No. 45, 1871.—Freud, New York Med. Gaz., Feb. 25, 1871.— Walshe, A Practical Treatise on Diseases of the Lungs. London, 1871.— Watts, Inhalation for Diseases of the Lungs. London, 1872.—Mey- hoffer. On Chronic Diseases of the Organs of Respiration; being a Series of Clinical Observations on Diseases of the Air-passages and the Lungs, Vol. I. London, 1871.—Delioux de Savignac, Bull. gen. de therap., Mars 30, 1871.—Baas, Experimenteller Beitrag zur Aufklarung der Frage iiber den Ent- stehungsort und die Entstehungsart des Vesicularathmens und der Rasselge- rausche, Deutsches Archiv fur klinische Medicin, Bd. IX.—Buhl, Lungenent- ziindung, Tuberkulose u. Schwindsucht. Miinchen, Oldenbourg, 2. Aufl., 1873.—Laffan, Brit. Med. Jour., Feb. 3. 1872.— Barrow, Phila. Med. and Surg. Reporter, June 22, 1872.—Dobell, On Winter Cough, Catarrh, Bronchitis, Emphysema, and Asthma. London, 1872.—Learning, Respiratory Murmurs, New York Med. Journal, May, 1872.— Waldenburg, Die locale Behandlung d. Krankheiten d. Athmungsorgane, Lehrbuch der respiratorischen Therapie. Berlin, 1872.— Woillez, Traite" clinique des maladies aigues des organes rcspira- toires. Paris, 1872.—Briigelmann, Die Inhalationstherapie bei Krankheiten BRONCHIAL CATARRH. 207 der Lunge, der Luftrohre und Broncnien, 1873.—Kosinski and Brodowski in Warschau, Syphilitische Degeneration der Bronchien, Sitzungsbericht. der Warschauer Gesellch. der Aerzte vom 4, Feb., 1873 in the Pamietnik tow. lek., I., pp. 16-19.—Lenac-Lagrange, Etude clinique sur diverses formes de bronchitis. Paris, 1873.— Friedldnder, Untersuchungen lib. Lungenentziindung. Berlin, Hirschwald, 1873.—Schrotter, Laryngologische Mittheilungen. Jahres- bericht der Klinik f. Laryngoskopie an der Wiener Universitiit, 1871-73. Wien, 1875.—Riegel, Die Athembewegungen. Wiirzburg, 187:5. — Gerhardt, Sitzungsberichte der physikalisch-med. Gesellschaft zu WLirzl)urg, Sitzung vom 21. Februar, 1874.—H Lebert, Handbuch der praktischen Medic, 4. Aufl. —Jarasz, Apomorphin als Expectorans, Centralblatt f. d. m. W. 1874, No. 32. —Loomis, Lectures on Diseases of the Respiratory Organs, Heart, and Kidneys. New York, 1875. The reader may consult, further, the manuals of pathological histology, the manuals of special pathology and therapy, of the diseases of children, and of the dis- eases of old age. Prefatory Remarks. While in earlier times a catarrh was spoken of only when the secretion from the affected mucous membrane was rich in mucine, and cellular elements were only sparsely mingled there- with, at the present day the richness in certain cellular elements of a fluid secreted from a mucous membrane is regarded as an indication of a catarrhal process. If this old view is retained, and catarrh is spoken of, as by Traube,1 only when the patho- logical secretion of a mucous membrane is rich in mucine, and the viscid, tenacious fluid contains but few cellular elements, and then such only as originate from the uppermost layer of the mucous membrane, it must be acknowledged that pure catarrn of the mucous membrane of the air-passages is a relatively rare manifestation. The processes which we encounter most fre- quently in practice, then, present a mixture of catarrh and inflam- mation. The designation of catarrhal inflammation has, there- fore, been justly applied to this frequently occurring form of dis- ease, both in its acute and its chronic varieties. This process is characterized by the exhibition on the part of the affected mucous membrane, not only of increased secretion of mucus, but also of the characters of true inflammation. The evidence for 1 Ilrtel, Mittheilung aus der Klinik von Traube. Berlin, klin. Wochenschr., 1871, Nos. 26, and 27. 298 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. the justness of this view is offered in the condition of the sputa, which are distinguished by their great richness in mucine, on the one hand, and, on the other, by the presence of more or less numerous cellular elements, especially lymph corpuscles. The reverse condition of both these factors may vary a great deal, both in the individual stages of bronchitis and in its individual forms. In the following pages, in treating of the peculiar characters of special forms, we will at first include all these different forms in one, and then return to the subject more closely. If it is said of catarrhal inflammations of the mucous mem- branes in general, that they belong to the most frequent of all forms of disease, the same remark is especially applicable to those of the mucous membrane of the air-passages. Hardly another organ evinces disorder as frequently as the mucous membrane of the respiratory apparatus ; and there is hardly a second form of disease which is so generally distributed as catar- rhal inflammation of the mucous membrane of the air-passages. But, as is well known, these catarrhal inflammations progress in very different manners. Sometimes the hypersemia and swell- ing preponderate; sometimes the increased secretion of the mu- cous membrane is the most prominent symptom ; sometimes the secretion has a more mucous, sometimes, again, a serous, some- times a purulent character ; and so on. In the same manner, the course of the catarrhal inflammation presents numerous vacilla- tions ; and it is no wonder then, that, according as it has been viewed from this stand-point or that, catarrhal inflammation of the mucous membrane of the air-passages has been arranged, at all times, in a series of different subdivisions. An enumeration of all the various classifications, which al- most every individual author has arranged in his own manner, would serve no purpose here. It is evident that the classifica- tion will be different according as the subject is approached from this or that stand-point; according as the clinical course chiefly is kept in view, or the nature, quantity, and other conditions of the secretions ; and so on. Certain principal subdivisions, how- ever, have been retained in common by all authors. The differ- ence between the individual forms of the disease is too great, not BRONCHIAL CATARRH. 299 to render it positively necessary to subdivide catarrhal inflam- mations into different sections. In the first place, then, catarrh is separated into two groups, acute and chronic, according to its course. Then, according to its seat, we must ascertain whether the catarrh has seized upon the coarser divisions of the bronchial tubes, or is located in their finer and most delicate twigs. In this way we distinguish a catarrh of the larger bronchi, with which the trachea is also fre- quently implicated, as tracheobronchitis, and a catarrh of the smaller and most delicate twigs of the bronchial tree as capil- lary bronchitis. The extension of the catarrhal process leads to still further discrimination. According as the catarrhal inflammation is ex- tended over most of the branches of both primitive bronchi, or according as it is limited to a small section of the bronchial tract, we distinguish the former form as diffuse bronchitis, and the latter as circumscribed bronchitis. Acute and chronic catarrhs of the trachea occur very seldom as isolated affections.1 They occur, as a rule, simultaneously with laryngeal, pharyngeal, and bronchial affections. It is, further, of great signilicance whether the bronchitis and tracheitis occur as a genuine primary disease, or whether they become associated in the form of a secondary affection, as a com- plication or result of a disease already existing. We recognize, therefore, a primary and a secondary catarrh. Further differ- entiations are made, too, according as the catarrhal process affects childhood, middle adult life, or old age. Not only are certain forms of catarrh observed in greater frequency at certain periods of life, but the same form of bronchitis presents itself as an unimportant affection at certain periods of life, and as a very serious one at others. We need only recall here the analogous relations of catarrhal ^aryngitis, which, as a rule, presents itself as an insignificant Schrotter observed (Laryngologische Mittheilungen. Jahresbericht der Klinik fiir Laryngoskopie an der Wiener Universitat, 1871-73. Wien, W. Braumuller, 1875) only twenty-six cases of pure tracheal catarrh among 3,693 cases of diseases of the respira- tory tract, while it occurred very frequently in conjunction with laryngeal, pharyngeal, arid bronchial affections. 300 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. form of disease in adults, while it frequently gives rise to very alarming symptoms, on the contrary, in early childhood. In addition to the conditions mentioned, the duration, seat, and extension of the process, its manner of origin, the age of the patient, and still other conditions have been selected as a basis for classification. Individual symptoms have been adhered to as a basis of classification, and the nature of the expectoration has been chiefly selected among the different symptoms as a prin- ciple for classification. In this way Laennec,1 starting on this principle of classification, established a series of subdivisions, and made a distinction between mucous catarrh, pituitary ca- tarrh, dry catarrh, and the like. The majority of authors have adhered to a similar classification, founded on the varying con- sistence of the secretions, and have especially accepted the dis- tinction into a dry, a mucous, a purulent, a muco-purulent, and a fetid bronchitis. The rales, also, have been adhered to as a measure for classifi- cation ; and in correspondence with their division into dry and moist, bronchitis has been divided into two principal varieties, a bronchitis with dry rales, and a bronchitis with moist rales. This classification was adopted by Beau,2 who divided bronchitis into a "bronchite a rales vibrantes," and a "bronchite a rales bullaires." It is readily comprehensible that the classifications main- tained by individual authors must vary very much, according as they start from this or from that point of view, in delineating the various forms of bronchitis. It is self-evident that it would be a useless beginning were we to introduce here all the different classifications which have been adopted by the numerous authors who have written upon the subject under consideration. It suf- fices to have indicated briefly the various points of view from which a classification may be adopted. Concerning the classification upon which will be based the following consideration of our subject, it is self-evident that we must first discriminate between two principal forms, acute and chronic bronchitis. The symptomatic features of these forms, ______________________i_____________________________________________________________________________________________________________________---------- 1 Traite de l'auscultation, etc. Paris, 1819, 1837. a Archiv. gener., Sept. and Oct., 1848. BRONCHIAL CATARRH. 301 however, as well as their course, their prognosis, and the like, present important differences according as only the larger bronchi, or the smaller and smallest bronchial twigs, or almost the entire bronchial tract, are affected. Physicians have justly, therefore, for a long period, made a distinction between tracheo- bronchitis, capillary bronchitis — or bronchiolitis — and diffuse bronchitis, and we, likewise, will here adhere to this classification as unconditionally essential. Those modifications which are occasioned by age, physical condition, and the like, will come under notice in our description of tliese individual varieties. Etiology. Before we pass to the consideration of the etiological condi- tions in their precise sense, it will be proper to make some remarks concerning the geographical distribution of tracheal and bronchial catarrhs, and their frequency in individual climates. Unfortunately we must here premise the remark, that statis- tic data in this direction are tolerably deficient. The reason for this may be in part assigned to the fact that bronchitis in general is such a widely spread disease that it has not been considered sufficiently worth while to gather exact statistics concerning the frequency of its occurrence in different climates. Frequently enough, too, sufficient discrimination has not been made between catarrh of the tracheal and bronchial mucous membrane and other lung affections, especially chronic pneumonia and tubercu- losis. As is generally known, catarrh of the respiratory organs is not only one of the most frequent of diseases, but it is also one of those most widely spread over the greatest part of the earth's surface. On this account, as already advanced by Hirsch,1 in his admirable manual, statistics possess too few data of cer- tainty to enable us to arrive at any mathematical conclusions as to the frequency of these forms of disease in different portions of the earth. This much, however, is firmly established, that t'otarrhal affections of the respiratory organs, other things 1 Handb. d. historisch-geographischen Pathologie. Erlangen, Enke, 1863-64. 302 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. being equal, are the more frequent the farther we proceed from the tropics towards higher latitudes, and that the maximum of their frequence in different portions of the frigid and temper- ate zones is found in general where frequent, sudden, and severe variations of temperature occur, in addition to the prevalence of a moist and cold climate. A comparison with the geographical distribution of croupous pneumonia is of especial interest. It appears that this is quite different from that shown by catarrh and bronchitis. With croupous pneumonia there is no increase of frequence, the fur- ther we proceed from the tropics into higher latitudes, as is the case, according to the concurring statements of Ziemssen and Hirsch, with catarrhs and bronchitis. Concerning the frequency and intensity of the occurrence of these forms of disease in individual regions, we refer to Hirsch, who has made the most accurate studies on this point, and merely mention that a very remarkable exemption from pul- monary diseases in general, and also from bronchitis, according to the coinciding reports of all observers, exists in both upper and loioer Egypt, the western prairies of North America, the plains of India, a portion of the Antilles, California, etc. The generally accepted opinion that the geographic extension of diseases of the respiratory organs bears a direct relation to geo- graphic latitudes, so that there is a decreasing frequence from a maximum at the poles towards a minimum at the equator, does not apply, according to Hirsch, to all diseases of the respiratory organs, but only to catarrh and bronchitis especially. The geo- graphic distribution of the latter affection certainly exhibits a uniformly decreasing frequency from cold regions towards the tropics. Among the characteristic conditions of climate in general, two especially come into consideration: temperature and humidity of atmosphere. From the comparisons made by Hirsch, as to the influence of temperature upon the frequency of bronchitis, it is evident that these diseases, in general, increase in frequency from lower to higher latitudes, in contrary relation to a fre- quency existing in moderate temperatures, notwithstanding that, as shown by Hirsch's tables, there are many exceptions to this BRONCHIAL CATARRH. 303 rule ; so that the average temperatures of a region offer no cer- tain standard for the frequency of tliese diseases. Hirsch believes that the influence of severe changes of tem- perature upon the frequency of catarrh and bronchitis in gen- eral is too highly estimated, and that the dependence of the lat- ter upon the condition of humidity of the atmosphere is much more weighty. It may be considered as firmly established that catarrh in such regions occurs most frequently and over greatest extent in those localities in which the air is loaded with moisture nearly to saturation, either periodically for long periods or con- tinuously. Absolute admixture of vapor does not come into con- sideration here so much as relative admixture ; and the differ- ence between the dew-point and the average temperature is the especial standard of measurement for estimating the humidity of a legion. The diseases named, therefore, will be principally observed at those periods of the year in which temperature and (low-point fall closely together ; in which severe thermometrical oscillations prevail in consequence of changes in the direction of the wind, and so on; in which the atmosphere, saturated with water, appears continuously moist, thus occasioning moderate or severe falls in temperature of longer or shorter continuance. This period occurs, in moderate latitudes, in spring and in the latter part of autumn; and in the tropics, at the periods of transition from the hot to the cool seasons, and vice versa. The experience that has been acquired, on the other hand, concerning the climatic condition of those regions in which catarrhs and bronchitis are seldom observed, is readily brought into accord with those laws established by Hirsch concerning the geographic extension of catarrh and bronchitis. The charac- teristics of tliese regions, remarkable for the infrequent occurrence of the diseases in question, lie in a higher, and, above all, uni- form temperature loitli a relatively low dew-point, and in pre- vail ing dryness of the atmosphere. Experience concerning the influence of the condition of the earth'' s surface upon the occurrence and geographic extension of catarrh and bronchitis, coincides also with these views of Hirsch. Configuration, elevation, and geological consistence of the surface form important factors in the climatic characters of a 304 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. region. Concerning the elevation of surface, it is especially to be noticed that mountainous regions and high plateaus are verv frequently the home of catarrhs and bronchitis. Biermer' draws especial attention to the concurrence of raw winds with the prevalence of catarrho-inflammatory affections of the chest; and he believes that the favorable atmospheric con- ditions for the production of catarrh of the chest reside in the coincidence of raw currents of air with relatively greater humid- ity. Leberta also adopts the views last mentioned, and draws especial attention, moreover, to the great influence of rapid depressions of temperature. We will recur to these influences in treating of special causes. Concerning the frequency of occurrence in individual years, Lebert justly remarks that very warm, dry, beautiful years are in no wise those in which catarrh occurs the least, as is the gen- eral opinion; on the contrary, he asserts that relatively fewer catarrhs occur in years which are wet and cool, neither decidedly warm nor beautiful, because the transitions of the seasons are less precipitate in such years as these, and the changes of tem- perature less marked. Lebert's meteorological analyses have also proven the fact that absolute means of atmospheric pressure and temperature predispose less to catarrh of the respiratory organs than great differences and sudden changes. It is further worthy of mention that while conditions of race are without important influence, in so far as any peculiarity of individual organization is concerned, acclimatization plays a part, to the extent of guaranteeing a certain immunity against catar- rhal disease. It happens, therefore, that people who remove from a warm, uniform climate into higher latitudes, where catarrh and bronchitis are indigenous, are the more readily and more severely attacked by these diseases the greater the differ- ence between the climatic conditions of the old and new places of abode (Hirsch). Finally, it is worthy of remark, as Hirsch contends, in rela- tion to the question under consideration, that in those tropical regions in which catarrh and bronchitis in general occur within 1 Bronchienkrankheiten, in Virchow's Handb. d. spec. Path. u. Ther., 5. Bd., p. 651. 2 Klinik der Brustkrankheiten. Tubingen, Laupp, 1784, 1. Bd. BRONCHIAL CATARRH. 305 tolerably extensive limits, the native-born population succumb much more than Europeans, especialljT those recently arrived from higher latitudes. The frequency of catarrhal inflammations during individual months is, self-evidently, variable. According to the data pre- viously mentioned, the maximum of these forms of disease must fall at different periods in different portions of the globe. In moderate latitudes this period occurs in spring and late in autumn. The months most predisposing to catarrhs are those in which the severest thermometric fluctuations take place, in which the atmosphere appears continuously moist, in which changes in the direction of the wind are very common, in which frequent rains take place, and so on. This period in our own country (Germany) includes the autumn and the commencement of spring, and, to a less degree, the winter. According to Lebert's ' accurate statistical tables from the clinique in Zurich, 50 per cent, of all cases occur in the first four months of the year; 11 per cent, in June and July together; 14 per cent, in October and December together ; 6 per cent, in M;iy and November each ; and the minimum, 5 per cent., in August and September each. Thus the last three months and the first four furnish the principal number of cases, and then there is a decrease from May on, the smallest figures occurring in the second half of the summer. The individual quarters show the figures: 1st, 39 per cent. ; 2d, 24 per cent. ; 3d, 17 per cent. ; and 4th, 20 per cent, In the Breslau clinique, the first four months yielded 50 per cent, ; May, Octo ber, November, and December, 30 per cent. ; June and July, 12 per cent, ; August* 2 per cent.; and September, 4 per cent. The quarterly figures are: 40 per cent., 27 per cent., 12 per cent., and 21 per cent. ; the relations of the two halves of the ye:u = 2:1. Ilaller's2 results from the Vienna Hospital are somewhat different, According to Ilaller's tables, catarrhs of the respiratory organs culminate in January; diminish.. markedly in February ; undergo a fresh though insignificant increase in March ; sink slowly from April on, and throughout May ; sink more rapidly in June, and :u-e at their lowest in September, while there is a moderate but steady increase again from October to th:; end of th;> year. It is further worthy of remark, in regard to frequency in individual seasons, that there is a want of coincidence between croupous pneumonia and catarrh of the respiratory organs, as is evident from different series of statistics, especially those of the general hospital of Vienna. 1 Klinik der Brustkrankheiten, I. Bd. p. 111-). ■ Die Volkskrankheiten in ihrer Abhangigkeit von den Witterungsverhaltnissen. Wien. I860. VOL. IV.—20 306 RIEGEL.—DISEASES OF TRACHEA AND BRONCni. In leaving these remarks concerning the geographical exten- sion of bronchial catarrh and its periodical appearance, to con- sider its etiological relations, we have, in the first place, to separate the predisposing influences and the special exciting causes. Though the disposition to catarrhal inflammations, as a whole, may be regarded in general as a common characteristic of very many persons, still there are many remarkable indi- vidual differences in reference to the localization of the ca- tarrhal inflammation. The disposition to disease in general, and to catarrhal affections in particular, always bears a relation proportionate to the general vigor of constitution. It is no won- der that robust natures, which exhibit a greater resistance than ordinary against all external injurious influences, should be less disposed to catarrhal affections of the respiratory mucous mem- brane in general. On the other hand, with increasing debility, and with greater delicacy of physical constitution, the disposi- tion to disease in general is increased, and so, likewise, that to catarrhs of the respiratory mucous membrane. On this account we see the same injurious influences meet with long-continued and often-repeated resistance from individuals of strong natures, while individuals of tender, relaxed natures, with anaemic or lymphatic habit, and the like, are in great measure predisposed to the diseases mentioned. In general, therefore, the adage is correct, that in the case of stronger constitutions the disposition to the diseases in question diminishes. On the other hand, it cannot be ignored that con- siderable fluctuations occur within these narrow limits. We are therefore disposed to speak of a certain individual predispo- sition, the ultimate cause of which we do not know with cer- tainty. While one man contracts a bronchial catarrh on the slightest exposure, such as a slight wetting, etc., a second indi- vidual, of probably the same vigor, reacts from the same influ- ence, or from an analogous injurious influence, with a coryza, a third with an angina, and so on. It has become customary in these cases to speak of a locus minoris resi stent ie (a locality of less resistance), without the least intelligent comprehension of the matter. Why, of three individuals exposed to the same BRONCHIAL CATARRH. 307 injurious influences, one should get coryza, another pneumonia, and the third bronchial catarrh, is by no means explained by the supposition that in the first the nose, in the second the luno-s, and in the third the bronchi, represent the locus minoris resistentie. That certain peculiar individual conditions of tissue must exist in tliese instances is evident; especially as we see it to be a fact that the same organ is repeatedly affected in the same manner by temporary injurious influences. In what, how- ever, this individual alteration of tissue consists is, as yet, by no means sufficiently explained. On the other hand, we also see a greater disposition to diseases of the bronchial mucous membrane developed as a consequence of debilitating diseases of long continuance. Such secondary bronchial catarrhs are met with in the wake of numer- ous acute and chronic diseases. In these cases the disposition is increased, on the one hand, by reason of the preceding acute or chronic disease ; but its origin is often to be sought for, on the other hand, in the circulatory disturbances occasioned by the fundamental disease. We need only recall, here, the frequent occurrence of bronchitis in diseases of the heart, (Specially in insufficiency of the mitral valve, in Bright's dis- ease and the like. For particulars concerning these secondary bronchites we must refer the reader to the appropriate sections. Sex, at any rate, plays only a subordinate role in reference to the disposition to catarrhal inflammations of the respiratory mucous membrane. The assertion has been repeatedly made, that men more than women contract bronchitis. This view has much apparent plausibility. The differences of employment and the manner of domestic life appear to account very well for such a different condition in the sexes. As yet, however, there is no precise statistical evidence of the justness of this view. But few exhibits of figures on this point are to be found in medical literature. It is self-evident that all those statistics, presenting merely the figures of mortality, such as those of Copland,1 for example, cannot be made available for the decision of this ques- tion. According to the few statistics of mortality that are acces- 1 On Consumption and Bronchitis, etc. London, 1861. 308 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. sible, there is much plausibility for the view of the greater frequency of these affections in males. Lebert (1. c.) also has exhibited a preponderance in favor of the male sex, in his very accurate statistics from the cliniques at Breslau and Zurich. According to Lebert's tables, bronchitis of all forms shows this sexual preponderance in the proportion of seven males to six females. It must not be forgotten, in this connection, that hos- pital statistics are insufficient for the decision of this question. The most plausible explanation of this difference is that which refers it chiefly, if not exclusively, to the difference in the avoca- tions of the sexes. Concerning the period of life, it has long been a correctly ascertained fact that, although bronchitis is observed at every time of life, there are certain periods in which it occurs with preponderating frequency. It is especially frequent in infancy. As is readily comprehensible, the respiratory organs of children are much more sensitive to atmospheric and other injurious influences than those of adults, and this explains at once the greater prevalence of respiratory diseases in childhood, in con- trast to that of adult life. The role, however, played by habi- tude or inuring, has been recently exhibited by Geigel,1 in a very admirable exposition of the infant mortality at Wurzburg. According to his observations, comparatively more legitimately born children die of respiratory diseases in the first year of life than illegitimate children; while the latter class succumb in greater number to diseases of mal-nutrition. While the latter circumstance is to be attributed, without doubt, to impaired nutrition, to which illegitimate children are naturally more exposed, in the melancholy conditions under which they are placed, and most so during the hot season, the preponderance of respiratory diseases among the more favorably placed legi- timate children can only be referred to the greater enervation to which they are subjected by the anxious mother, who keeps them in the room during every little raw puff of air; and this enervation so increases their disposition to disease as to over- balance the otherwise slighter resisting powers of the poorly matured illegitimates. 1 Deutsche Vierteljahrsschr. f. offentl. Gesundheitspflege, III., 520. BRONCHIAL CATARRH. 309 In spite of this, a slighter resistance of the infant organism to external, and especially to atmospheric injurious influences, in contrast to that of adults, cannot be questioned. West1 has further proved, by the aid of statistics, that inflammatory respi- ratory diseases are less frequent during the first six months of life than during the succeeding eighteen months; and he endeavors to explain this by a greater sensitiveness of the respi- rator}' mucous membrane, at a later period, than in the new- born babe. Biermer has justly rejected this view as unfounded ; and he prefers the self-evident explanation that children, as a rule, are more carefully protected from unfavorable atmospheric influences during the earlier months of life than at a later period. Perhaps, also, the process of dentition may play a certain role in this connection, even though but a distant one. According to Lebert all forms of bronchitis collectively (ca- tarrh of the coarser bronchi, bronchitis diffusa, and bronchi- olitis) exhibit an average of 27 per cent, for the first ten years of life, 25 per cent, for the second, 15 per cent, for the third, and 17 per cent, for the fourth decennium. After this period the average on the whole is only 8 per cent. A very different numerical relation appears, however, if the frequency of the individual forms of bronchitis at the different periods of life are considered separately. As in childhood, so again in old age, diseases of the respi- ratory mucous membrane play a major part. This is expli- cable by the rarefaction that the pulmonary tissue undergoes, in connection with the same conditions of all the tissues, in advanced life ; by the general feebleness of body, and in part, also, by the special alterations in the heart, the great vessels, and the like, attendant upon old age. As a general thing the disposition to bronchial catarrhs is relativelv less in adolescence and vigorous manhood. It must be maintained, withal, that the individual forms of catarrh exhibit very important differences in this respect. AVhile, for example, chronic bronchial catarrh is to be reckoned among the 1 Lectures on the Diseases of Infancy and Childhood. London, 1853. Philadelphia, is<;o. 310 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. forms of disease by no means infrequent in middle age, we observe the same affection relatively infrequently during the earlier periods of life. Instead of this, the acute forms, espe- cially bronchiolitis, are observed the more frequently. Second- ary catarrhs, as resultant conditions from cardiac insufficiency, emphysema, asthma, and Bright's disease, are, accordingly, rela- tively more infrequent also in childhood than in the period of completed growth. But it must always be maintained, that although the relative frequency of bronchitic affections is vari- able at the different periods of life, diseases of the bronchial mucous membrane are to be reckoned among the most frequent of all forms of disease at all periods of life. With respect to the special exciting causes, an important etiological role has always been attributed to "taking cold," without our always having any very clear notions of the mean- ing of that term. A satisfactory physiological explanation of the process of taking cold has never yet been advanced. The fact, as such, that a man becomes sick immediately after this taking cold, and in direct consequence of it, has long stood as firmly established. From the remotest period men have included under the term "catching cold," not only the inspiration of moist and cold air, but every too severe and sudden cooling of the entire body, or a portion of it. Experience showed that sometimes a thorough wetting, sometimes a cold draught of wind upon an over-heated and perspiring bod}^, sometimes the sojourn in a freshly cleansed, still wet room, and similar injuri- ous influences were immediately followed by the onset of the diseases under consideration. The occasion for the exertion of most of tliese injurious influences is naturally greatest at times of changes in the weather, and at times when the weather is moist and cold; and hence it is easy to understand how, when these causes are specially prevalent, the number of these diseases must also increase. It is evident, however, that the exciting causes mentioned may act as favoring factors of disease at every period of the year, independently of season, and thus give rise to catarrhs at any time. With ref srence to the process of " catching cold," its physiological explanation is as yet wanting, as already mentioned. In this relation the experiments and BRONCHIAL CATARRH. 311 researches recently reported by Rosenthal,1 seem to me to bo of significance. Rosen- thal, in his experiments upon the retention of animals in elevated temperatures, placed the animals in a peculiarly constructed hot box, as had been done by Acker- man '' and myself 3 in our analogous experiments. He has observed the character- istic fact, which I can fully substantiate on the basis of numerous experiments of my own, that when the animals are removed from the hot box and replaced in the ordinary temperature of the apartment, the temperature sinks not to the normal degree only, but below it. For this Rosenthal has offered the following, and, as it appears to me, excellent explanation. The blood-vessels of the animals become paralyzed in the high temperature ; more blood then courses through the skin than under normal conditions, and in spite of the reduced difference of heat, the animal loses so much heat that its own heat increases but little proportionately. If it is now replaced in a room at the ordinary temperature, its vessels still remain para- lyzed for some time, and for a longer period, the higher the temperature to which it had been previously subjected, and the longer it has remained in this high tem- perature. Now, in the considerable difference between its own temperature and the temperature of the apartment, the animal must lose much more heat than a normal animal loses in the same apartment. Its own heat, therefore, declines, and not only down to the normal degree, but also considerably below it. The cause of this decrease, therefore, is to be sought principally in the paralysis of the vessels. Rosenthal believes that this fact of the subsequent decrease in temperature is cal- culated to throw some light upon the process of '' catching cold." He recalls, in the first place, the generally known fact that taking cold occurs most readily in the sudden transition from a higher temperature to a lower one. There can be no doubt that the sinking of the body temperature below the normal standard may also occur in human beings, if they are exposed to high temperatures and then return to moderate temperatures. Temperatures of from 30° to 35° C. (8G° to 95° F.) arc not at all impossible in dancing and other saloons; and people frequently pass from these high temperatures into temperatures lower than those employed in the experi- ments mentioned. Now, in such hot places the temperature of human beings must increase above the normal degree, and sink again afterwards, on the other hand, below the normal degree. This cooling, in itself, however, does not yet represent any "taking cold." To effect this injurious influence, another element must be added, and that is the suddenness of the transition. If the heated body, with its enormously dilated superficial vessels, is suddenly exposed to cold, there is not only a considerable amount of heat abstracted, but the blood of the superficial parts of the body so suddenly cooled now courses through the internal organs, and cools these off much more suddenly than would be the case from the simple influence of 1 Rosenthal, Zur Kenntniss der Warmeregulirung bei den warmbliitigen Thieren. Programm zum Eintritt in die med. Facultiit und in den Senat der k. Universitiit zu Erlangen. Erlangen, 1872. '' Deutsches Archiv f. klin. Med., VI., 359. 3 Riegel, Pfliiger's Archiv, V., 629. 312 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. cold without the previous influence of greater heat. The cooling off, therefore, is not only more considerable, but also much more rapid. This sudden cooling may then, in itself, act as an injurious influence, and excite a disaase in this or that organ, especially if it is already enfeebled and hence less resistant. According to this exposition it may be understood how the disease under consideration may be excited, in persons disposed to catarrh in general, in consequence of a sudden cooling off of the entire surface of the body, or one portion of it. It is further comprehensible, why one man will acquire one disease, and another man another one, from exposure to the same injurious influence. According as in the one case one organ, and in another case another organ, is the locus minoris resistentie, sometimes this disease and sometimes that disease will result from the same exposure. We are, moreover, the more inclined to presuppose a slighter power of resistance in the one organ or in the other, because experience frequently shows that the same or similar injurious influences always produce the same disease in the same individual. It is hardly necessary, therefore, to insist more particularly upon the importance of a methodical invigoration of the body, as a preventive measure against taking cold. We will have occasion to enter into detail on this point when treating of pro- phylaxis. Here we may simply again recall the verification of the fact, already mentioned as proven by Geigel (I.e.), as an evi- dence of the great role played by pampering: viz., that com- paratively more legitimate than illegitimate children die of res- piratory diseases in the first year of life, while the latter class suffer in greater numbers from diseases of mal-nutrition. Among the further causes of tracheal and bronchial catarrh, injurious admixtures in the atmosphere play a very important part. It is only recently that the so-called diseases from the inhalation of dust have been better appreciated than formerly; and for this we are especially indebted to Hirt,1 who by his thorough researches has shown the great influence that employ- ments and the sojourn in an atmosphere filled with injurious admixtures have upon the general health of the laborer, and 1 Hirt, Die Krankheiten der Arbeiter. Breslau, 1873. BRONCHIAL CATARRH. 313 upon the occurrence of respiratory diseases in particular. We must therefore refer those especially interested in this question to his excellent monograph. It is clearly evident that the diseases to which injurious admixtures in the atmosphere chiefly predispose, must especially concern the respiratory organs. k'If a workman," says Hirt, " of that class to which Ramazzini has already applied the term 'dustj' handiworker,' breathes during the greater part of the day in his workshop filled with dust, or in the working room of a manufactory, then with every breath of air a smaller or greater quantity of fine, dusty molecules will be carried into the respira- tor}' tract, by means of which it is uninterruptedly exposed to mechanical irritation." Accordingly we find a high percentage of diseases of the respiratory organs among workers in dust, and indeed a much higher percentage than loith others who are not exposed to the action of dust. Among the different diseases of the respiratory organs of workers in dust, catarrhs of the respiratory organs, and among these again chronic bronchial catarrh, take the first rank. These result from the influence of all dusty avoca- tions, even those otherwise relatively uninjurious, but by no means with equal frequence. According to the researches of Hirt, these catarrhs arc more frequently produced, on the average, by the inhalation of the dust from vegetable substances : then follow, with less activity, metallic dusts ; then, still less actively, animal dusts ; while mineral particles close the series as the least injurious in general. The so-called "compositions" exercise, according to Hirt, an evil influence upon the respiratory organs of the workmen, similar to that caused by vegetable dust. Among the various diseases occasioned, chronic bronchial catarrh in particular occurs most frequently among workers in dust. There arc even avocations in which almost every individual working at them for a long time suffers from bron- chial catarrh ;—modelers, millers, and workers in coal, for example, are the chief sufferers in this respect. Concerning the relative frequency of chronic bronchial catarrh among the indi- vidual workers in dust, we must refer to the tables of Hirt. "We may the more readily dispense with a closer discussion of these relations, because they have already received special consideration in another volume of this Cyclopaedia 1 from the pen of Merkel, so especially wrell versed in this very question. It is self-evi- dent that the special diseases from the inhalation of dust, which are only produced Vol. I. of the German edition. Omitted from this edition for reasons already stated.—Editor's Note. 314 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. by the inhalation of a particular form of dust, such as anthracosis, chalicosis, and the like, do not enter into the theme before us. The inhalation of gases and vapors is to be mentioned as a further cause of catarrh of the tracheal and bronchial mucous membrane. Concerning this, however, there is an important dif- ference between the diseases thus caused and those occasioned by the inhalation of particles of dust. While in the action of dust upon the respiratory organs, primary bronchial catarrh almost always occurs as a result of the mechanical irritation, before any more deeply seated disease of the lung can take place, gases and vapors excite bronchial catarrh only when in the con- dition of great attenuation. When breathed in a concentrated condition, on the contrary, the severest symptoms may occur in the shortest time, without any previous catarrh of the respira- tory mucous membrane. It is also shown here, in a manner analogous to that occurring in the inspiration of dust, that catarrh of the air-passages is not occasioned with uniform frequency by the different gases and vapors. Hirt represents it as probable, on the basis of numerous observations and experiments, that it occurs most often, relatively, after the inhalation of hyponitrous acid fumes and those of nitric acid ;—sulphuric acid follows in the second rank. Muriatic acid vapors produce it relatively infrequently; sometimes it is observed after the inhalation of small quantities of chlorine gas. Acute bronchial catarrh among workmen from inhalation of iodine appears to be exceptional. Although chronic catarrhs are by no means infrequent after the inhalation of gases and vapors, their frequency is certainly not equal to that occasioned by the inhalation of dust. It appears, as remarked by Hirt, that the inhalation of injurious gases—and to a certain extent, also, of dust—may perhaps be borne without further bad results after it has excited acute catarrh once or several times; the workmen thus becoming gradually accustomed to the gaseous atmosphere without experiencing any difficulty on the part of the respiratory organs. Hirt draws attention to a second point in explanation of the fact that chronic bronchial catarrhs are less frequent after the inhalation of gases in general than after the inspiration of dust. While all forms of dust possess more or less the com- mon characteristic of exciting chronic bronchial catarrh when they come in contact with the mucous membrane of the respiratory organ, we see on closer consideration of the various gases and vapors that there are not only some which can be breathed without exciting catarrh, but also not an inconsiderable number which possess the property of diminishing a disposition to catarrhal disease, and even of contributing to the favorable termination of a catarrh already existing. To this class belong the BRONCHIAL CATARRH. 315 vapors from oil and from glue, the vapors produced by burning tar, and, furthermore, salt-air, the air prevailing in the vicinity of drying-houses. That inflammations of the tracheal and bronchial mucous membrane may also be occasioned by large foreign bodies which gain access into the air-passages, in a manner analogous to that occasioned by particles of dust, hardly requires any further special mention. Usually the inflammation excited by foreign bodies is circumscribed, and limited to the immediate vicinity of the locality directly irritated by the foreign body. The symp- toms of local inflammation in these cases, however, unless deep- seated inflammation, ulceration, abscess, and the like are excited, recede so far in the background, in contrast to the symptoms directly occasioned by the obstacle to respiration, that they hardly come even into remote consideration. A further cause of catarrhs of the tracheal and bronchial mucous membrane lies in the transient contagions by which they are occasioned, such as epidemic influenza, whooping-cough, and, in a more indirect manner, by a further series of infective diseases—measles, small-pox, and the like. Inflammatory foci may also be occasioned by the local irrita- tion which occurs from the eruption of the pustules in small-pox. Pustules occur, not altogether infrequently, at the point of divi- sion of the bronchi, as Wagner1,has shown. Among 170 cases, carefully examined, Wagner found pocks in the pharynx, larynx, and trachea, in fifty-four cases ; in the pharynx, larynx, trachea and larger bronchi, sometimes as far as the bronchi of the second and third order—especially, however, at the points of division of the bronchi—in fifty-two cases. In a previous part of this article we have especially indicated, among the predisposing elements of tracheitis and bronchitis, various diseases of the heart, especially those valvular insuf- ficiencies which are associated with impediment to the pulmonary circulation. It is self-evident that it only requires the develop- ment of these affections up to a certain degree to justify us in regarding them also as direct exciting elements. The hyperemia Wagner, Die Todesfiille in der letzten Pockenepidemie in Leipzig, der H, Archeil- kunde, 1872, p. 107. 316 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. thus occasioned must, in these cases, form the starting-point for all those disorders which are collectively included under the name of catarrhal inflammation ; and even the hypersemia must be regarded as one of the most important original elements of their production. In an analogous manner a series of other affections, which in their milder grades can only be designated as predisposing ele- ments, may become direct exciting causes when they are further developed. This applies, for example, to various diseases of the lungs. Finally, we observe bronchi tic affections as a secondary con- dition in a great number of infective diseases. Thus bronchitic symptoms are almost constantly observed in typhoid fever. Here, in addition to the feebleness of the circulation, the dorsal decubitus favors its occurrence, as is shown by the appearance of pulmonary hyperemia and bronchial catarrh in the most dependent portions of the lungs ; and especially by the results of hydrotherapy. In the same manner secondary bronchitic affections are not infrequently observed in Bright's disease, in various cerebral diseases, in certain dyscrasic conditions, and the like. It follows from what has been said that we must distinguish a primary and a secondary mode of origin for bronchitis. In the primary cases, the injurious influence immediately excites an inflammation of the bronchial mucous membrane. We see sec- ondary bronchitis make its appearance with especial frequency in all those affections which disturb the lesser circulation mechan- ically ; to which category diseases of the heart belong chiefly, and among these again insufficiency of the mitral valve plays the first role. Then we have aneurisms of the aorta, tumors of the mediastinum, exudations into the pericardium, and other affections of similar character. It must be remembered here, in order to comprehend the method of origin of many of these bronchial catarrhs, that the bronchial arteries given off from the aorta or intercostal arteries give up only a portion of their blood to the bronchial veins, from which the blood enters into the azygos vein, and, further, into the vena cava. A portion of the blood of the small bronchial veins flows within the substance of the lung in the pulmonary veins. It follows from this that an insufficiency and stenosis BRONCHIAL CATARRH. 317 of the bicuspid valve, by means of which the emptying of the left auricle, and also of the pulmonary veins is impeded,—that an aneurism, a mediastinal tumor, in short, any of those affections which may exercise compression on these veins, will give rise at first and principally to hyperaemia of the lungs (i.e., to a distention of the capillary reticulum of the alveoli) ; and that when these affections are of a high grade, a chronic bronchial catarrh will be one of the manifestations most frequently observed. This circumstance wTill be comprehensible, in the first place, by the fact that a portion of the blood flows from the bronchial mucous membrane not into the right heart, but into the left one. The circumstance, also, that most chronic diseases of the parenchyma of the lungs show a tendency to become complicated with bronchial catarrhs, is in part explained by the vascular arrangement just mentioned (Seitz, Niemeyer). Furthermore, all those diseases of the bronchial mucous mem- brane in which the inflammation of a neighboring organ has be- come extended upon the bronchial mucous membrane, must be included in the category of secondary affections. Thus inflam- mations of the larynx, trachea, the parenchyma of the lungs, and the like, are not infrequently extended directly upon the bronchial mucous membrane. Anatomical Alterations. The name '' catarrh,'' with which tracheal and bronchial catarrh have been designated according to an old-established custom, is evidently taken from but one manifestation of the catarrhal inflammation, and that is the hypersecretion of the mucous membrane. It must not be forgotten, however, that this forms but one link in the chain of manifestations. It must be retained in mind that this hypersecretion is almost always associated with an hypersemia of the mucous membrane, and that the hyperaemia represents the primary manifestation, and the hypersecretion only a partial one. Swelling, turbidity, pigmentation also, under certain circumstances hypertrophy or atrophy, hemorrhage, etc., are to be designated as further, and in part important, features of the catarrhal inflammation. It is the sum of tliese manifestations which represents the sympto- matic picture of catarrhal inflammation. The disturbance of the circulation of the blood, therefore, although an important link in the chain of catarrhal inflammatory manifestations, is never- theless in no manner sufficiently important as such. 318 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. The hyperemia itself, again, may be of a different kind, active or passive. Active hypersemia is the direct sequence of the injurious influence which has occasioned the inflammation. Passive hypersemias, on the contrary, often precede the charac- teristic bronchitis for a long time, especially in those diseases which are associated with a disturbance of the pulmonary circu- lation. These affections thus exert a certain predisposition to the catarrhal inflammations under consideration. There is no reason to separate tliese secondary catarrhs altogether from special catarrhal bronchitis, as has been attempted by Mon- neret.1 Though there may be some differences, there is no essen- tial difference between this and the remaining forms of chronic bronchitis, either in an anatomical or in a clinical point of view. Swelling of the mucous membrane is to be designated as a second anatomical element of the catarrhal inflammation. That it stands in intimate and direct relation to hypersemia is self- evident, even though it must be borne in mind, on the other hand, that the swelling in no wise always progresses exactly parallel with it. The third important element of catarrhal inflammation lies, as the name "catarrh" already indicates, in the alterations which the secretion of the mucous membrane undergoes in con- sequence of the catarrhal inflammation. Important and signi- ficant as this very symptom is for clinical observation, just so erroneous would it be to consider catarrhal inflammation as simply an increase or anomaly of secretion. We have already referred to these differences between catarrh proper, as an altered secretion of the mucous membrane, and catarrhal inflammation. According as, in individual cases, this symptom sometimes preponderates, and sometimes that one, while the remainder recede more or less in the background, a series of different forms come under consideration. Sometimes the hypersemia prepon- derates, sometimes the swelling, while the secretion is much diminished, or even fails altogether; sometimes the increased secretion is the chief symptom ; and so on. In considering the anatomical alterations, it must be borne in 1 Traite elementaire de Pathologie interne, T. I., 1864. BRONCHIAL CATARRH. 319 mind, in the first place, that all of the features mentioned as peculiar to the catarrhal inflammations are not always anatomi- cally demonstrable. Neither the hypersemia nor the swelling is to be detected in the corpse in every case of catarrhal inflamma- tion. Often, and especially in cases of slight degree, the hyper- emia is no longer distinguishable upon the corpse, notwithstand- ing that there is every reason to maintain that it had existed during life. Not infrequently this manifestation recedes so much in the act of dissolution, and after death, that hardly any indications of its existence remain. So also the swelling of the mucous membrane fails in not a few instances, while it is very pronounced in others. Often the swelling of the mucous mem- brane appears less in the corpse than had been anticipated on the basis of the clinical manifestations. This is especially justi- fied by the analogy with other mucous membranes, particularly of the larynx, the accurate inspection of which during life no longer presents any difficulty. In the larynx we can readily become convinced, from the much more considerable swelling so often observed during life, in comparison to that observed after death, that the anatomical examination affords no trustworthy data for judgment concerning the degree and intensity of the swelling which had existed during life. Concerning this point, the individual mucous membranes, as is well known, by no means comport themselves in the same man- ner. While many mucous membranes offer but a very slight resistance to dilatation of the vessels, on account of the delicacy of their epithelial layer and the softness of their tissue, other mucous membranes, and especially the mucous membrane of the respiratory apparatus, are much less favorably disposed to the occurrence of severe hypersemia and swelling. This depends, in the first place, upon the richness of the mucous membrane in elastic fibres. With the greater richness of the mucous mem- brane in elastic fibres the obstacles increase which oppose dila- tation by hypersemia. The richness of the respiratory mucous membrane in elastic fibres thus renders it readily explicable how the elastic force, under certain conditions, overcomes the pressure exerted on the part of the vessels, and how, in cases in which severe hypersemia and swelling existed during life, 320 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. the demonstration of this condition is no longer possible after death. The hypersemia and vascular injection, which, as already mentioned, represent one of the most important features of bron- chitic manifestations, may exhibit very different grades both in intensity and in extent. Sometimes the reddening is altogether uniform, and extended diffusely over the mucous membrane of the trachea and many bronchial twigs ; sometimes it pre- sents only a very fine punctiform capillary injection ; and some- times, again, the mucous membrane is reddened, throughout a greater or smaller extent, in the form of individual disseminated foci. The color of the hypersemic portions of the bronchial mucous membrane is equally changeable. Sometimes it is a more clear red, especially in the acute primary forms of bronchitis ; some- times it is of a darker, even blue-red color, as in severe forms of chronic, and especially of secondary, bronchitis. The degree of injection varies likewise in reference to the depth to which it extends. Thus in mild forms of catarrhal inflammation the injection extends only over the superficial capillary reticulum of the mu_ous membrane; in severe grades and in long-existing inflammations the injection may extend as far as the submucosa, and still more deeply. With reference to the extent of the hypersemia, it does not often happen that the bronchial tract presents a uniform redden- ing of its mucous membrane in all its branches down to its ter- minal twigs. In acute genuine cases the reddening is most frequently limited to the inferior portion of the trachea and the larger bronchi, or in part to the medium-sized bronchi also. On the contrary, in secondary catarrhs, those of diseases of the heart, for example, the reddening, though by no means uniform in all parts, is nevertheless often extended over the greater portion of the bronchial tree. As with the degree of hypersemia, so also its extent must be very different, according to differences in the etiological elements, the duration and intensity of their influence, and the like. Here and there, especially in old catarrhs, the mucous mem- brane is not infrequently found so pale as to look gray, only BRONCHIAL CATARRH. 321 isolated small vessels glistening through it. The possibility of a mistake, therefore, is very probable in such cases. Swelling represents the second important symptom of inflam- mation of the tracheal and bronchial mucous membrane. This again depends in part upon the increased fulness of the vessels, in part upon the nutritive changes occurring in the tissue itself, and in part upon the greater saturation of the mucous mem- brane with serum. This increased serous saturation of the mucous membrane, which often imparts to it a characteristic velvety appearance, a certain lardaceous aspect, plays a great part, especially in diseases of obstruction. If an incision is made into these parts, a tolerably clear serum escapes from them. The more, too, the deeper layers of the bronchi participate, not only in the hyperse- mia, but in this serous saturation also, the more considerable must the swelling become. If the swelling affects the narrower and finer bronchi principally, the passage of the air is greatly impeded, or even rendered entirely impossible. The relative narrowness of the finer bronchi in children renders it readily intelligible how somewhat severe conditions of swelling may even completely prevent the entrance of air under certain circum- stances. The nutritive changes that have been arrested in the cells also contribute, in a measure, although only in a slight measure, to this increased swelling of the mucous membrane. In the acute forms of the disease, the catarrhal inflammatory process is limited to the special tissue of the mucous membrane, and in these cases, therefore, the swelling in most instances is merely moderate. In cases of longer duration of the affection, and in cases of frequent recurrences of acute catarrh, on the contrary, severe grades of swelling readily remain behind, especially be- cause the infiltration is often not confined to the mucous mem- brane alone. The process then no longer concerns chiefly a cel- lular infiltration of the sub-epithelial connective tissue only ; for with the frequent recurrence of such catarrhs, or in catarrhs of protracted existence, we see the number of cells in the connec- tive tissue of the mucosa undergo gradual increase ; the epi- thelium and also the glandular apparatus take part in the VOL. iv.—21 322 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. enlargement, and the mucous membrane in toto passes into the condition of hypertrophy. We thus see hypertrophy of the mucous membrane as a significant result of protracted or fre- quently recurring catarrh. These alterations are almost always bilateral in old cases of bronchitis. While, however, in the trachea, the chronic inflammatory process eventually produces an enlargement of the mucous glands (even to the size of a hemp-seed and larger), and moderate hyper- trophy of the mucous membrane, inveterate catarrh of the bronchi may result in a series of much more important altera- tions, among which bronchiectasis (dilatation of the bronchi) assumes the most important role. As is well known, we distinguish a saccular, a spindle-formed, and a cylindrical dilatation. Saccular bronchiectasis will not be further alluded to here, inasmuch as it stands in intimate con- nection with alterations in the parenchyma of the lungs. A cylindrical ectasia of the larger bronchi of one or of several lobes occurs not unfrequently as a result of inveterate catarrh. In these cases the walls of the bronchi are thickened for the most part, and are encompassed externally by thick connective tissue that radiates in the surrounding tissues. The free surface of the mucous membrane exhibits, further, some ledge-like pro- jections, arranged partly longitudinally, and partly horizon- tally, and which are especially prominent on the soft non-carti- laginous side of the bronchus, and between the cartilaginous portions of the opposite side. In this way the hypersemia often reaches a very considerable grade, and is so superficial withal, and the color is so uniformly clear, that it not infrequently has the appearance as though there were a suffusion with blood (Kindfleisch.) A microscopic examination discloses the fact that there is here a very advanced grade of development of the connective- tissue Constituents of the bronchial walls. The ledge-like pro- jections consist of a very richly cellular germinal tissue, which encloses longitudinal and horizontal bundles of elastic fibres; that is to say, it is the normal, so-called inner fibrous sheath in a hyperplastic condition. While the muscular element is unal- tered, the inner fibrous layer lying on the inside of the cartilag BRONCHIAL CATARRH. 323 inous rings is considerably thickened. Numerous wide blood- vessels penetrate this layer and send equally wide communicat- ing canals through the muscular layer to the inner fibrous layer, where there is a thick capillary reticulum, especially upon the ledge-like prominences (Rindfleisch). The cartilages of the dilated bronchi also exhibit a series of alterations worthy of notice. A portion of the cartilage disap- pears with the formation of spaces along its periphery, which are filled with a young connective tissue carrying vessels. At the same time the mucous glands disappear also, and their place is occupied by the young connective tissue developing from the neighborhood. Rindfleisch not inaptly designates this pro- cess as a supplantation of the cartilage by the encroaching growth of the irritated connective tissue of the neighborhood. Biermer describes the outgrowth of the vessels of the mucous membrane into papillary loops, as a result of long-continued and frequently recurring catarrh. In tliese cases the mucous mem- brane is very much swollen, hypersemic in a high degree, uneven, and filled with very small elevations corresponding to the papil- lary growths. These, according to Biermer, are usually directed in the longitudinal diameter of the bronchi, or they are in such close contact with each other that the mucous membrane at the localities affected appears shaggy or like granulating gland substance. The last-mentioned conditions represent alterations that be- long to the domain of hypertrophies. Even chronic bronchitis, in its further course, not infrequently leads to such hypertro- phies. Even the bronchial cartilages may participate in this hypertrophy, and it is the medium-sized bronchial twigs, less frequently the smaller and smallest ones, which become affected with this thickening. Diverticulum-like bulgings occasionally occur in the trachea, under the influence of chronic inflammations ; to which circum- stance Rokitansky was the first to direct attention. While the termination in hypertrophic conditions, principally induced by extensive hyperplasia of the connective-tissue consti- tuents of the bronchial wall, is not a thing of rare occurrence, processes of softening and maceration are only seldom observed 324 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. as results of the catarrhal inflammation. Ulcers of the mucous membrane, which are due to suppuration or partial necrosis, are exceedingly exceptional in both simple, acute, and chronic bron- chial catarrh. In like manner, actual softening of the mucous membrane is only exceptionally observed, and then in putrid bronchitis. Atrophy of the mucous membrane, even with larger or smaller—though usually only epithelial—losses of substance, is, on the contrary, not infrequently observed. Disturbance of the secretion has been described as the third important element of tracheitis and bronchitis. The alterations which the secretion of the mucous membrane undergoes on account of the catarrhal inflammation, are of special clinical sig- nificance. Indeed, owing to this symptom, it has been believed proper to consider catarrhs as mere anomalies of secretion ; and even at the present day genuine catarrhs are considered in this light, and are accordingly separated from the catarrhal inflam- mations. The disturbance of secretion, which continues during the entire existence of the catarrhal inflammation, may present the most numerous modifications in reference to both quantity and quality. As a matter of course, increase of secretion is more frequently observed, and a diminution or an entire absence of secretion, less frequently. The secretion furnished by the follicles of the respiratory mucous membrane is secreted, under normal conditions, just in quantity sufficient to maintain the mucous membrane constantly moist and smooth. It is otherwise in cases of acute or chronic catarrhal inflammation, in which important deviations in quan- tity and quality of this secretion are present. Even in the indi- vidual stages of catarrhal inflammation we see alterations of this pathological secretion appear ; these alterations, however, are more apt to escape observation in their finer gradations than is the case in other mucous membranes, as, for example, that of the nose. The changing consistence of the secretion in the different stages of acute catarrh of the nasal mucous membrane is familiar to every one ; and similar alterations are also encountered at different periods of acute bronchial catarrh. Thus, in acute BRONCHIAL CATARRH. 32o catarrhal inflammation of the nasal mucous membrane, we first observe a state of dry swelling of the mucous membrane in which all secretion fails ; then a stage follows in which a saline watery fluid is secreted; then a tenacious, translucent mucus follows; and finally a secretion rich in cells is discharged. In a similar manner the amount and quality of the bronchial secretion vary, according to the different stages of the catarrhal bronchitis. In acute bronchitis there is, as a rule, a tolerably protracted stage, in which secretion fails altogether, or in which it is only exceedingly slight. This is the stage of the so-called dry swell- ing of the mucous membrane. After a time, the secretion becomes more copious. The secretion now furnished still con- sists principally of the elements of the normal secretion from the mucous membrane, only in increased quantity; it is purely mucous, and consists chiefly of a tenacious, translucent mucus, and very few formed elements, such as mucus corpuscles; it runs together in the vessel, and contains air-bubbles ; it is frothy {sputum crudum of the older authors). This lower grade of catarrhal inflammation is often incorrectly designated by the name of mucous catarrh, or catarrh. If, on the contrary, the irritation has become more intense, or even if the affection has simply been of long continuance, further metamorphoses of the secretion are observed. This alteration of the secretion culminates in an increased casting-off of cell-elements. In connection with this, the originally more viscid mucous secretion gradually becomes looser, but, at the same time, more turbid, because more rich in cells. It now con- tains many pus-cells in addition to the mucus. It acquires a greater consistence, the cellular elements gradually preponder- ating more and more ; and the sputa show a tendency to form balls, then representing the sputa cocta of the older authors. As in the acute, so also in the chronic stage of bronchitis are manifold variations of the secretion coating the bronchial mucous membrane encountered. Here, also, cases are observed in which the secretion is exceedingly scanty ; and again other cases in which the secretion is exceedingly copious, as in the so- called broneho-blennorrhcea, or the so-called pituitous catarrh of 326 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. Laennec. At one time the secretion is chiefly mucous in char- acter, at another, purulent; and then again it has more of a mixed character. Hence, according to the extent, duration, and intensity of the catarrhal inflammation, we see, even in the corpse, great differences in the condition of the secretion coating the bronchial mucous membrane. The microscopic examination of this secretion furnishes differ- ent results, according to the different forms and stages of the bronchitis. At one time the mucous elements predominate, at another the purulent, and at still another the epithelial. On this account, also, some authors have discriminated between a mucous, a purulent, and an epithelial catarrh. The discrimina- tion into epithelial and into purulent catarrhs is hardly practi- cable in reference to inflammations of the bronchial mucous membrane, because the epithelium is thrown off in barely greater quantity than usual even in severe catarrhs. With reference to other localities, on the contrary, this discrimination is amply justified. Thus, for example, a pure epithelial catarrh of the lingual mucous membrane is observed not infrequently; the entire coating of the tongue here often represents nothing else but a scaling-off in mass of the pavement epithelium. Biermer, also, has expressed an opinion averse to this discrim- ination into epithelial and purulent catarrhs of the respiratory mucous membrane. If there were such a thing as a bronchial catarrh, characterized by a copious secretion of epithelium in addition to the formation of mucus and pus corpuscles, similarly to what is observed on mucous membranes that possess a pave- ment epithelium, then we ought to find ciliary epithelium, or at least cylindriform epithelial forms, in greater quantity in the ex- pectoration. But ciliary cells are altogether wanting in catarrhal expectoration, or are present only as isolated cells (Biermer). With reference to the different formed elements found in the sputa, we encounter in the first place epithelial cells, and most usually those of the pavement variety, more rarely cylin- drical and ciliary epithelium. The pavement epithelium that is mingled with the sputa comes mostly from the cavity of the mouth ; but it may also come from the upper portions of the air-passages, that is, from the vocal cords. Cylindrical epithe- BRONCHIAL CATARRH. 327 lium, on the other hand, is usually found in relatively small quantity. Ciliary epithelium is also not often found in the expectorated masses. Sometimes it is encountered in unaltered configuration ; sometimes, and that more frequently, after loss of the hair-like appendages ; and sometimes, again, changed to a more or less globular form. But it is always to be borne in mind that ciliary and cylindrical epithelial cells are relatively seldom observed in the expectoration examined during life; and it is self-evident that the sputum taken from the dead body affords no just conclusion concerning the copiousness of that thrown oft during life. The second and much more important class of formed ele ments found in the sputa, comprises the mucus and pus corpus- cles. These pus corpuscles represent nothing else than wander- ing white blood-corpuscles. According to others, on the other hand, this is not to be regarded as the only source of the pus ; they believe it probable that the pus furnished by the mucous membrane may even be produced, in part, by the endogenous formation of superficial epithelial cells. Mucus and pus corpus- cles occur in every sputum, but in exceedingly varying quan- tity. The richer the bronchial secretion is in pus corpuscles, the less translucent it is. The secretion becomes more opaque with the increased abundance of pus corpuscles, and acquires a more or less yellow or greenish-yellow color. On the other hand, the bronchial secretion is the more translucent the less the quantity of cell-formations it contains. In addition to the mucus and pus corpuscles, red blood-cor- puscles are also often found in the secretion. Crystals of sebacic acid and of margarine, and fungous formations may be desig- nated as further constituents of the bronchial secretions. Crys- tals of ammonio-magnesia phosphate may also be encountered in decomposed masses of expectoration ; and, less frequently, plates of cholestearine. We will consider the special occurrence of these last-mentioned formations in treating of the symptoms. The mucus plays the most important part among the amor- phous constituents of the sputa. Mucus exists in all sputa ; but the quantity present is naturally very different in individual cases. 328 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. Finally, in reference to the condition of the parenchyma of the lungs in the different forms of bronchitis, those alterations only of the pulmonary parenchyma come into consideration here which are to be regarded as the immediate consequences of bronchitis, and those which stand in intimate causal connection with it. On the other hand, simple complications of bronchitis, in which the parenchyma of the lungs is involved, are, as a matter of course, excluded from consideration in this place. Ordinary simple catarrh of the trachea, the larger and the middle-sized bronchi, has, as a rule, no further injurious influence upon the parenchyma of the lungs; and consequently the special parenchyma of the lungs is found intact in this form of catarrh if there are no co-existing complications. It is other- wise, on the contrary, when the catarrh extends into the minuter and minutest bronchial twigs. Under these circumstances there is not infrequently observed a series of further alterations, which occur the more readily because this very form of bron- chitis is especially likely to affect individuals already enfeebled. It is especially children, aged persons, and individuals debili- tated by any cause whatever, who are attacked by this catarrh of the smaller and the smallest bronchi. In proportion as these smallest bronchi become occluded by secretion, access to the affected alveoli will be impeded. A second danger from the catarrh of the smallest bronchi resides in the fact that the catarrhal inflammation may become extended into the very lung- tissue itself, so that a so-called catarrhal pneumonia becomes superadded to the existing disease. Buhl1 justly makes the remark that as there is no mucous membrane in the lung itself, the name "Catarrhal pneumonia" is not well chosen. Although the alveolar wall at its termination is nothing else than the continued inner fibrous sheath (mucous membrane) of the bronchi, it is so very much reduced that it no longer resembles a mucous membrane in anything; its inner enveloping epithelium has undergone such marked alterations of form, becoming squamous, and being spread out in only a single layer, that it can no longer be identified with the bronchial 1 Lungenentziindung, Tuberkulose und Schwindsucht. Zwolf Briefe an einen Freund. Miinchen, 2. Aufl., 1873. BRONCHIAL CATARRH. 329 mucous membrane which supports ciliary cells and is composed of several strata. According to Buhl, the disease called catarrhal pneumonia is no pneumonia, but only a capillary bronchitis, a bronchiolitis, in which the lung participates by collateral oedema, atelectasis, local emphysema, and obstruction in consequence of the secretion forced from the bronchi towards individual lobules of alveoli. Emphysema is to be mentioned as a further, and not infre- quent disease of the lung in chronic catarrh. Thus, for exam- ple, in severe catarrh of the lower section of the lung, a second- ary emphysematous dilatation of the upper section is observed not infrequently. The lack of action due to the partial immo- bility of the lower section will be compensated for by a vicarious increased activity of the upper section ; in addition to which the severe efforts of cough associated with this bronchitis contri- butes to this excessive dilatation of individual sections of the lung. The seat and intensity of the emphysematous destruction will naturally bear different relations in different cases, accord- ing to the seat and extent of the catarrh. In affections of still shorter duration the changes which occur resemble less an actual emphysema than that condition designated as acute inflation of the lung. In other cases still further complications with diseases of the lungs are observed, as, for example, collapse of the lung, atelec- tasis, etc. ; for the more accurate anatomical relations of which diseases we must refer the reader to the special chapters treating of tliese affections. Diseases of the pleura are but very seldom observed in con- nection with the affections of the bronchi under consideration. Sometimes small subpleural ecchymoses are found. Inflamma- tory diseases of the pleura, on the contrary, when occasionally encountered in patients with bronchial affections, are in but dis- tant connection with the latter, or in no connection whatever. A more intimate relationship is presented between diseases of the bronchi and diseases of the lymphatic glands of the lungs and the bronchi. The circumstance that the vessels of the glands mentioned are given off from the bronchial vessels renders it a matter of no surprise that the bronchial glands should frequently 330 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. become sympathetically diseased in severe affections of the bron- chi. The diseases of the glands that are observed under tliese circumstances are naturally of varying nature, according to the duration and intensity of the bronchial affection. Sometimes it is but a simple hypersemia, sometimes a hyperplasia, sometimes a more or less chronic inflammation, with pigmentation, sometimes cheesy degeneration, calcification, and the like. In the earlier stages of inflammation of the bronchial glands, the glands are found enlarged, the tissue still soft, and of a red- dish-gray color, and the surrounding connective tissue hyper- semic. In the later stages the tissue of the bronchial glands becomes denser, and spots of caseous degeneration are dissemi- nated through them, which may finally replace the entire tissue of the gland. In this manner several such degenerated glands may eventually become conjoined into a humped caseous mass. Sometimes, also, there is a partial suppuration of the gland, while cheesy degeneration and calcification are going on in another portion of the fluid. This participation on the part of the bronchial glands in chronic or acute bronchial catarrh is of no special clinical signi- ficance in by far the greatest number of cases. A further series of disturbances results from this complication only in cases in which the bronchial glands have acquired such size as to com- press the larger bronchi. With regard to the symptoms thereby produced, we refer the reader to the chapter on bronchial steno- sis. A series of further dangerous accidents may be occasioned, also, by the pressure of an enlarged gland upon nervous trunks and blood-vessels, and by the suppuration of either an entire bronchial gland or a part of one, followed by perforation into a bronchus. Among further alterations which are to be regarded as results of chronic catarrh, those of the heart are still to be espe- cially mentioned. Enlargement of the heart, in the form of hy- pertrophy and dilatation (usually of the right side), is a fre- quent occurrence in chronic catarrhal inflammations of the bron- chial mucous membrane. In the later stages of severe cases the substance of the heart is for the most part uniformly degener- ated, its color being at one time of a rather reddish gray, at BRONCHIAL CATARRH. 331 another, of a pale yellow. Fatty degeneration of the heart is one of the conditions quite often observed. Dropsical manifestations are also often observed, and espe- cially when the complication of emphysema exists. Their origin is purely a mechanical one. The dropsy is sometimes confined to the lower extremities, and sometimes more extended upon other regions of the body. The veins are dilated in correspond- ing measure. The evidences of obstruction are more pronounced in the veins of the hepatic region; there being at first simple hypersemic obstruction, then nutmeg-liver, fattyr degeneration, partial atrophy of the liver-cells, and so on. Similar alterations occur in the kidneys. These alterations of the large abdominal glands are analogous to those which are found in insufficiency of the mitral valve, and the like. They are here, as there, the result of venous obstruction. Their occur- rence in chronic bronchial catarrhs is in great measure favored by the existence of emphysema of the lungs. Symptomatology. Analysis of Individual Symptoms. Before describing the special course of tracheitis and bron- chitis in their exceedingly manifold forms, it appears desirable to present, in advance, a short analysis of the individual symp- toms of these diseases. This being done, the description of the individual forms will then follow. In the description of these symptoms only the more important ones, as a matter of course, will be mentioned somewhat in detail. Alterations of Breathing.—Difficulty of respiration is not observed in every form of catarrhal inflammation of the trachea and bronchi. Well-marked difficulty of respiration is almost always wanting in the milder forms of catarrhal tracheo-bronchi- tis, because the respiratory interchange of gases is hardly sub- jected to any important restriction. As a matter of course, the greater the number of obstacles presented to the ingress and egress of the air, the greater must be the resulting dyspnoea. The greater the number of bronchi over which the catarrhal inflam- mation is extended, the more severe will be the dyspnoea. In 332 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. other words, the degree of dyspnea is in direct proportion to the extent and intensity of the inflammatory changes in the bron- chial mucous membrane. To this rule, just announced, that the degree of difficulty in breathing increases in general in proportion to the extent and severity of the bronchitic manifestations, there are numerous exceptions. Thus Traube! first directed attention to some further conditions which must contribute to the condition of orthopncea independently of the impediment to breathing. Traube cites as such, in the first place, a certain grade of consciousness and a certain amount of muscular force. In support of this opinion, he calls attention in the first place to what occurs in typhoid fever and in putrid bronchitis. When full consciousness fails, as in certain stages of typhoid fever, or when the necessary muscular force fails, as so frequently occurs in putrid bronchitis, then every indication of orthopncea may be wanting, in spite of a con- siderable impediment to the breathing. From this it follows, as Traube pertinently remarks, that when a patient, who is suffering from considerable impediment to his respiration, has orthopncea, we should consider it as a better sign than if with the same degree of impediment this symjrtom were absent. The dyspncea seldom reaches in bronchitis that high grade which is so fre- quently observed in tracheal and bronchial stenosis, to be described later. When the dyspncea is severe, the patient frequently endeavors to maintain a sitting posture. The reason for this is, in the first place, because the distensibility of the thorax is more complete in this posture than in any other; and, in the second place, because in the sitting posture the patient can put muscular forces in action which other- wise remain unemployed; for example, the pectoral muscles. In addition to the amount of respiratory obstruction dependent upon the extent and intensity of the catarrhal inflammation, a series of further elements are of im- portant influence in occasioning difficulty of breathing. Fever, for example, belongs to this series. It is a fact, long ago clinically established, that a proportionate increase of the number of respirations accompanies elevation of the body-temper- ature. This clinically established fact has received additional support from the splendid investigations of Ackermann,2 who first proved experimentally that the number of respirations increased in direct proportion to the elevation of the tem- perature of the body. In continuing this investigation, the truth of which has been confirmed by various other observers, especially by Rosenthal,3 myself,4 and others, Fick5 has adduced proof that it is the higher temperature of the blood which 1 Traube, Die Symptome der Krankheiten des Respirations- und Circulationsappa- rates, 1. Liefernng, 1867, p. 11. 2 Deutsches Archiv f. klinische Medicin, Bd. II., p. 361. 3 Zur Kenntnis der Warmeregulirung bei den warmblutigen Thieren. Erlangen, 1872. 4 Pfliiger's Archiv f. die gesammte Physiologie, V. Bd., and Virchow's Archiv, Bd. LXI. 6 Wiirzburger Verhandlungen, 1871, pp. 156-169. BRONCHIAL CATARRH. 333 excites the breathing centre to increased activity. It would appear, therefore, that the grade of fever which complicates a tracheo-bronchitis may influence the degree of dyspnoea; and it is thus comprehensible how exceptions to the rule mentioned above may readily occur. It is therefore easy to understand how, in one case, in which there is no fever, only a moderate amount of dyspncea may exist, despite a severe grade of the bronchial affection; and how, in another case, in which there is a high fever, much severer dyspncea may exist, despite the relatively less extent and intensity of the bronchial affection. It is well known, too, that at different periods of life, and in different individuals, the capacity for reaction, as regards fever, is very different, even under the same injurious influences. While a pneumonia during middle age is almost always associated with considerable fever, it is by no means a rare thing to encounter pneumonias in persons of advanced age which run their course not only without any special subjective symptoms, but often also with- out any fever, or with but slight febrile movement. The period of childhood, on the other hand, reacts with considerable fever under slight injurious influences; and thus it is comprehensible how a child often evinces a good deal of fever with a bronchitis of slight extent. In a child, then, there is double ground for dyspncea: on the one hand, because from the narrowness of the air-passages the insufficiency of a small section is here of much greater significance than in adult life ; and, on the other hand, because the fever contributes in no small measure to the increase of the dyspncea occasioned by the diminution of the respiratory surface. The points mentioned above—the further discussion of which in this place would carry us too far—will suffice to show why the parallelism between the amount of respiratory obstruction and the dyspncea must exhibit many exceptions to the rule. If we investigate more closely the symptom of dyspncea, as it appears in connec- tion with inflammations of the tracheal and bronchial mucous membrane, we must discriminate different forms, according to the seat and extent of the affection. In the first place, it must be borne in mind that there is a large series of bronchitic affections, which, as a rule, occasion no impediment to respiration whatever. On the other hand, again, a careful observation shows that the form of dyspncea may be different even in those cases in wiiich dyspncea exists. As I have shown upon another occasion, on the basis of graphic examinations of the respiratory organs in their various diseased conditions, it is not sufficient to con- sider dyspncea simply as a difficulty in breathing, but we must discriminate between three important different forms of dyspncea—an inspiratory, an expiratory, and a mixed dyspncea. Biermer and Gerhardt had previously established the division into an inspiratory and an expiratory form of dyspncea, founded upon simple clinical observation. A positive and certain basis for this division was first assured in the stothographic observations of the respiratory organs in various diseased conditions, as first reported by myself; ' and also through the pneumatometric investigations 1 Riegel, Die Athembewegungen. Eine physiologisch-pathologische Studie. Wurz- burg, 1873 ; and Deutsches Arch. f. klin. Med., Bd. XI. 334 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. of Waldenburg.1 Without entering more closely into this topic it will suffice here to make the statement that both methods have accurately demonstrated that there are some diseases in which inspiration is impeded exclusively or in greater part—diseases with inspiratory dyspnosa; others in which expiration is impeded principally—diseases with expiratory dyspnosa ; and others still in which both acts of respiration are more or less impeded, a class which I have designated as diseases with mixed dyspnosa. It therefore no longer suffices, as has too frequently been the case, to speak simply of dyspncea; but the special form of the dyspnoea must always be deter- mined. If we ask ourselves, however, what are the special characteristics of the respiratory impediments occurring in the acute and chronic inflammations of the tracheal and bronchial mucous membrane, it must be borne in mind that here, also, a series of different forms are observed, according to the special seat of the process and its extent. For the solution of this question the subjective difficulties of respiration are of little interest; deviations in the frequency of breathing, and especially in the form of the type of the respiration, are, on the contrary, of much greater interest. That form of respiratory type, which authors have agreed to designate as the inspiratory form of dyspncea, is only occasionally observed. As is well known, it is observed in a very pronounced form in the laryngeal croup of children, and like- wise in paralysis of the posterior crico-arytenoid muscles. This inspiratory dyspncea is observed in all the more considerable constrictions of the trachea, in very much the same manner as in constriction of the larynx. Whistling, prolonged inspi- ration, with relatively short and freer expiration, the participation of all the adjunct inspiratory muscles, inspiratory depression of the epigastrium and lower portion of the chest, relatively slower breathing, and some other manifestations characterize this form of pure inspiratory dyspncea. As is readily comprehensible, even intense forms of tracheitis are hardly calculated to produce this form of dyspncea, because, for the most part, they are not associated with any, at least considerable, diminu- tion of the calibre of the passage. In actual stenoses of the trachea, on the contrary, there is frequent opportunity of observing the pure form of inspiratory dyspncea. It is not a rare thing to meet with that form of dyspnoea in which the only anomaly consists in an increased rapidity in the movements of respiration, while the individual phases of the act of breathing exhibit no deviation from the normal type, and the auxiliary muscles of respiration do not participate to any extent in the process of breathing. This form of dyspncea, with simple acceleration of the respiratory movements, is observed with tolerable frequency; relatively more often in the acute forms of catarrhal bronchitis than in any other. It is otherwise in protracted catarrhs of the larger divisions of the bronchi, especially when they are severe. Here, not infrequently, a further form of dyspncea is observed, characterized by relatively normal inspiration, with markedly prolonged 1 Berlin klin. Wochenschrift, 1871, No. 45. BRONCHIAL CATARRH. 335 and impeded expiration. This condition is recognized with greatest distinctness by the graphic method of exploration of the respiratory organs. Tliis variety of breathing, which may or may not be associated with appreciable increase in the number of respirations, corresponds, in a measure, with that form of dyspncea which occurs in regular emphysema. On closer investigation it is further ascer- tained that those portions of the thorax which are the chief seats of the catarrh and of accumulations of mucus, participate relatively least in the inspiratory expan- sion of the thorax. According to a wrell-known law in physics, then, so much the more air must penetrate into the intact portions of the lungs, and these must be the more severely burdened, sometimes even to the degree of excessive expansion, and even to actual pulmonary inflation. As is well knowui, in this very way may be explained the occurrence of various forms of the emphysema, which so frequently accompanies and follows chronic catarrh. Thus, for example, in a case of chronic catarrh of the lower portion of the lung, and in cases of considerable accumulation of mucus in the same locality, the upper portion is overtaxed, even to such a degree that there is a complete reversal of the normal type of respiration; in fact the true female type of respiration may be observed in these cases, even in male sub- jects. Hence in these diseases a certain diagnostic value attaches itself to an inves- tigation into the type of respiration, with reference to the part borne by the indi- vidual sections of the thorax. In the higher grades of this affection, the actual asthmatic type of respiration may set in, in wdrich all the auxiliary muscles of inspiration and expiration are brought into overstrained action, and in which an increase of the dyspncea sets in paroxysmally, with impeded expiration especially. This form is chiefly observed in cases of chronic catarrh, in which the frequent com- plication of emphysema already exists. Finally, there are forms in wThich the breathing is temporarily irregular, so that sometimes marked acceleration of breathing occurs, and then, again, retarded breathing, and so on. This form, which is by no means frequent, is observed espe- cially in the acute catarrhs of young nervous individuals. This form of dyspncea is also encountered in the bronchitis of children, and is generally considered as an unfavorable prognostic sign. Finally, this irregular, intermittent form of dysp- ncea is sometimes observed, also, at approaching dissolution. In the types just described we have grouped together only those forms of dysp- ncea which occur most frequently. It must not, however, be forgotten that there are a great number of especially mild catarrhal inflammations of the tracheal and bronchial mucous membrane, which, in general, occasion no dyspncea what- ever. Cough.—-Cough is to be mentioned as the second symptom, and one of the most important. As is well known, diseases of the tracheal and bronchial mucous membrane are almost con- stantly associated with cough ; and only in very rare cases is the reflex act of cough wanting in these forms of disease. The 336 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. cough, too, which is observed in diseases of the parenchyma of the lungs, must be regarded, in accordance with the present results of experimental research, as occasioned only by the simultaneous implication of the tracheal, bronchial, or even the laryngeal mucous membrane; for no one has yet succeeded, at least experimentally, in exciting cough by irritation of the alveoli (Nothnagel, Kohts). For the minuter details we refer the reader to our previous remarks concerning the production of cough; we will only recall here the fact, that, as far as the cough proceeding from the mucous membrane of the trachea and bronchi is concerned, all the experiments agree in showing that cough is most vigorous on irritation of the bifurcation of the trachea, and less active on irritation of the remaining por- tions of the trachea and of the bronchi. There is by no means any precise relation between the amount of secretion present in the trachea and bronchi, and the severity of the cough, as has been maintained by various authors. On the contrary, the cough is often the severest just in the first stage of the catarrhal inflammation, in which hypersemia and swelling are the most prominent symptoms. The locality of the irritation is of much greater importance than the degree of the accompanying hyper- semia and swelling. With reference to the different sorts of cough, two different forms have long been recognized, based chiefly upon the expec- toration : a so-called dry, and a moist cough. It is self-evident that this division has reference to the secretion discharged by the cough, and not to the cough itself. The designations " dry catarrh" and "moist catarrh," chosen by Laennec, are there- fore preferable. A dry cough, or a dry catarrh, is spoken of when there has been no accumulation of secretion upon the mucous membrane, so that there is no discharge of secretion despite severe paroxysms of cough ; and also when the sparse secretion is so viscid and so firmly adherent to the mucous mem- brane that even severe efforts of cough do not suffice to expel it. The first of the stages mentioned has also been frequently designated by the name of so-called dry sioelling of the mucous membrane. On the other hand, a moist cough is spoken of in cases in which a loose secretion, readily detached, lies upon the BRONCHIAL CATARRH. 837 mucous membrane, and in those in which this secretion can be readily removed by the succussion of the cough. In addition to this a further variety of cough has been estab- lished. Thus we hear of a so-called irritative cough, which is characterized by very severe paroxysms of cough, with but slight or even absolute absence of expectoration. This form of cough, which is distinguished by the disproportion between the, severity of the cough and the paucity of the expectoration, is especially observed in the commencing stages of acute severe inflammations of the mucous membrane of the trachea and the larger bronchi. The patients, in tliese cases, are tortured by the exceedingly severe and frequently recurring irritative cough, in spite of which, however, in most instances, only a small quan- tity of tenacious mucus is expelled, with the discharge of which the paroxysm reaches its termination, to be succeeded, after a short time, by another in the same manner. Intelligent patients assert, in such cases, that they feel that it is always the same spot which gives occasion to the irritable cough. This spot rorresponds most frequently with the point of bifurcation ; but sometimes, also, with the inter-arytenoid incisure. Many designate the characteristic spasmodic cough as a special subdivision, one that represents the highest grade of straining cough. It occurs in the form of exceedingly severe paroxysms, similar to those of whooping-cough, and the parox- ysms of cough often reach so high a grade in this form, that marked cyanosis, and even vomiting, coughing of blood, and the like set in. The most frequent form of cough observed is that in which the cough is relatively slight, the expectoration following it without especial trouble ; in this form, after a few succussions of cough, there always follows a pause free from cough, some- times of shorter and sometimes of longer duration. This is the form which is most frequently observed in those forms of inflam- mation under consideration. The consistence of the secretions of the mucous membrane is of important influence in the production of those different forms of cough. The looser and more rich in cells the secretion is, the more readily it is detached, and the less severe and straining will VOL IV.— 2-> 338 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. the cough be. On the other hand, where the secretion is very viscid and can be detached only with difficulty, severe spasmodic paroxysms of cough readily occur. Condition of the Skin.—As in many other diseases, so also in those of the tracheal and bronchial mucous membrane, the con- dition of the external skin is of significance. The results afforded by this indication often yield better information con- cerning the duration and severity of the affection than is deriv- able from percussion and auscultation ; and, consequently, they are not without interest in a prognostic point of view. The pres- ence of cyanosis, and the degree it has reached, are here of espe- cially great significance. As in other diseases connected with circulatory disturbances, so also in inflammations of the tracheal and bronchial mucous membrane, the cyanosis is hardly ever spread over the entire periphery of the body. For the most part only the slighter grades of cyanosis are observed in the diseases under consideration. The cyanosis undergoes a remarkable increase in the severe paroxysms of cough mentioned earlier. Cyanosis is encountered most frequently in the later stages of the chronic bron- chitis of adults; a form of disease which, as is well known, is observed with espe- cial frequency in the working classes, and which, in a certain number of cases, may even lead to a fatal termination with the appearance of dropsical manifestations. High grades of cyanosis are frequently observed in those cases especially in which the chronic bronchitis is complicated with emphysema, as is indeed often the case. The characteristic bluish color is not confined to those portions of the body which ordinarily exhibit a somewhat livelier coloration, and which first become affected by the slighter grades of cyanosis, as for example the lips, cheeks, ears, and the like, but the entire visage presents a bluish-red, dull aspect; the jugular veins are swollen and strongly dilated, and exhibit undulatory or even pulsating move- ments; the eyeballs project more strongly; the nails are bluish-red; the tips of the fingers are thickened ; and so on. The cyanosis always comes on gradually in these cases, so that its occurrence may be watched, step by step, from its slightest commencement to its greatest intensity. For a certain length of time the circula- tory disturbance caused by the fundamental disease is adjusted by a compensa- tory hypertrophy and dilatation of the right ventricle of the heart. Then, when this compensation becomes insufficient, or when, as sometimes happens, the hyper- trophied and dilated ventricle can no longer sufficiently equalize the increased resistance—in consequence of fatty degeneration, for example—the cyanosis rapidly reaches a high grade. In other cases the cyanosis often undergoes a rapid increase. especially in the very acute forms of diffuse bronclrnl catarrh. Even in the capil- BRONCHIAL CATARRH. 339 lary bronchitis of children, cyanosis is quite often rapidly developed, even though of only moderate grade in most instances. In the same manner, in the acute forms of tracheitis, with very copious secretion of mucus, a moderate cyanosis is some- times observed, which disappears rapidly again with the diminution of the swell- ing and the secretion, and the consequent increase in calibre of the passages. In the later stages of chronic catarrh, a state of general dropsy may even occur, the swelling always commencing at the ankles and then extending gradually upwards. With reference to the secretion of sioeat in bronchitic pa- tients, a general outbreak of perspiration as a sort of critical phenomenon, attended with a reduction of temperature, occurs only occasionally. Night-sweats, which are so frequently observed after mid- night or towards morning in tuberculous patients, occur only occasionally and temporarily in bronchitis. On the other hand, the occurrence of perspiration upon lim- ited sections of the body, especially upon the head, neck, and upper portions of the chest, is observed rather more frequently, especially in intense forms of bronchitis associated with severe dyspnoea. Condition of Nutrition.—According to the severity and dura- tion of the inflammatory process, according to its extent, and according to the more or less active febrile movements associated therewith, the general constitution and the nutrition are some- times more or less involved. The nutritive condition at the time of the commencement of the disease, as well as the age of the patient, is of great significance. Thus it makes a great differ- ence whether the affection occur in earliest childhood, in robust adult life, or in extreme old age. In the simple acute bronchial catarrhs of adults, especially those associated with but little or no fever, nutrition suffers either very slightly, or not at all, in the majority of cases. It is otherwise in children and in aged subjects, in whom severe catarrh is apt to involve the general constitution. Chronic catarrhs, in general, also may exist for a long time without special injury to the general system. It is only at a very late stage of the trouble, when considerable evidences of obstruction have become manifested, that the nutrition suffers to 340 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. any great extent. In this very particular there is an important contrast between the chronic tuberculous process and simple bronchitis, inasmuch as the former malady is always associated, even at an early period, with marked impoverishment of the blood, and severe disturbance of the general health. This slight participation of the general system in chronic catarrh is the cause also why cyanotic and dropsical manifesta- tions are observed more frequently than in tuberculous processes, in which the impoverishment of the blood is unfavorable for the production of obstructive manifestations of any consequence. Expectoration.—The expectoration in catarrhal inflammation of the trachea and bronchi varies, in individual cases, not only in reference to quantity, but a great deal also in reference to quality. Its volume may vary from quantities hardly worth mentioning to very considerable masses. In individual cases and in certain stages expectoration may fail entirely for a longer or shorter period. This absence of expectoration may have its origin in different causes. It may be that the mucous membrane, as a whole, furnishes secretion only sparingly or not at all. In other cases the patient may swallow the sputa, as, for example, is the rule in children. In other cases, again, the secretion, especially when very viscid and located in the smallest bronchi, adheres to the parts, and here often even very forcible efforts of cough, continued for a long time, may either fail to remove it, or remove it only with difficulty. Frequently enough the expectoration does not simply repre- sent the secretion of the diseased tracheal and bronchial mucous membrane, but many other constituents become mixed with it in its transit through the air-passages to the mouth, such as the contents of the pharynx, mouth, and the like. In passing to the description of the more important characters of bronchitic sputa, we will follow in the main the divisions made by Biermer in his admirable account of bronchial diseases, and in his valuable monograph on the expectoration. Biermer distinguishes the following varieties of expectoration : 1. The viscid, mucous, transparent sputum, poor in cells, which corresponds with the first stage of acute bronchitis, and which is characterized by its slight amount of cellular elements as well as by its great viscidity. This expectoration (usually BRONCHIAL CATARRH. 341 though inappropriately designated as mucous sputa) is, as a rule, expelled with severe cffoits of cough. It is always viscid and tenacious; often so tenacious and so adherent to the vessel into which it is expectorated, that it does not flow out of it even when placed upside down. It is colorless, semi-translucent, in part vitreous, and grayish-white, and not infrequently air-bubbles are copiously mixed with it. This increased amount of air is explained by the severe efforts of cough which often precede the detachment and expulsion of the viscid masses of mucus. The severer and more protracted the cough, the more frothy is the expectoration. This severe and straining cough is also the cause why small quantities of blood are some- times mixed with the expectoration. Microscopic examination reveals very few formed constituents: mucus and pus-corpuscles, and isolated cells of ciliary epithelium. Not infrequently squamous epithelium also is mixed in with the sputa. This sputum, which is readily confluent in the spit-cup, and corresponds with the initiatory period of tracheo-bronchitis, represents the so-called sputum crudum of the older authors. The most important characteristic of the expectoration of this first period is, th.it the secretion is relatively poor in cellular elements. With the further progress of the process more and more of the cellular elements become freed ; and with tliis increased production of cellular elements the culmination of the process is passed. 2. The richly cellular, non-translucent mucous expectoration of Biermer consists chiefly of mucus and pus cells. This form has been designated by most authors by the appropriate name "muco-purulent sputa.'1'' It is very closely connected with the form first described, the "mucous sputa;" it results immediately from it, and indicates the second stage of acute catarrh. Even in chronic bronchial catarrh this form of expectoration is frequently enough observed. The appearance of the richly c.'lhilar secretion coincides with the decline of the inflammatory hypersemic mani- festations and the relief to expectoration progresses in the same ratio in most instances. The older authors named this sputum " coctum," in contrast to the sputum crudum. With the increased admixture of cellular elements the viscid, adhesive, transparent secretion of the first stage of acute catarrh becomes thicker, more yel- low, and less translucent. Microscopically examined, it is found to contain mucus and pus corpuscles chiefly; but squamous and cylindrical efnthelium, etc., may be mixed with it as more inconstant constituents. The proportion of mucus to pus is naturally a variable one in individual cases and at the different periods of the catarrhal inflammation. In proportion, however, as the increased production of the cellular elements preponderates, there is a gradual transition to a further form which we 3. Designate as purulent sputa, chiefly, or according to Biermer, as muco-purulent and pur if arm sputa. In contrast to the form just described, this form of sputa is characterized by being chiefly composed of pus cells. Pure purulent sputa are hardly ever expelled in bronchitis, though seen in abscesses of the lung and in purulent pleuritis with perforation into a bronchus. 342 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. While in the sputa previously described the mucous constituents still prepon- derate, there is also a mucous admixture in this form, but pus cells form its princi- pal constituent. The appearance of these sputa differs considerably, also, from that previously described. It resembles very much the ordinary pus from con- nective tissue, only that in consequence of the admixture of mucous constituents the color does not represent that exquisite creamy character which is presented by pure connective-tissue pus. This form of sputa is especially observed in the chronic forms of bronchitis. Microscopic examination shows numerous pus cor- puscles as the predominant formed clement, then epithelial cells, in part in a state of fatty degeneration, and so on. Elastic fibres are never found in the expectoration in simple bronchitis. If a large series of these muco-purulent sputa are examined in a spitting-cup, a number of variations Avill be exhibited in individual cases. With reference to these different conditions of the sputa in the spit-cup, Biermer has distinguished three types of muco-purulent sputa :— a. Greenish or yellowish clumps of muco-pus, in a sero-mucous fluid; one por- tion of the clumps may remain floating on account of the admixture of air, while the remaining portions sink to the bottom. b. The muco-purulent sputa have run together in the spit-cup. These masses separate after a while into several layers ; the heavy, purulent portions sink to the bottom ; above this sediment there is a sero-mucous layer, in which some shreds of mucus containing bubbles of air are suspended; upon the surface there is consider- able froth. This broncho-blennorrhceic secretion is often expelled in considerable quantity; its odor is often fetid in a high degree. c. Roundish, nummular sputa, which lie separate beside each other in the spit- cup. The first two forms of sputa occur frequently enough in chronic bronchitis. The second form described is observed, especially in the bronchial blennorrhcea, associated with dilatation of the bronchi; but, as shown by Traube,1 it is by no means peculiar to this form of disease; it is also observed in the same manner in fetid bronchitis, to which we shall recur more particularly later. Concerning the third form, the nummular sputa, it is true that it is most frequently encountered in tuberculous cavities. The spherical or coin-like form is the more definitely marked the less the amount of fluid mingled with the sputum ; where this fluid is abun- dantly present, the nummular sputa become confluent with the mucus after remain- ing for some time in the spit-cup. On the other hand, it is not proper to regard nummular sputa as the product of a cavity only. Biermer has also mentioned that he has observed this form of sputa a few times in simple chronic bronchitis. 4. A sero-mucous sputum, which is characterized by its thin, thready consis- tence. It is frequently copiously mixed with air-bubbles, so that a complete layer of froth caps the surface of the expectorated mass. The quantity of this expectora- tion is often very considerable, so that an actual bronchorrhcea exists. It is observed 1 Deutsche Klinik, 1861. BRONCHIAL CATARRH. 343 most frequently in the chronic forms of bronchitis ; but there are also acute cases of such bronchorrhcea, although they are infrequent. Concerning the chemical composition of the sputa wre are especially indebted to the minute investigations of Bamberger.1 He analyzed the ashes from the sputa obtained in chronic bronchial catarrh, bronchiectasia, chronic pulmonary tuber- culosis, acute tubercular infiltration, and pneumonia in the characteristic inflam- matory stage, and at the period of resolution. The results of these investigations acquire so much the greater interest from the fact that we can compare them with the results of analyses of the lungs. We cannot enter here into any special presen- tation of the numerous interesting results reported by Bamberger, results obtained by the analysis of the constituents of the ashes of the sputa; but we shall con- tent ourselves with a short comparison of this analysis with that of the ashes of the lungs as obtained by Kussmaul '2 in his well-arranged investigations. It thus appears that the constituents of the ashes of the sputa and the lungs are as follows: Chlorine, sulphuric acid, phosphoric acid, potassa, soda, lime and mag- nesia, oxide of iron and silicic acid; but the quantitative composition of the ashes of both differs greatly. The difference is especially with reference to the chlorine, the phosphoric acid, the potassa, the oxide of iron, and the silicic acid ; while soda, potassa, lime, and magnesia appear in both ashes in about the same percentage, and the sulphuric acid is a characteristic only in the sputa of pneumonia. While, according to the investigations of Kussmaul, phosphoric acid plays the preponderating role in the ashes from the lungs, and the chlorine recedes in propor- tion as the lung-tissue is free from infiltrated exudation, tubercle, and bronchial secretion, we see the phosphoric acid remain behind the chlorine in the ashes of the sputa. In the ashes of the sputa, phosphoric acid was present in the maximum of 14 per cent.; in those of catarrhal and purulent sputa, there was from 10 to 13 per cent. The ashes of the lung, on the contrary, constantly contained a very large amount of phosphoric acid, from 30 to 4S per cent. The different proportions of potassa in the ashes of the lung and in those of the sputa are worthy of remark. Potassa plays a very subordinate role in the lung, whereas it is found in the proportion of from 16 to 24 per cent, in the ashes of catarrhal and purulent sputa. The proportion of soda, on the contrary, appears to differ much less in the two sorts of ashes. Oxide of iron, again, is found always in exceedingly small amount in the ashes of sputa, while it always forms a considerable proportion in those from the lung. From a comparison instituted by Bamberger concerning the chemical composi- tion of pus and the puriform sputa, it is shown that pus contains a greater quan- tity of organic constituents and organic salts than sputa; while, on the contrary, there is almost always found a like proportion of soluble and insoluble salts, among which the earthy phosphates play the chief role, though silica seems to be entirely absent in pus. 1 Wiirzburger med. Zeitschr., Bd. II., 1S61., p. 333 8 Kussmaul, Aschenbestandtheile der Lungen and Bronchialdriisen, Deutsches Archiv f. kiln. Med., Ed. II., p. 113. 344 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. The views of Laycock' concerning the cause of the foul odor of the 3puta in fetid bronchitis are worthy of consideration. In three cases of putrid bronchitis he had the sputa examined by Gregory, who detected methylamine, butyric and acetic acids, as the cause of the foul odor. He believes that the presence of volatile fatty acids in the sputa will not serve to distinguish fetid bronchitis from gangrene of the lung. The reports of Petters '2 concerning the chemistry of broncho-blennorrhceic sputa, are also worthy of consideration. Petters found more mineral constituents (2. 42. 43 per cent.) in broncho-blen- norrhceic sputa than were found by Biermer and Bamberger. The sputa contained 6.0772 per cent, of organic substances. So much for the chemistry of the sputa. We will take opportunity to recur to the apecial peculiarities of the sputa when describing the individual forms of disease. Thoracic Pains—Disturbances on the Part of the Nervous System. Thoracic pains are by no means infrequent in both acute and severe chronic catarrhs. The patients, especially in acute ca- tarrhs of the trachea and of the larger bronchi, often complain of dryness, tickling, and burning, downwards along the trachea. The characteristic thoracic pains are located most frequently at the sternum, sometimes more at its upper portion, as in simple tracheo-bronchitis, and sometimes farther down. Quite often, too, the pain extends to the thoracic muscles upon both sides. The epigastrium also is sometimes painful in bronchial catarrhs. This epigastric pain has its seat most frequently in the muscles, and is chiefly occasioned by the severe efforts of cough. This epigastric pain is not to be confounded with that which occurs in very late periods of chronic bronchial catarrh, and which is referable to the hypergemic and enlarged liver. In the majority of cases in which pain is complained of in the locality mentioned, palpation of the spot does not bring out any special pain. Only occasionally is pressure painful at this point, especially in those cases in which there have been slight ruptures of muscles or hemorrhages between the individual muscular 1 Med. Times and Gaz., May 16, 1857, p. 479. 2 Prager med. Wochenschr., 1864, Nos. 4 and 5. BRONCHIAL CATARRH. 343 fibres in consequence of the severe succussions of cough. These two accidents are confined chiefly to the expiratory muscles. Lateral pains, stilcha in the side, are less frequently ob- served. The}' are most frequently located in the lower lateral section of the thorax. If there is no complication with inflam- matory affections of the pleura, these stitches in the side are of but slight intensity and usually cease spontaneously after a short time. In addition to the thoracic pains mentioned, actual nervous symptoms are in the main rarely observed in the different forms of tracheitis and bronchitis. They are in part only the result of the fever, and cease again after it has passed away. In part also they depend upon the secondary circulatory disturbances occa- sioned by the bronchial affection. A sensation of chilliness, with which acute bronchitis is not infrequently ushered in, is to be included among the nervous manifestations associated with the fever. An important differ- ence between this and certain other affections, pneumonia in par- ticular, lies in the fact, as already advanced by Niemeyer, that the chill observed in acute febrile bronchitis is usually repeated several times, while in pneumonia a repetition of the chill is among the rarest exceptions. In by far the greatest number of cases, however, there is not a characteristic rigor, but rather in most instances a slight shiver, a sensation of being cold, or an excessive sensitiveness to changes of temperature. These slight manifestations of chill are observed towards evening especially, that is, at the time of the exacerbations of temperature. As a rule, the}' gradually pass away after a short time. Headache requires special mention among the remaining nervous manifestations. Slight pains in the head, slight vertigo, and the like, are not infrequently complained of, especially at the commencement of acute bronchitis. Their origin may be dif- ferent in different cases. Thus, in acute febrile bronchitis, a portion of these nervous manifestations may be at once attri- buted to the fever. On the other hand, in the later course of chronic bronchitis, after considerable evidences of obstruction, such as cyanosis, dropsy, and other like symptoms, have become developed in consequence of the disturbed relations of the circu- 346 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. lation, tliese nervous symptoms are not infrequently encoun- tered in direct connection with the disturbed relations of the cir- culation. In like manner complaints of pains in the limbs at this period are by no means infrequent, but, at the same time, they are not of any great importance. The occurrence of severe neuralgic headache is mentioned by some observers. Thus Rilliet and Barthez describe a severe supra- and infra-orbital headache which occu;s paroxysmally in children affected with severe bronchitis, and they also make mention of eclampsia as an initial symptom of infantile bronchitis in rare cases. Soporific manifestations are but rarely observed in the diseases under consideration. In the acute form of bronchitis they are encountered with most frequency in old people, in whom, as is well known, an intense bronchitis is always a serious affection, and also in very small children. In the case of chil- dren they are frequently preceded by delirium, and under cer- tain circumstances even by mild convulsions. In children these cerebral symptoms may become developed to such a degree that the possibility of mistaking them for evidences of tuberculous meningitises not out of the question. On the other hand, again, in the later stages of chronic catarrh, when cyanosis, dropsy, and similar symptoms of disturbance of the circulation have become more developed, it is not unusual to encounter a certain hebe- tude of the sensorium, great drowsiness, and apathy. Even mild delirium is sometimes observed in these cases. Impairment of sleep is by no means an infrequent occur- rence. In many cases, indeed in the majority of cases, this is due to the severe paroxysms of coughing ; but in many cases the fever and other causes may cooperate to a certain extent. Disturbances of the digestive organs frequently accompany the severer forms of acute bronchitis. As in all affections asso- ciated with fever, so also in tliese forms of acute bronchitis, there is not infrequently loss of appetite, a more or less coated tongue, increased thirst, and more symptoms of the like character. Vomiting is but rarely observed, and then most frequently in the bronchitis of children. In the acute forms of disease these disturbances of the digestive organs usually subside after a few days. It is otherwise in the chronic forms of bronchitis, espe- BRONCHIAL CATARRH. 347 cially at an advanced period when secondary hypertrophy of the heart, intense cyanosis, dropsical manifestations, and other sequehe of the same kind have become established. At this stage, disturbances of the digestive organs are by no means infrequent. The appetite, then, is often more or less impaired ; sometimes there is great disposition to constipation; in other cases, again, the stools are more diarrhceal in character; and sometimes, again, constipation and diarrhoea interchange with each other. The origin of tliese disturbed intestinal functions lies in nothing else than the manifestations of obstruction which become extended upon the intestinal tract. On the other hand, in the milder forms of both acute and chronic bronchitis, gastric disturbances fail, as a rule, altogether, or exist in but slight intensity. Condition of the Urine.—The urine by no means always exhibits alterations in the diseases under consideration. Some- times tliese alterations are completely absent, sometimes, again, the}" are present in a tolerably high degree. Here, too, as in the occurrence of many of the symptoms mentioned, the accom- panying fever plays an important role. The alterations which the urine undergoes in fever, and also, therefore, in bronchitis accompanied with fever, are, as is well known, so conspicuous, that even the older pathologists spoke in an inaccurate manner of "febrile urine." We may consider as the ordinary, though by no means characteristic, peculiarities of all febrile urine, diminished quantity, high specific gravity, dark-red coloration, and increased proportion of urea. But we see on the other hand, as Traube' says, in the course of diseases of the respiratory apparatus, a condition of urine appear without fever, very similar to that occurring in fever, a condition which we frequently have opportunity to observe in cardiac diseases also. This sort of urine is not infrequently observed in diffuse bronchial catarrh. Like the febrile urine, this also frequently shows a yel- lowish-red sediment of uric acid salts. Sometimes, especially when severe mani- festations of obstruction, cardiac hypertrophy, dropsy, and similar consecutive dis- turbances have become developed, the urine contains, in addition, albumen, tubular casts, and the like. On the other hand, no important deviation in the condition of the urinary secretion is observed, for the most part, in the milder forms of tracheo- bronchitis, and in diffuse bronchitis, whether acute or chronic. Febrile Symptoms.—Fever is by no means a constant attend- 1 Die Symptome der Krankheiten des Respirations- u. Circulationsapparates, 1. Lieferung, 1667. 348 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. ant on bronchial catarrh. There are cases of bronchitis with which fever is associated, and others in which there is no fever. In general it may be stated as a rule that acute bronchitis is often associated with fever, which is usually but slight, and is present as a rule only at the commencement. The course of chronic bronchial catarrh, on the other hand, is usually unat- tended with fever; it is only at times, as in sudden exacerba- tions of chronic catarrh, that its course is also interrupted by slight febrile movements. No certain iuiLlj can be established concerning the occurrence of febrile move- ments under the influence of acute bronchitis. In cases of bronchitis of equal severity we see no fever at all in some instances, and in others moderate or tempo- rary, or even severe fever. Age, constitution, general condition of strength, and other similar factors are of influence here. Thus the acute bronchitis of children is usually associated with few, the fever being more intense the greater the number of bronchial twigs involved. Long continued and intense fever is observed chiefly in capillary bronchitis, and in the catarrhal pneumonia of children. On the other hand, the bronchitis of adults usually occurs with but little fever, and often even without fever at all; and when fever is present in adults at the commencement, it usually subsides entirely in the course of a few days. The bronchitis of the aged also fre- quently enough runs its course without fever. Lebert,1 on the ground of his numerous statistical compilations, comes to the con- clusion that fever is absent in almost one-half of all cases (all the forms of bronchitis being taken together). In many cases a catarrh runs its course without fever, so long as only the coarser bronchi are affected. Fever suddenly occurs later, on the other hand, as soon as simple bronchitis passes into diffuse bronchitis, or into bron- chiolitis. There is no determinate type of fever in the catarrhal affections of the bronchial mucous membrane. Wunderlich'2 has determined, for catarrhs of the mucous mem- branes in general, that they exhibit no typical relation concerning the tempera- ture in general, and th j same holds good also in reference to bronchial catarrhs. In many cases there are only somewhat greater fluctuations than in the healthy con- dition ; the temperature rising in the evening beyond the normal degree, or to that of the subfebrile or moderately febrile condition. Here and there, again, irregular elevations of temperature are m with, which are usually associated with fresh injurious influences, or with incidental exacerba- tions of the catarrhal affection. The severer a case is, and the higher the fever, the 1 Klinik der Brustkrankheiten, 1874. 2 Wunderlich, Das Verhalten der Eigenwiirme in Krankheiten, 2. verm. Aufl. Leip- zig, 1870. BRONCHIAL CATARRH. 349 less marked usually are the remissions. The character of the fever is usually that of a moderate remittent (Lebert). Concerning the lysis of the affection, it is still to be remarked that there is not, here, for the most part, as in pneumonia, a sudden fall of temperature down to the normal degree, or below it, but that the lysis usually occurs slowly and. gradually. The course of the temperature is in no sense typical, or characteristic of the dis- ease. The temperature in almost every instance, as I can substantiate by my own numerous observations, reaches but a moderate height, between 38° and 39° C. (10(f_102..V F.). Temperatures, therefore, of 41° C. (10G° F.) and upwards, as are reported to have been found by individual observers in acute bronchitis, must awaken suspicion as to some complication, or else be designated as unusually exceptional. Sweating is absent in many forms of bronchitis. In the acute forms the skin is usually inclined to be dry the first few days, though later there may be a secretion of sweat, sometimes copi- ous and sometimes very slight. jNTo definite regularity exists here in reference to the occurrence of perspiration. Slight sweat- ings are sometimes observed in the later stages of chronic bron- chitis. In the terminal stage, also, both of the acute and the chronic forms, an outbreak of sweat is sometimes observed, but it occurs in these instances as part of the phenomena of collapse. Nothing certain is known concerning the nutritive changes which take place in the different forms of bronchitis. It is a known fact that children are often considerably reduced in their nutrition in consequence of capillary bronchitis. Inasmuch as fever exerts the greatest influence on these changes, and inas- much as bronchitis is more apt to be associated with severe fever in children than in adults, the comprehension of this fact in general is not attended with any difficulty. Adults, on the con- trary, as a rule, suffer no material diminution of vigor, even in bronchitis lasting for years. The condition of the activity of the heart, and of the pulse, is nearly parallel with that of the body temperature, as in the majority of the febrile diseases. Cases without fever, therefore, in general present no important acceleration in the frequency of the contractions of the heart. The number of pulsations, on the other hand, increases in close proportion with the elevation of the body heat. As daily practice shows, there are numerous exceptions to this rule, which has been established clinically as 350 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. well as experimentally, and the disease in question furnishes examples in sufficient number. Thus, in the capillary bron- chitis of children especially, a very considerable acceleration of the pulse is exhibited, which often bears no relation to the slight or moderate increase of bodily heat. Of much rarer occurrence is the reverse abnormal relation, in which there is observed a relative diminution in the frequency of the pulse, with in- creased temperature. Concerning the remaining characters of the pulse there is no special characteristic or constant alteration. In the beginning of an acute bronchitis, especially where it is associated with fever, the pulse is as a rule, full and tense, and even hard ; and in the further course of the disease, and chiefly in severe forms which influence the general health a good deal, it becomes weak and small. Irregularity in the action of the heart comes on especially in the later stages of chronic bronchitis, when fatty degeneration begins to be developed in the hypertrophied and dilated right ventricle, which has become thus affected in consequence of the disturbed conditions of the circulation. The irregularity and feebleness of the pulse, which are not infrequently encoun- tered in the terminal stage of chronic bronchitis, are therefore always to be considered as unfavorable manifestations. Symptoms furnished by Physical Exploration. The results of physical exploration, in the restricted sense of the phrase, are of especial and much greater importance than the symptoms already discussed. In the first place, as far as inspection is concerned, it reveals, according to the form and extent of the catarrh, sometimes more marked and sometimes slighter deviations from the normal type of breathing; for special details of which we refer to the remarks already made. Of these deviations two are chief. The first is in the reciprocal relation between inspiration and expiration, which is most frequently disturbed in such manner that the expiration is impeded while the inspiration follows without special embarrassment. When expiration is prominently ob- BRONCHIAL CATARRH. 351 structed, it must, from obvious reasons, be compensated for principally by two methods : first, by increased expiratory force through the assistance of the auxiliary expiratory muscles, as is evinced in these cases by the strong development of those mus- cles ; second, by increased duration of the effort. Inasmuch as a considerably longer time is then devoted to expiration than is normally requisite, the expiratory obstacle is overcome to a cer- tain degree. This abnormal relation between inspiration and expiration is therefore, on the one hand, a valuable diagnostic aid, which facilitates our judgment as to the nature of the respi- ratory disturbance, and, on the other hand, a good compensating medium. The second deviation from the normal type of breathing is evinced by the abnormal action in certain individual sections of the thorax with diminished action in other sections. As the effort of the lung is to constantly take in about the same quan- tity of air, if the penetration of the air is impeded to a greater degree in certain sections of the lungs and the bronchial tubes, an increased penetration takes place in other sections, in those which present no obstacle to the entrance of the air, or present the least obstacle relatively. This disproportionate labor of individual sections of the thorax in cases in which the entrance of the air to certain sections of the bronchial tract is impeded, explains, at least in part, how origin is given in chronic bron- chial catarrh to one of the most frequent causes of pulmonary emphysema. Sometimes, however, in chronic bronchial catarrh, and chiefly in its intense grades, we see this irregular labor of the different sections of the thorax manifested in a very marked manner. It is observed especially in cases in which numerous bronchial tubes are occluded with secretion in such a manner that little or no air can penetrate into them and into the alveoli to which they lead. In other cases, not few in number, there is no deviation at all from the normal type of respiration; while in others, again, acceleration of the respiration is the only abnormal deviation observed. Spirometry furnishes no special indication in the different forms of bronchitis. Apart from the defects connected with the 352 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. method in general, into the closer consideration of which we can- not enter, spirometry is hardly of any special diagnostic value as a simple measure of the vital capacity in the diseases under con- sideration. The great value of spirometry does not so much reside in the absolute figures obtained at any one time, as in the comparison of a continuous series of figures obtained at different periods. In mild cases of bronchial catarrh, the diminution of vital capacity is very slight, or there may be none whatever. On the other hand, in intense diffuse catarrhs, or in chronic catarrhs of long continuance, especially when they are associated with emphysema, the diminution of vital capacity, in most instances, is not inconsiderable. A more important method of examination in the diseases before us is presented, as it appears to me, in the physical method of exploration introduced by Walden- burg1 and denominated pneumatometry. By means of pneumatometry Walden- burg was first enabled to detect an expiratory insufficiency of the lung in chronic bronchial catarrh? analogous to that found in emphysema. He found a more or less considerable diminution of the positive force of expiration as exerted upon the man- ometer. In contrast to this, tuberculosis exhibits an inspiratory insufficiency, that is to say, a diminution of the inspiratory suction on the manometer. Unfortu- nately, the method, as I can verify by numerous personal experiments, presupposes some practice and tact on the part of the patient, without which errors may very readily occur. As verified by the investigations of Eichhorst3 and one of my own pupils,4 the expiratory insufficiency always appears to be a constant characteristic of chronic catarrh, as of emphysema, and thus can be utilized as an important diagnostic aid in distinguishing the affection from tuberculosis, which at its com- mencement is already associated with inspiratory insufficiency. The results obtained by the pneumatometer are in complete accord with those that I have obtained by means of the graphic method of investigation, undertaken with my simple and double stethograph,5 in individuals laboring under chronic bronchial catarrh. Here also it is distinctly shown that it is the expiration which is especially impeded. According to the graphic method, this is marked by an elongated expi- 1 Berlin, klin. Wochenschrift, 1871, No. 45. 3 In health, the force of expiration always exceeds that of inspiration, as Walden- burg has shown by numerous experiments. 3 Deutsches Archiv f. klin. Medicin, Bd. XL, Heft 3, p. 2G8. 4 Lassar, Zur Manometrie der Lungen. Inaug. Dissert. W'rzburg, 1872. 5Deutsches Archiv f. klin. Med., Bd. X., p. 124; and Riegel, Athembewegungen, mit 12. Tafeln. Wiirzburg, A. Stuber, 1873. BRONCHIAL CATARRH. 353 ratory arm of the curve, in which, from obvious reasons, the last portion of the expiratory part of the curve must exhibit the greatest deviation; that is to say, the last portion of the expiratory arm of the curve is accomplished with the least relative speed. Slight catarrhs, on the contrary, as has also been shown by my graphic investigations, exhibit no important deviation from the normal form of the respiratory curve. The examination with the double stethograph is especially instructive in such chronic catarrhs, because it exhibits in the sharpest manner the unequal labor of individual sections of the thorax already mentioned. Percussion is of little value in the diseases in question. In the majority of cases it does not show any variation from the normal resonance, inasmuch as the pulmonary parenchyma proper is unaltered. Where the percussion sound exhibits any alteration, it is always evidence of complications with lung affections. It is especially capillary bronchitis, with its second- ary affections, collapse of the lung, catarrhal pneumonia, and the like, which produces alteration of the percussion sound. The so-called catarrhal pneumonia, which is so frequently devel- oped from a capillary bronchitis, is, as one of the most frequent complications of bronchitis, also a frequent cause of alteration in the percussion sounds. A further cause of modification of the sound in bronchitis is furnished in the not infrequent consecutive distention of individ- ual portions of the lung ; the occurrence of which is chiefly favored by the severe efforts of cough associated with the affec- tion. This consecutive distention takes place most readily at the edges of the lungs, and in their upper portions. The con- tinuance of the cause may gradually develop a characteristic emphysema out of this acute distention of the lung. As is evident from what has been said, all modifications of the percussion sound which are observed in the different varie- ties of bronchitis, do not depend upon the disease itself but upon complicating diseases of the pulmonary parenchyma. In contradistinction to percussion, the results furnished by auscultation are of greater moment; especially the different varieties of rales, which occupy the first rank. Their absence by no means indicates that the tracheal and bronchial mucous mem- brane is completely intact; but their existence must be con- sidered in a measure as pathognomonic evidence of the diseases VOL. IV.-23 354 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. in question ; because, whenever they are observed they almost always indicate disease of the bronchial mucous membrane. The accurate determination of the characters of the rales is of especial importance, because we can determine thereby the special sort of alteration existing in the bronchial tubes. Thus the long-used distinction between moist and dry rales has an important significance. The former are due to the movement of thin liquid products in the trachea and bronchi, and the latter are due to the friction of the current of air against the swollen mucous membrane of the bronchi, and to the presence of very viscid products. Dry rales indicate, therefore, more or less con- siderable swelling of the mucous membrane, and eventually the presence of small quantities of very tenacious fluid in the bronchi. These dry rales have been further distinguished from the sonorous, sibilant, and whistling sounds, in which nothing like a real rale can be any longer perceived. According as these latter exist in the larger and medium-sized, or in the smaller and smallest bronchi, they are designated as sonorous, and as sibi- lant and whistling sounds. All these sounds, but those occur- ring in the larger bronchi especially, may, under certain circum- stances, be also detected by palpation with the open hand laid upon the chest. The sensation produced is technically known 2& fremitus. The so-called moist rales, on the contrary, have an essentially different significance. Their existence shows that fluid secre- tion is present in the bronchi. They are especially significative of the breaking of bubbles, but they may also possess very dif- ferent characters. Sometimes they are audible only during inspiration, sometimes only during expiration, and sometimes during both acts of respiration. According to the quantity of fluid present in the bronchi these rales are sometimes more copious, and sometimes more scanty, provided that the perme- ability of the bronchi is not obstructed by plugs of mucus. On the other hand, the intensity of the rales does not depend only upon the copiousness of the fluid present, but also upon the depth of the respirations, the diameter of the bronchi, and the greater or lesser distance of the affected bronchi from the surface of the thorax. BRONCHIAL CATARRH. 355 The determination whether the rales are due to large, medium- sized or small bubbles, is of especial importance, inasmuch as the seat and extent of the affection may be thereby determined. Thus, from the extent of the rales and from the special character of the bubbles—whether large, medium-sized, or small,1 conclu- sions can be drawn as to the extent of the catarrhal inflammatory affection, and also as to its seat in the larger, medium-sized, or minute bronchi. It must not be forgotten that one or another portion of the bronchial tract may be completely occluded, at least temporarily, by mucus and the like, under which circum- stance, as a matter of course, the necessary conditions for the existence of the sounds do not prevail. In the same manner an alteration in the nature of the rales, even within a very brief period, is to be expected as a matter of frequent occurrence. Alteration in the characteristic respiratory murmur is to be mentioned as a further auscultatory manifestation in bronchial catarrh. While the respiratory murmurs are soft and smooth in the normal effort of respiration, they often become harsh and shrill in catarrhs of the bronchial mucous membrane, in con- sequence of the increased friction of the currents of air upon the swollen membrane. The shrill and harsh breathing will be heard over a greater or less surface according to the extent of the catarrh. A shrillness, and at the same time a prolongation, of the expiratory murmur is frequently associated with this harsh- ness of the vesicular breathing. Prolonged expiratory murmur is observed with especial fre- quency in chronic catarrhs, particularly those which are compli- cated with asthma and emphysema. This prolonged expiration always indicates that there is some obstacle preventing the egress of the air. For this reason it is encountered in almost all severe catarrhs of the bronchial mucous membrane, and espe- cially in diffuse chronic bronchial catarrh. The harshness of the expiratory murmur usually increases 1 We cannot enter into a description of the special meehanism of the production of the r;iles and the different theories that have been proposed regarding this question. We refer, on this point, to the manuals and treatises on percussion and auscultation, especially those of Scoda, Oerlmrdt, Guttmann, P. Niemeyer, Wintrich, Seitz, and others. 356 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. proportionately with its prolongation. It is due to the friction of the current of air upon the swollen mucous membrane, and is therefore likewise a valuable symptom of bronchial catarrh. In addition to the anomalies of the respiratory murmurs already mentioned, there is not infrequently a feebleness of the murmur in bronchitis. Such feebleness may be due to super- ficial and light breathing on the part of the patient, but there is another cause which is much more important and frequent, namely, occlusion or partial obstruction of the bronchi by mucus and the like. With the removal of these plugs of mucus by coughing, the normal respiratory murmur returns. The swell- ing of the mucous membrane alone does not suffice, as a rule, to produce any considerable feebleness or a failure of the respi- ratory murmur. On the other hand, the normal respiratory murmur may also appear modified from being obscured by the intensity of the contiguous murmurs, especially the moist rales. SPECIAL FORMS OF TRACHEITIS AND BRONCHITIS. I. Acute Tracheo-bronchitis ; Acute Catarrh of the Trachea and Larger Bronchi. The diseases of the mucous membrane of the trachea, as already remarked in our introduction, very rarely occur as inde- pendent affections. They are usually combined with analogous diseases of either the larynx or the bronchi. We shall not, therefore, present a detailed description of independent catarrhal inflammations of the trachea, but shall keep in view chiefly that form in which it comes most frequently under observation, that is, the so-called tracheo-bronchitis, in which it is associated with a simultaneous analogous affection of the larger bronchi. On the other hand, that form of tracheitis which is associated with an analogous affection of the larynx must be referred to the corresponding chapter on diseases of the larynx. In the same manner the croupous processes of the trachea, which almost always take their starting-point from an analogous affec- tion of the larynx, will, to avoid repetition, be referred to the appropriate chapter of the article on diseases of the larynx. BRONCHIAL CATARRH 357 Acute catarrh of the trachea, which, as above stated, almost always occurs in combination with an analogous disease of the larger bronchi, may occur either as an independent disease or as a symptomatic or secondary affection, as in the acute exan- themata, typhoid fever, and other diseases. Inasmuch as the symptoms of these different forms are identical, it may suffice here to describe those of the one which most frequently occurs, viz., primary acute tracheo-bronchitis, in its principal features. Acute catarrh of the trachea and the larger bronchi is a form of disease which is observed at every age of life, but which exhibits different shades according to the severity and extent of the catarrhal inflammation, the age and individuality of the patient, and other circumstances. Very often, though by no means as a rule, as asserted by some, acute tracheo-bronchitis begins with a catarrh of the pharynx or of the nasal mucous membrane, or of the larynx also. In these latter instances either the symptoms of the coryza, the pharyngeal catarrh, and the like, precede the symptoms of the tracheo-bronchitis by a brief period, or both become developed at the same time. In not infrequent instances, sometimes from greater intensity of the affection or in irritable constitutions, the commencement is ushered in, as in pneumonia, by slight chills, but rarely with a marked rigor. It is of significance, however, as also stated by Niemeyer, that there is seldom a single paroxysm of chill. The patient complains rather of frequently recurring slight sensations of chilliness, which are followed by sensations of heat, without giving rise to any thermometrical evidences of a temperature much above the normal standard. There is often, in addition, pain in the forehead, a feeling of languor and weak- ness in the limbs; usually, also, diminution or even loss of appe- tite, increased thirst, and the like; in short, a group of symptoms formerly often inappropriately designated as "catarrhal rheu- matic fever," especially when they immediately followed taking cold. In most instances this fever attends tracheo-bronchitis but for a short time, and the temperature seldom rises above that which characterizes a slight fever, except in children, in whom also the acceleration of pulse does not always preserve that rela- 358 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. tion to the increase of temperature, which is observed in the case of adults, but often exceeds it to a considerable degree. The fever is usually remittent, without otherwise exhibiting any special peculiarities ; it is very rarely intermittent in char- acter. The great disposition of this catarrhal fever, as it is often improperly termed, to the development of sweating, is worthy of remark. Cough is always present, and may even appear at the com- mencement of the disease. As previously remarked,' it has been experimentally proven that irritation of the tracheal and bron- chial mucous membrane excites cough, and that of all points of the trachea and bronchi cough is most readily excited at the point of bifurcation. This coincides with the fact that catarrh of the mucous membrane of the trachea and upper section of the larger bronchi is usually associated with very severe cough, while catarrh of the deeper sections of the bronchi, and of the medium-sized and smaller bronchi, often occasions but slight cough. For the first few days the cough is dry, a simple cough of irritation, which may or may not be attended by insignificant expectoration, according to the severity of the hypersemia and swelling of the mucous membrane existing at this stage. The cough is not muffled and hoarse except when there is a complication with an analogous affection of the larynx. On the contrary, as long as there is no extensive secretion from the mucous membrane, it has often a cavernous, barking sound, and is sometimes characterized by actual spasmodic paroxysms {spasmodic cough). Furthermore, the cough frequently increases in intensity during the horizontal decubitus, to become less fre- quent and less severe upon the resumption of the upright posi- tion. This is explained by the fact that in this position not only is it easier for the patient to breathe deeply, but the mucus is less likely to be detained at the points of irritation; it is also explained in a measure by the excessive sensitiveness of the mucous membrane of the posterior wall, and especially of the ! See " Introductory Remarks," also Nothnagel, Zur Lehre vom Husten, Virchow's Archiv, Bd. XLIV., and Kohts, Experimentelle Untersuchungen iiber den Husten, Vir- chow's Archiv, Bd. LX., Hft. 2. BRONCHIAL CATARRH. 359 inter-arytenoidal incisure, a locality in which the mucus easily becomes accumulated during rest in the horizontal position. The severest grade of spasmodic cough is therefore also observed in those forms of tracheitis which are combined with a laryngitis, the so-called laryngo-tracheitis. The patient frequently complains of a feeling of pressure, con- striction, and fulness of the chest. On the other hand, charac- teristic stitches in the side, the occurrence of which in tracheo- bronchitis is mentioned by some authors, do not belong to the disease as such, but rather suggest the suspicion of some compli- cation. Painfulness of the muscles of expiration is not infre- quently observed, especially in those forms associated with severe spasmodic cough. Traube1 further distinguishes, as a diagnostic indication of tracheal catarrh, an abnormal sensitiveness of the trachea to pressure, and the ready excitement to cough produced by this pressure. After a short time, in most instances after but a few days, the cough loses its dry character and becomes looser, for the mucous membrane now furnishes more secretion, which is more readily detached. Considerable subjective amelioration goes hand in hand with this loosening of the cough and increased production of mucus. If fever had been present previously, it then subsides completely in this stage in most instances, and the patient in mild cases then gradually progresses towards conva- lescence. It is otherwise in severe forms, whether they have appeared as such at the commencement, or have become so later. Here the affection not only lasts a considerably longer time, but the indi- vidual manifestations, such as the fever, the general languor, the cough, and similar symptoms, take on a more intense char- acter. In nurslings and young children, especially, the dyspnoea often reaches a considerable degree. Indeed, certain observers, as Rilliet and Barthez, describe such cases in children which pro- gressed to a fatal termination under symptoms of eclampsia and asphyxia, without any further complication. 1 Die Symptome der Krankheiten des Respirations u. Circulationsapparates, Bd. L, 1867. 360 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. The expectoration, but scanty at first, is always a transpa- rent, foamy mucus at the commencement. It gradually becomes more abundant, contains more and more of yellow stripes between the transparent masses of mucus, and then always becomes richer in cells and less translucent. Finally, becoming constantly richer in cells, it reaches that consistence which we have described in a previous article as belonging to the sputum coctum. In general, too, as the expectoration gradually becomes richer in cells, the cough is also looser and less straining, and the breathing is facilitated to a corresponding degree. As far as physical examination is concerned, it is self-evi- dent that the percussion sound never undergoes any essential modification, even in intense forms of tracheobronchitis. It is otherwise with auscultation. If the mucous membrane of the trachea and the larger bronchi is swollen to a considerable degree, or if viscid, tenacious masses of mucus are adherent, then auscultation along the course of the trachea and larger bronchi reveals dry rales, the so-called sonorous rales {rhoncus sonorus, rale sonore sec of Laennec). Tliese rales are produced by the friction of the current of air upon the much swollen tra- cheal and bronchial mucous membrane, which at this stage fur- nishes but very little fluid product or none at all. If smaller bronchi are also the seat of this swelling, then we speak of whistling and sibilant rales {rhoncus sibilans). In addition, the term sibilant rale is also applied to those shrill tones which occur when viscid mucus almost closes a bronchus, so that but a narrow slit remains. Only very seldom does a simultaneous swelling of the sub- mucous tissue occur to such a degree as to constrict the calibre of the tubes. This takes place somewhat more frequently in chronic inflammation, which may even give rise to induration of the submucous tissue, to simultaneous hypertrophy of the car- tilages, with or without calcification, and to other conditions of similar character. Concerning the symptoms that are manifested under tliese circumstances, the reader is referred to the chapter on tracheal and bronchial stenosis. These sonorous rales in the trachea and bronchi are distin- BRONCHIAL CATARRH. 361 guished from all other rales by their marked intensity. They are much louder than the moist rales, and are frequently audible not only at those places in which they arise, but even over a wide extent of the thorax. They are frequently so loud and intense as to attract the attention of the patient and those about him. Under certain circumstances they can even be felt with the hand. In cases of slight severity they are audible only at the points at which they arise, and are therefore to be sought for along the trachea and in the region of the root of the lung. In many cases these rhonchi have an intensity so considerable that they mask all the other thoracic sounds, so that even the characteristic respiratory murmur can no longer be detected. AY here, on the other hand, the respiratory murmur can still be heard, slight changes in it are sometimes found; it is at times somewhat weakened, and then at others sharpened. In other cases it remains normal. At a later stage, when the secretion is less viscid, and has become richer in cells, the character of the rhonchi becomes altered. Moist rales take the place of the sonorous rales,—rales which may be designated as coarse, inasmuch as they occur only in the trachea and the larger bronchi. The designation of these rales as moist in no wise confirms the usual theory that they are produced by the passage of air through the secretion contained in the bronchi, and the bursting of the air-bubbles formed in this manner. We shall have an opportunity later to return to this theory, and to the objections brought against it by Traube ' especially. In proportion as the secretion of the tracheal and bronchial mucous membrane again becomes less, the rales become sparser, until they are finally entirely replaced by the normal sounds. In most instances all the manifestations mentioned give place to the normal state of things after a short time, corresponding to the brevity of the duration of the general affection. Concerning palpation it is only to be mentioned that under certain circumstances the fremitus of the rhonchi may be felt by 1 Hcrtcl, A case of chronic bronchial catarrh and enlargement of the volume of the lungs, with remarks on cyanosis, bronchial catarrh, bronchiectasis, and the phenomenon of the diastolic double-tone. Berlin, klin. Wochenschr., 1871, Nos. 26, 27. 362 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. the hand; these rhonchi being conveyed to the thoracic walls, where they are felt as vibrations. Inspection furnishes no characteristic results in catarrhal tracheitis and bronchitis. In ordinary cases the disease, espe- cially in adults, gives rise to no disturbance in the respiratory movements, either in form or in frequency. The expansibility of the thorax is but insignificantly dimin- ished, or not at all affected. In severe grades, however, there exists, in addition to subjective dyspnaza, a disturbance of breath- ing in this respect that the respiration is accelerated, without undergoing, in most instances, any considerable diminution in depth; on the contrary, the individual breaths sometimes exceed the average of normal expansion which they exhibited in conditions of quiet, uniform breathing. This manifestation is in complete harmony with the experimental results of the influence of progressive constriction of the trachea. On the other hand, the impediment to the aerial current in the trachea hardly reaches such a grade as to occasion that form of respiratory type which we shall have occasion to mention later, in connection with tracheal stenosis, as belonging to the severer grades of this affec- tion, and which also occurs in the higher grades of laryngeal stenosis. It only happens very exceptionally that an acute swelling of the mucous membrane and submucous tissue leads to a high degree of this sort of stenosis. Such a stenosis occurs much more frequently through chronic swelling of the mucous membrane and submucous tissue, through oedema, through peri- chondritis, through hypertrophy and induration of the tissues named, with the formation of callosities and cicatrices, especially as a sequence of syphilis.1 In children, as a matter of course, dyspnoea occurs, in severe grades of swelling of the mucous membrane, much more readily than in adults. Further, according as the affection is associated or not with fever, there is or is not a further basis afforded for dyspncea. Moreover, a certain dependence of dyspnoea upon the paroxysms of cough may be recognized, inasmuch as the severity and frequent recurrence of the paroxysms of cough seem to increase the dyspncea. 1 Consult the chapter on tracheal stenosis. BRONCHIAL CATARRH. 363 The remark of Traube * is furthermore worthy of mention, viz., that the symptomatic picture belonging to catarrh of the minuter bronchi may be produced by the downward flow of a copious tracheal secretion into the bronchial tract. The appearance of the patient is not materially altered in most instances. In cases in which tracheo-bronchitis appears at the same time with coryza, or is preceded by it, the face is fre- quently reddened, the nose is swollen, the eyes are watery, and the lids are often somewhat puffy. Tracheo-bronchitis, as such, on the contrary, hardly ever occasions any material alteration in the appearance of the patient. Only slight grades of cyanosis are observed here, as a rule, and even these are frequently enough altogether wanting. Among further symptoms and complications still to be men- tioned are mild gastric manifestations which sometimes attend the bronchitis. Even in the first few days the ajjpetite appears to be impaired, and the tongue coated; sometimes, especially with severe and exhausting paroxysms of coughing, even vomit- ing is observed ; sometimes, too, there is a disposition to consti- pation, and less frequently, a disposition to diarrhoea. Some- times these mild gastric disturbances continue for quite a long time, in some cases even to the period at which the manifesta- tions on the part of the respiratory apparatus have already begun to retrograde. Sleep is disturbed, especially at first, by the severe paroxysms of coughing which during this period result from the dry and swollen condition of the mucous membrane. "With the loosen- ing of the secretion from the mucous membrane, and the conse- quent diminution of the irritation to congh, sleep improves, as a rule. Other nervous symptoms are usually absent, except that in very small children severe cerebral symptoms sometimes become developed, these partaking at one time of the character of excitement, at another of the character of depression. Even slight convulsive twitchings of the face, or of the limbs also, and temporary rigidity of the trunk and limbs have been men- tioned Ivy some observers. 1 Die Symptome der Krankheiten d. Respirations- u. Circulationsapparates, Bd. I., 1807. 364 RIEGEL.—DISEASES OF TRACHEA AND BRONCni. The most frequent termination, as already mentioned, is in recovery. A fatal termination occurs only exceptionally in acute tracheo-bronchitis, in patients already considerably debili- tated by previous diseases. In other cases, on the other hand, recovery does not take place after a short time, but the catarrh gradually spreads along the finer divisions of the bronchi, and continues for months, or even years, sometimes with slight, and sometimes with severe exacer- bations and remissions. In many case's acute tracheo-bronchitis thus passes into the chronic form, or into a diffuse bronchitis. II. Acute Catarrh of the Medium-sized and Minuter Bronchi, Bronchitis Capillaris, Acute Diffuse Bronchial Catarrh. Inasmuch as we contrast acute catarrh of the trachea and larger bronchi with that of the medium-sized, and smaller bron- chi, and with bronchiolitis, we must commence with the remark that such a sharp distinction as we shall have to present in the description of the individual varieties does not by any means always exist in practice. On the contrary, daily experience suf- ficiently shows that numerous transitional and intermediate forms exist. Thus we not infrequently see both forms more or less combined in such a manner that, in addition to a catarrh of the trachea and larger bronchi, a few medium-sized and minuter bronchi are affected also. In one series of cases the bronchioli- tis and broncho-pneumonia begin in the finer bronchial branches from the very commencement. In other cases, on the other hand, the disease begins with a catarrhal inflammation of the larger bronchi, and thence extends into the smaller bronchi. Acute diffuse bronchial catarrh represents that form of bron- chitis in which most of the bronchial tubes are affected, tubes therefore of very different calibres. Hence, capillary bronchitis is, to a certain degree, also included in diffuse bronchial catarrh, inasmuch as at least some of the minuter bronchi are affected as a rule. The course of the affection is frequently such that the larger and medium-sized bronchi are affected in the first instance, and then the process is extended secondarily upon the BRONCHIAL CATARRH. 365 smaller and minutest bronchial ramifications. Thus cases are frequently encountered in which bronchial tubes of the most varying calibre—larger, medium-sized, and minute alike—are all simultaneously involved in the affection. As is self-evident, the danger and significance of the affection are increased with this extension of the catarrhal-inflammatory process upon smaller and smaller, and finally upon the minutest bronchi. Should these be naturally very narrow it may readily happen that the passage of air through them may be impeded to a great degree, and at times totally prevented, in cases of severe inflammation and swelling, and of copious accumulation of secretion. In this way considerable disturbance may be occasioned, and the affec- tion may readily involve great danger, especially in children, in whom the calibre of the bronchi is so small. Capillary bronchitis is by no means always a secondary development from a bronchitis of the larger tubes. Indepen- dent forms are not infrequently observed, especially in child- hood and in advanced age ; while in middle life the disease is for the most part a secondary process arising in the manner mentioned, or a secondary affection or consecutive disease asso- ciated with other diseases, especially infective maladies, such as diphtheritis, the acute exanthemata, erysipelas, typhoid fever, and the like. As a further characteristic of capillary bronchitis, the circum- stance must be mentioned that lobular catarrhal pneumonia is not infrequently developed in immediate connection with it; the pneumonia always representing a secondary condition. Ca- tarrhal pneumonia affects the lower lobes of the lung most readily, and especially those portions situated near their pos- terior borders. The inflammatory process here extends from the minuter and terminal bronchi upon the lung texture itself, which now appears dark red in color, and swollen, at different points. The catarrhal inflammatory process then gradually ex- tends forwards and upwards from the posterior and inferior sections of the lungs affected in the first instance. As, however, there is no mucous membrane in the lung, the process which appears as a catarrh in the mucous membrane of the medium-sized and smaller 366 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. I bronchi, must, as Buhl' observes, be considered as transferred to the pulmonary parenchyma in a highly modified manner. If, as Buhl says, an affected lung be closely examined, it will be found to display an inequality of texture. In one part there are places where the tissues are gorged with blood, swTollen and promi- nent ; ecchymoses are also noticeable upon the pleural surface, and from the cut sur- face of the lung not only more blood escapes, but also a serum copiously mingled with air-bubbles (acute cedema of the lungs). In another part, and especially at the edges of the lungs and towards their roots, the alveoli are seen collapsed, retracted, nearly or entirely empty of air, and colored blue red (atelectasis). In other lobules ' again, on the contrary, the pulmonary vesicles are found very much distended with air, pale, and richer in blood only at their circumference, as if enclosed by a wreath of injected vessels (local emphysema). Finally, lobules are found which when cut with the knife show a smooth, somewhat hard non-granular cut surface, that projects above the level of the rest of the section, and displays disseminated yellow spots of the color of pus. Lobules like these are generally found in cases of bronchitis of long standing. This appearance is due to the alveoli being filled, not with fibrinous, but with thick mucous secretion rich in pus corpuscles. The immediate vicinity of these foci is also distinguished by the presence of an increased proportion of blood. In addition to the accumulation of mucus and pus corpuscles, the microscope also detects epithelium in a state of fatty degeneration, though in insignificant quan- tities. The same condition is also found diffusely distributed in the cedematous localities, the inflamed portions sending processes into the surrounding tissues (Buhl). Of all these alterations only the filling of the lobules with mucus and pus can be considered, as Buhl states, as belonging to the catarrhal process. Buhl considers that the greater part, if not all, of the catarrhal product lying in the alveoli origi- nates from the bronchi and is sucked in by aspiration, and is no longer remo- vable on account of the simultaneous obstruction of the bronchial twigs with which they are connected; this being especially proved by the co-existence of simple cedematous lobules, with atelectatic and emphysematous ones. "Although the purulent accumulation in the lobules of the alveolar parenchyma is apparently not a direct inflammatory product, it must not be asserted that the lung tissue cannot eventually become subjected to inflammatory irritation in consequence of the long continuance of this condition" (Buhl).2 Returning again, after this digression concerning the anatom- ical relations of catarrhal pneumonia, to diffuse and to capillary 1 Buhl, Lungenentziindung, Tuberculose u. Schwindsucht. Munchen, Oldenbourg, 2. Aufl., 1873. 2 Concerning the minuter anatomical details of catarrhal pneumonia, we refer the reader especially to Friedlander's admirable work, the conclusions in which differ from those of Buhl in many points. We also refer to JUrgensen's chapter on Catarrhal Pneumonia, in Vol. V. of this work. BRONCHIAL CATARRH. 367 bronchitis, we must first direct attention to the much greater severity of this affection in contrast to that of tracheo-bron- chitis. With the greater extension of the catarrhal inflamma- tory process from the larger to the smaller bronchi in many dif- ferent parts of the lung, the respiratory interchange of gases must be disturbed to a great degree, and the circulation too, therefore, secondarily. The more the access of air to the alveoli is impeded by the swelling and occlusion of numerous, espe- cially the minuter bronchial tubes, the less sufficient is the decarbonization of the blood, and the more readily symptoms of asphyxia may occur, as is frequently enough seen, particu- larly in the capillary bronchitis of children. That suffocative symptoms occur more readily in children than in adults may be readily explained by the difference in the anatomical conditions, —viz., by the smaller diameter of the minuter bronchial tubes in children, for the occlusion of which moderate swelling and accumulation of mucus are amply sufficient. In turning, now, to the description of the individual symp- toms and the course of the disease, we will consider them sepa- rately, as they occur at different periods of life and under differ- ent circumstances, inasmuch as the clinical picture varies in many particulars according as the disease affects young chil- dren, adults, or old people, and in consequence of other condi- tions also. The limits of a manual like this do not afford sufficient space to present a sepa- rate description of all these individual forms. Concerning this point the reader is especially referred to the recent monograph of Lebert,1 and also to the numerous special monographs, upon the very interesting subject of the capillary bronchitis of children. We will present the picture of the disease in its principal outlines, and devote special attention only to the more important differences of the indi- vidual varieties. Diffuse bronchial catarrh, as well as capillary bronchitis, may either commence as such from the very beginning, or may become developed from a simple tracheo-bronchitis. Whether it has made its appearance in one way or the other, the breath- ing in these cases is always more or less disturbed. In both 1 Klinik der Brustkrankheiten, Zwei Bande. Tubingen, Laupp, 1873, 1874. 368 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. diffuse and capillary bronchitis the breathing is usually accel- erated and more labored, and the dyspnoea is always closely proportionate to the amount of impediment in the air-pas- sages. In mild cases the dyspncea is restricted to a moderate degree, but under certain conditions it may increase to a very severe degree, and even to almost suffocative want of breath. Severe dyspncea is often developed with especial rapidity in the capillary bronchitis of children. The smaller the original calibre of the bronchial tubes, the more readily will a moderate swelling and accumulation of mucus occasion complete impermeability. This explains why the breathing is often considerably impeded and accelerated in nurslings and small children ;—and it is just during the first three years of life that they are most frequently attacked by capillary bronchitis and catarrhal pneumonia. As a rule, the individual breaths are short and interrupted; at intervals, even suffocating paroxysms set in, in which the dysp- ncea increases to a very severe degree; the children are often able to breathe only in the semi-recumbent posture ; they obtain no rest; they change their position continually ; the nostrils dilate powerfully with each inspiration ; the countenance is cyanotic ; the thorax is drawn up in a hasty manner, and by jerks; the lowest portion of the sternum and the lower ribs undergo even an inspiratory retraction, especially upon deep inspira- tion. There are also numerous cases in children in which the dysp- noea, as well as all the other manifestations, exhibits a less active character. This is not only the case in the milder grades of bronchiolitis, but in severe cases also, when they concern little children already much weakened by previous diseases, in which instances catarrhal pneumonia soon becomes readily added to the existing condition. The children lie in bed apathetic, awa- kened from their semi-slumber at intervals only by severe paroxysms of cough; the lips and face are strongly cyanotic; the pulse is small, and often it is impossible to count it. These cases represent the variety described by Rilliet and Barthez under the name "Cachectic Broncho-pneumonia of Children." In elderly subjects a more insidious course is not infre- BRONCHIAL CATARRH. 369 quently observed. Dyspnoea is indeed present, and the breath- ing is shallow and accelerated, but the number of respirations hardly reaches that observed in children; in short the entire symptomatic manifestations progress in a far less stormy man- ner in most instances. In adults, also, the diseases under consideration for the most part produce a moderate grade of dyspncea,—never so intense as that which is observed in children. We do not observe here that stormy, galloping, though nevertheless superficial breath- ing which we have the opportunity of observing—and by no means infrequently—in children. The number of the respira- tions is sometimes increased to a third above the normal stand- ard in adults, and even to double the number and more ; but nevertheless the frequency of the respiratory efforts is far removed from that which we are accustomed to see in children. The type of breathing, much as it differs from the normal, exhibits no deviation in an}r way characteristic of the affection under consideration. In the more diffuse form of bronchitis, the only noticeable change frequently consists in nothing more than slighter and less extensive movements of the thoracic walls; the relations of the individual phases of respiration to each other being hardly appreciably disturbed. In the capillary bronchitis of children, which occurs particularly in nurslings, and in the very earliest years of life, a more abrupt, jerky breathing is frequently observed; so that despite powerful con- traction of all the inspiratory muscles an intermission occurs again and again. Both inspiration and expiration appear im- peded, and the auxiliary expiratory forces are called into play. Thus both acts of respiration are impeded, while the relations of the two phases to each other remain nearly the same as in normal breathing. Biermer,1 describes, also, the occurrence of a type of respiration similar to that observed in asthma. We will recur later to its more detailed peculiarities in our descrip- tion of asthma. A temporary intermission of the dyspnoea is not infrequently observed, and generally the degree of dyspncea is frequently ' Bronchlenkrankheiten, in Virchow's Handbuch der speciellen Pathologie und Therapie. VOL. IV.—24 370 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. changeable in that form of bronchitis under consideration. A frequent cause of rapid increase of dyspnoea is to be found in plugs of mucus which suddenly obstruct a larger or smaller bronchus, and then become detached at a later period. Although the dyspncea exhibits now a severer, and now a slighter degree, according to the extent over which the process is distributed, and the age of the affected individual, it almost always reaches its maximum gradually within a few days or after a longer period, maintains its height, with remissions, for some time, and then gradually decreases. In children deception may readily occur in consequence of this relatively slow progression of the dyspncea and other manifestations, so that the attendants often mistake the affection at first for a trifling one, until by the rapid increase of the dyspncea to its maximum within a short period, especially upon the onset of a catarrhal pneumonia, or, more frequently, by the rapid emaciation, by severe febrile exacerbations, and the like, they are taught that it is something more severe. Percussion reveals no deviation from the normal condition as long as no further complications are present; these, however, are by no means infrequent. Where, however, as is especially frequent in the capillary bronchitis of children, alveolar thicken- ings, atelectasis, and the like are superadded, an alteration in the percussion sound is frequently observed ;• but by no means always. It may be lacking even in catarrhal pneumonia, when the pneumonic foci are very small and are entirely enclosed in parenchyma containing air. In other cases the full, clear, pulmonary resonance exceeds the normal limits, as in emphysema, especially when an acute dilatation of the lung is added to the existing conditions. Where the lung power is insufficient, in capillary bronchitis, to overcome the obstruction, atelectasis must occur in places. Concerning the other results ascertained by percussion, we have to do only with the occasional occurrence of an extension of cardiac dulness, produced by dilatation of the right side of the heart in diffuse and widely extended bronchitis. This is readily explained by the disturbed condition of the circulation. Auscultation furnishes numerous deviations from the normal BRONCHIAL CATARRH. 371 condition. The respiratory murmur is sometimes normal, but it is more frequently enfeebled. Less frequently it is rough and harsher than normal, or it may even be muffled and indistinct. The expiratory murmur, particularly, is often harsher than normal. Of greater significance are the numerous rales which at times are to be heard distributed over nearly the entire thorax, as in diffuse bronchitis, and at other times are discernible only over small, circumscribed sections of the thorax. Sometimes the rales are loud and moist; sometimes they are more dry; sometimes we hear only small bubbling rales, and then again an admixture of sonorous, whistling, large, and small bubbling rales. According to whether the process is spread over nearly all the bronchial ramifications, or over only a few, especially the smaller ramifications, and according to the quantity and vis- cidity of the secretion, the sounds produced must be of varying characters. An interchange of tliese rales within short periods of time is demonstrable frequently enough. Concerning the diagnostic significance of the different rales, it may be permitted to add a few remarks. As is well known, the existence of moderate-sized, bubbling, muffled rales formerly led at once to the conclusion that fluids were present in the middle-sized bronchi. That this conclusion is inaccurate has been shown by Traube' especially. Concerning the crepitant rale of Laennec, it was long ago shown that it also occurs in cases in which, beyond a doubt, no fluid is present in the air-passages. As regards the moderate-sized, bubbling, muffled rales, Traube first furnished the evidence of their occurrence even in cases in which there was no fluid in the bron- chi. Thus, he observed them in cases of commencing pleuritis, and in moderate hydrothorax. From these and other facts Traube justly draws the conclusion that the existence of a fluid iu the air-passages is by no means a necessary condition for the occurrence of such rales. The similarity between those rales which are pro- duced by liquid in the air-passages, and those which certainly occur without the help of a liquid, justifies the assumption of a common cause. Traube, therefore, considers as inaccurate Laennec's view that the rales produced by fluid in the air- passages are due to the passage of the air in larger or smaller bubbles through the fluid; he attributes them rather to the successive detachment of the viscid bron- chial contents, as a whole, from the bronchial wall in the acts of inspiration and expiration. The inspiratory rale is due to the entrance of the air with a certain quickness into the little empty spaces left by the detachment of the bronchial 1 Berlin, klin. Wochenschrift, 1871. Nos. 26, 27. 372 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. contents. The occurrence of the expiratory rales is to be accounted for in the same manner, according to Traube, only that here the condensation of the air in the pul- monary parenchyma, and not its rarefaction, acts as the propulsive power for the penetration of the air between the bronchial wall and the bronchial contents. The rales, then, which occur without fluid in the air-passages are essentially due to the same mechanism. This is not the place, however, to enter into the consideration of the mechanism and interpretation of the various rales. Cough occurs with variable frequency. It is often severe, and even spasmodic. Expectoration is often altogether wanting for a long time, or only isolated viscid sputa are expelled after long-continued, severe paroxysms of cough, attended with great straining. In contrast to the form of tracheo-bronchitis already described, in which in most instances the cough loosens after a short time, in this form, difficult expulsion of the secretion often continues for a long time. Among the remaining symptoms, the febrile manifestations are the first to be discussed. Slight febrile movements almost always accompany both diffuse acute bronchitis and capillary bronchitis. The fever, however, very seldom reaches a high degree of severity. High temperatures, that is, up to 40° C. (104° F.) and above it, are only exceptionally observed. Those chronic catarrhs also, which suddenly acquire an acute character from the influence of some new irritant, and which up to that time had progressed without fever, then, as a rule, become asso- ciated with mild febrile movements. In favorable cases the fever soon subsides again with the abatement of the severe paroxysms of cough, and the occurrence of easier and more copious expec- toration. It is just these forms that evince a special disposition to recurrences and acute exacerbations. In old people, as a rule, but slight elevations of temperature are observed. The capillary bronchitis of children is usually associated with but moderate febrile movement, the temperature being ordina- rily maintained at 39° C. (102.2° F.). It is in these very cases that observations of temperature, as first mentioned by Ziems- sen,1 are of great diagnostic significance, inasmuch as the transi- tion of bronchiolitis into broncho-pneumonia is often so latent 1 Pleuritis und Pneumonie im Kindesalter. Berlin, 1862. BRONCHIAL CATARRH. 373 that it may evade observation. If careful examinations with the thermometer are made it will be found that the temperature increases rapidly with the onset of the broncho-pneumonia, and often reaches 40° C. (104° F.), and even higher figures, although it had previously remained at or below 39° C. (102.2° F.) (Ziemssen). This is not to be construed to mean that every elevation of temperature above 40° C. (104° F.) is an indication that the disease can no longer be a capillary bronchitis, but must already have become a catarrhal pneumonia. I have repeatedly observed a temperature of 40° C. (104° F.) and over in the simple capillary bonchitis of children in whom the affection has been verified on autopsy. That higher temperatures may also exceptionally be observed in capillary bronchitis is by no means to be denied. As Ziemssen justly remarks, the onset of a catarrhal pneumonia in a case of capillary bronchitis is usually indicated by a sudden exacerbation of temperature. Inasmuch as the elevation of temperature is only moderate, as a rule, in capillary bronchitis, a sudden rise from this moderate level to a point above 40° C. (104° F.) suggests the probability of the onset of a catarrhal pneumonia. The action of the heart and the pulse exhibit, in general, an acceleration corresponding to the height of the fever. In chil- dren, on the other hand, the acceleration of pulse does not cor- respond with the elevation of temperature, being much greater, as a rule. It reaches even 140 and more in the minute, and sometimes the pulse is so rapid that it can hardly be counted. In adults the frequency of pulse rarely, or but little, exceeds 100 in the minute. At the commencement of the affection the pulse is usually full and tense ; at a later period it is small. The skin is usually dry at the commencement; at a later period, on the other hand, there is frequently a disposition to sweating. Marked cyanosis often becomes developed in a short time in the severe forms of the bronchitis under consideration, especially in the form of catarrh associated with symptoms of asphyxia, a form in which the numerous bronchi become filled with very copious, tenacious mucus, so that the penetration of air into them is impeded to a very great degree. The more considerable the swelling of the mucous membrane, 374 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. the more extensive the occlusion of the bronchi, and the more sudden its occurrence, the more readily will severe cyanosis be likely to ensue. The appearance of the patient often undergoes considerable alteration in a short space of time, in cases in which many, and especially the minuter bronchi, are obstructed. Apart from the cyanosis already mentioned, which exists in marked degree in the lips, ears, nose, nails, and the like, the features of the patient exhibit a certain inquietude and anxiety corresponding to the disturbance of respiration. With longer duration of the respira- tory disturbance a certain degree of apathy and somnolence often sets in ; the extremities become cool and markedly cyano- tic, and, with increasing sopor and constantly increasing cyano- sis, the patient in severe cases dies suffocated. The condition of the urine exhibits nothing characteristic. It is usually small in quantity, concentrated, and rich in urates, and sometimes a small quantity of albumen is observed in the later stages. Cerebral symptoms are always wanting in the milder cases. In severe cases, especially when a catarrhal pneumonia has become superadded to the capillary bronchitis, cerebral symp- toms are frequently observed towards the end, sometimes even recalling the picture of tuberculous meningitis. In acute diffuse bronchitis, on the other hand, hardly any severe cerebral symptoms are observed. Gastric disturbances of slight grade are likewise not infre- quently observed. In children, especially, vomiting often occurs, and even diarrhoea. Loss of appetite is usually observed, for a longer or shorter time, in the majority of these forms. As regards the subjective symptoms, there is frequently more or less severe feeling of oppression, considerable shortness of breath, and lassitude. On the other hand, with the exception of that produced by the efforts to cough, the disease, as a rule, is not accompanied by any severe pain. The expectoration, as in catarrh of the trachea and coarser bronchi, is also scanty at the commencement, and expectorated with difficulty. After a short time it usually becomes more copious, and at the same time less tenacious. The sputum is BRONCHIAL CATARRH. 375 at first more mucous, later it becomes richer in cells and more consistent, and, in addition, sometimes exhibits the following special characteristics : Inasmuch as the secretion which fills the minutest bronchi is not mixed with air, it tends to sink in water, its specific gravity being greater than that of water ; and when it possesses a certain tenacity and coherence it retains the form of the minutest bronchi, and at the same time adheres firmly to the secretion coming from the larger bronchi, which is mixed with air, and which therefore floats upon the water. Thus the expec- toration forms a foamy layer upon the surface of the water, from which thin threads hang down below the surface (Seitz, Niemeyer). Frequently enough the expectoration of tliese sputa is tolerably difficult. The course of the forms described varies in different cases. In general, however, certain methods of progress may be re- garded as the rule ; and tliese we will detail briefly in describing the individual symptoms. Let us first consider the acute diffuse form of bronchitis, which is by no means to be reckoned as an infrequent affection among adults. In general it does not often happen that the acute diffuse bronchitis begins without other prodromes. Some- times the symptoms of a mild acute tracheo-bronchitis, an angina, a coryza, or the like, precede the affection for some time, and then the symptoms of an acute diffuse bronchitis become developed ; in other cases both sets of symptoms make their appearance simultaneously. It frequently happens, also, in individuals who have already suffered for some time with chronic bronchial catarrh, that the catarrh suddenly takes on an acute character in consequence of some new injurious influence. These severer symptoms of acute diffuse bronchitis sometimes become developed with great rapidity from a simple, mild, chronic, bronchial catarrh. In other cases the acute diffuse bronchitis becomes developed suddenly under the influence of some accidental cause, as taking cold, or becoming thoroughly wet. In other cases, again, the bronchitis is superadded to other existing affections, such as the acute exanthemata, cardiac insuf- ficiency, Bright's disease, and the like. It occurs in a similar manner, both in adults and in chil- 376 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. dren, only that, as a matter of course, in children it gives rise to severe symptoms much more readily. This form is frequently observed in aged persons also, but it is more apt to progress under adynamic manifestations. The commencement of acute diffuse bronchitis is usually sudden, with a light febrile movement, which is frequently pre- ceded by a slight chill, or by repeated chilly sensations. A certain amount of dyspncea is rapidly superadded, with short, and at first dry cough, which occurs in frequently recurring severe paroxysms ; the respiration is accelerated, short, super- ficial, and frequently accomplished only with the aid of the inspiratory and expiratory muscles. In those cases, also, in which diffuse bronchitis does not com- mence suddenly but is rather preceded, for a longer or shorter period, by slight bronchitic or other manifestations, the severe symptoms usually become rapidly developed to their maximum within one or more days. In those instances in which the indi- vidual attacked has been debilitated by a previous ailment, or is still suffering from some disease, the bronchitis may, within a short period, develop even suffocative symptoms. The temperature soon increases above the normal standard, but stops at 39° C. (102.2° F.), or even a lower point in the major- ity of cases. This temperature is only exceptionally exceeded, and then chiefly when further complications, especially on the part of the alveolar parenchyma, become superadded. The action of the heart, also, is moderately accelerated in the major- ity of cases ; but often the acceleration of pulse does not remain directly proportionate to the increase of temperature, but is then much more considerable than would be anticipated from the moderate increase of temperature. The pulse often shows a remarkably increased tension, at least in severe cases. In the form of disease under consideration, it may be taken for granted that this increased tension, which, as Traube long ago remarked, occurs in various affections of the respiratory apparatus with the onset of dyspnoea and cyanosis, has its cause only in the repeated and prolonged contraction, into which numerous small branches of the aortic system are thrown by the influence of the accumulated carbonic acid gas. At all events, in certain very BRONCHIAL CATARRH. 377 severe forms this explanation is amply sufficient, and probably the correct one. The sudden extensive diminution of the calibre of numerous air-tubes produces considerable oppression and anxiety. The patient is often unable to gratify his desire for air, despite the assistance of the auxiliary muscles of inspiration ; he changes his position frequently, and even assumes the sitting posture, because he can in this manner most readily satisfy his desire for air. In spite of all this the dyspnoea continues, even though only moderate in degree in most instances; at times, however, it may become considerably increased by severe paroxysms of cough. Despite these severe paroxysms, the expectoration is but slight at first; in some instances there is no expectoration at all, especially during the first days. It is only after some time that the expectoration becomes more copious, and then it shows the characters already described. Auscultation at this time reveals the most various rales, extending over the entire thorax ; the respiratory murmur now failing altogether at cer- tain points, and again being audible after the expulsion of sputa has freed some of the bronchi, while at still other points it is again indistinct or feeble. At the same time the fever remains at about the same height, with but slight morning remissions and evening exacerbations. This condition is maintained for a variable period, usually for a series of days, at the same height, and then gradually improves. The expectoration then becomes more copious, and is more readily detached ; it loosens, so to speak, it becomes richer in cells and more puriform ; the fever diminishes; the cyanotic manifestations usually subside, as more numerous bronchial twigs become pervious again ; the severe paroxysms of cough become less and less frequent; the breathing becomes steadily easier ; the appetite, which up to this time has usually remained in abeyance, returns again ; and in this manner the patient gradu- ally passes into convalescence. In other cases, especialby in aged subjects, and in persons already laboring under chronic catarrh or emphysema, or al- ready weakened by some former disease or by one that still continues, all the symptoms mentioned undergo progressive 378 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. increase. Evidences of adynamia soon become apparent, the cyanosis gradually becomes more severe, and the expectoration becomes more and more difficult; and often even the sensorium becomes implicated, delirium and comatose symptoms manifest- ing themselves ; the cyanosis steadily becomes more intense; the pulse becomes steadily smaller, and at the same time un- usually frequent and often even irregular; the extremities begin to grow cool to the touch; the rales become louder and louder, and even audible at a distance, as more and more mucus becomes accumulated in the larger bronchi; and finally death ensues under manifestations of sopor or asphyxia. In very rare cases eclamptic symptoms are observed shortly before death. From this severe course, which is indeed but rarely observed, there are numerous variations. The greater number of cases progress under much milder manifestations ; so that the febrile movements, cyanosis, severe paroxysms of cough, and the like, figure more as important features in the entire picture of symp- toms, than as alarming evidences of the dangerous character of the disease. After the earlier and somewhat stormy manifesta- tions have continued for a few days, they gradually subside, to disappear in complete recovery, or to leave behind for a certain length of time a few residual manifestations, or to pass into the chronic form of the affection. The second form, capillary bronchitis proper, as is well known, is one of the most alarming diseases of infancy. It does not often begin suddenly with full severity in the midst of per- fect health. Much more frequently, the disease appears in con- nection with measles, scarlatina, whooping-cough, and other dis- eases ; or it appears as an ordinary catarrh (usually with coryza), which for a time is limited to the larger bronchi, and then sud- denly or gradually becomes transmitted to the smaller and the minutest bronchi. It is also observed as a result of cardiac in- sufficiency, emphysema, anomalies of thoracic configuration, and the like. Capillary bronchitis, as is well known, is a much more alarming disease in children and nurslings than in adults. This is due in great part to purely physical conditions, viz., the nor- BRONCHIAL CATARRH. 379 mally greater narrowness of the smaller bronchi, which readily become completely impervious under a moderate amount of swelling and accumulation of mucus. The commencement of the disease, as above mentioned, is frequently but little marked. Capillary bronchitis is almost always associated with fever from the beginning. Where fever has already existed, it becomes increased with the extension of the catarrhal inflammation to the smaller bronchi. The dysp- nea, also, soon increases to a marked degree; the breathing is unusually accelerated and laborious ; the number of respirations reaches sixty and more in the minute ; the respiration is often but little effectual, despite the assistance of numerous auxiliary muscles, and it is subject to short intermissions. Evidences of disturbance in the circulation soon become added ; the patient acquires a bluish, dull aspect, while the arterial pressure gradu- ally sinks more and more; the pulse, at first full, becomes cor- respondingly small and much accelerated, and often but barely perceptible. The urine becomes scanty, and for this reason as well as owing to the diminished absorption of oxygen, uric acid is copiously secreted (Gerhardt). The cough is at the same time severe and frequently repeated. Notwithstanding the severe paroxysms of cough, there is but little or no expectoration in most instances. In children it is swallowed for the most part. Where expectoration exists, it presents at first crude, tenacious, vitreous masses of mucus; and at a later period, sputa of a rather grayish-yellow color are discharged. Sweating is frequently observed. Physical exploration furnishes important results only as far as regards auscultation. The respiratory murmur may fail entirely in places, and is masked particularly by the different kinds of fine bubbling rales mentioned in a former part of this article It is sometimes possible to recognize, by percussion, dilatation of the right side of the heart, which has ensued as a result of extensive venous obstruction. In many cases, especially in children, the symptoms of respi- ratory insufficiency increase in a short time to a very great degree; the dyspnoea steadily increases, and soon symptoms of asphyxia set in, under which the patient finally expires. 380 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. Death occurs, in most instances, with the well-known symptoms of carbonic acid poisoning. One symptom more deserves particular mention here, a symptom which may by its gradual increase or decrease, fur- nish a diagnostic indication, and that is the condition of the hypochondrium and the epigastrium. As is well known, these parts in the normal condition are always distended on inspira- tion, and undergo retraction again with expiration ; of course in different intensity, according to age and sex. So long as a suffi- cient quantity of air can penetrate this most distant and lower- most portion of the thorax, these parts must undergo an inspira- tory distention. But it is otherwise when a sufficient quantity of air cannot gain entrance. Then the rarefaction of the air with each inspiration can no longer compensate for this increased re- sistance to the entrance of the air, and this section of the thorax, as the furthest removed from the fixed point, must undergo an inspiratory retraction, which must extend the further upwards the more considerable the impediment to respiration. For this reason we see in every form of laryngeal and tracheal stenosis a varying degree of retraction of tliese parts ensue, sometimes greater and sometimes slighter, according to the degree of con- striction. The condition is somewhat different in capillary bron- chitis, as a matter of course. But if numerous bronchi of the lowermost sections have become impervious in consequence of swelling and accumulation of secretion, so that air can no longer penetrate into the alveoli to which they lead, then a retraction of these lowest sections of the thorax must follow also. If, therefore, in capillary bronchitis, the epigastrium and hypo- chondrium still undergo distention in the normal manner, we are justified in the conclusion that breathing still takes place in a manner relatively adequate for the purposes of respiration. In proportion, however, as these parts and larger or smaller por- tions of the thorax undergo inspiratory retraction, we are justi- fied in concluding that larger or smaller bronchial districts have become impervious. Seitz mentions still another important symptom of incom- plete breathing that occasionally occurs, but which has as yet hardly attracted the attention it merits, and that is the bulging BRONCHIAL CATARRH. 381 forwards of the supraclavicular and, infraclavicular regions, and the indistinctness of the respiratory movements in these sections of the thorax. Seitz correctly designates this pulmon- ary enlargement as distention of the lungs. Its origin is to be recognized in a distention of the pulmonary vesicles in conse- quence of the impeded egress of the air which has penetrated into them. I have already referred on a previous occasion1 to this pulmonary distention in general, as occurring in the differ- ent forms of bronchitis. Donders especially, in his beautiful work3 on the movements of the lungs and the heart in respira- tion, first appreciated these relations properly, though only in a general manner. In the act of inspiration the resulting increase in volume calls for a corresponding increase in the quantity of air supplied to the lung, and those pulmonary vesicles will be the first to undergo distention, which require the least tension for this purpose. This tension, however, as shown by Donders, may become so great as to lead to emphysematous dilatation of these parts. If the capillary bronchitis tends to a fatal termination, this takes place, as a rule, within the first fourteen days. If it follows at a later period, it is usually due to some complication, especially the so-called catarrhal pneumonia. The younger and more delicate the child, the greater the danger, as a matter of course, and the more readil}r the disease under consideration may become fatal. But it is in just this class of cases that the magnitude of the danger is often first recognized only when the child has already begun to show signs of asphyxia. Vigorous efforts to cough, which might still remove the mucus, are not made by children. The narrowness of the mi- nuter bronchial ramifications renders it intelligible how they may rapidly become occluded, and then even all auscultatory signs may fail. The advanced cj^anosis, mingled with the pallor of the skin, the sopor and delirium, the small, thready pulse, and sim- ilar indications often furnish the first evidence of the severity of the affection, which then in most instances leads to a fatal termi- nation within a short time. 1 Riegel, Die Athembewegungen. Wiirzburg, 1878. 2 Zeitschrift f. rationelle Medicin, Neue Folge, Bd. III., p. 39. 382 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. The older and stronger the child, and the better able he is to remove by vigorous coughing a portion of the accumulated secretion, the better the prospect of recovery. If the disease tends towards improvement, as will naturally be the case in those instances in which the impermeability of the bronchi (owing to the presence of mucus and the swelling of the mucous membrane) has not involved too large an extent of the lung, and in which the power of the heart has not already been too much enfeebled, then the dyspnoea gradually diminishes, and the fever gradually subsides. Powerful efforts of coughing are made to remove a portion of the secretion ; the cyanosis dis- appears as the air-passages become more pervious; the pulse becomes fuller again and stronger, and the pallid, livid aspect fades away. The respiration becomes freer; the rales, which have acquired the moist character, gradually become fewer and fewer, and thus the patient finally enters the stage of convales- cence. Still, however,—and it is by no means a rare occurrence —a sudden fresh exacerbation of the symptoms may be ob- served, a relapse, to which, then, lobular catarrhal pneumonia is frequently superadded; and even though this complication may terminate favorably, it puts off the patient's ultimate recov- ery to a distant period. It is apparent then that the course of the disease may often be protracted, and even in its later periods sudden exacerbations and complications may not infrequently lead to a fatal termination. The diagnosis of capillary bronchitis presents no particular difficulty in the majority of cases. It is readily made out from the greater or less degree of dyspnoea, associated with febrile movements, the frequent cough, without expectoration for the most part, the characteristic fine-bubbling rales, the absence of changes on percussion—the latter of special importance in ena- bling us to distinguish between this affection and lobular consoli- dation, though it cannot positively be relied upon, inasmuch as small broncho-pneumonic foci often cannot be demonstrated with certainty—the notable acceleration of the pulse, the cyano- sis, associated in most instances with pallor of the skin, and finally the soporific manifestations and the like, in the later stages. The diagnosis presents difficulties, at the commencement BRONCHIAL CATARRH. 383 of the affection, only in very small, weakly children, in whom the cough is but slight, and by whom powerful efforts to get up the sputa are not made, so that the rales fail completely in a short time in consequence of the obstruction of the bronchi, and thus soporific manifestations soon become evident. The careful consideration of the above-mentioned circumstances would soon lead to a proper diagnosis even in such cases. Finally, it is of importance to recognize at once the advent of a catarrhal pneumonia. Concerning the diagnosis of this condi- tion, we must refer the reader to the chapter on catarrhal pneu- monia. III. Chronic Forms of Bronchitis. Chronic bronchial catarrh appears either in a genuine, idio- pathic form, or as a secondary affection in other chronic diseases of the lungs and in other affections, and especially often as a result of mechanical disturbance of the circulation. In the latter instance, it is easy to understand how mechanical disturbance of the pulmonary circulation exerts a retrograde action upon the bronchial vessels also. As is well known, the circulatory apparatus of the respiratory organs is a special one. Not only the pulmonary arteries, but the bronchial arteries also, have a share in the capillary circulation of the lungs, and therefore, likewise, in disturbance of the nutrition of the tissues. The bronchial arteries course more interstitially, be- tween the lobules, to ramify finally in the pleura, while the pulmonary arteries form the chief mass of the alveolar capillaries. Thus, therefore, peribronchial inflamma- tions and parenchymatous pulmonary inflammations interest mainly the territory of the bronchial arteries; while, on the other hand, the superficial inflammations of the lungs interest the domain of the pulmonary arteries. This explains the participation of the pleura and bronchi in diseases originating in the parenchyma of the lungs, as well as the possibility of extension of diseases of the bronchial tract and pleura into the pulmonary parenchyma; and it explains, too, on the other hand, the cause of the regularity in the mode of manifestation of both classes of disease (Buhl). Thus, for example, we see an especial disposition to chronic inflammation of the bronchial mucous membrane in pulmonary emphysema, as well as in nearly all the affections of the pulmo- nary parenchyma, and in insufficiency of the mitral valve and similar affections. In the second place, dyscrasise are to be 384 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. mentioned, as a result of which secondary bronchial affections are not infrequently observed. In like manner, severe constitu- tional diseases, especially infective diseases, loss of blood, and the like, occasion an increased disposition to catarrhal inflamma- tory affections of the bronchial mucous membrane. Chronic bronchitis is frequently developed from the acute disease; but it may creep on so stealthily from the commence- ment that an acute period cannot be ascribed to it. Concerning the special originating causes of chronic bronchitis, we refer the reader to what has already been said at the beginning of this chapter on the etiology of catarrh in general. Chronic catarrh limited to the trachea alone is one of the most exceptional forms ; larger or smaller portions of the bron- chial system being affected at the same time, as a rule. But whether the tracheal mucous membrane is affected alone, or in association with a portion of the bronchial mucous membrane, hardly any marked impediment to respiration is produced, at least in adults, even in cases in which there is considerable swelling of the tracheal mucous membrane. Symptoms of stenosis can be occasioned only where there is oedema and inflammation of the submucous connective tissue, where there is perichondritis, or where, as occurs especially in consequence of syphilis, a constricting, callous, or cicatricial formation has become developed from hypertrophy and induration, or from ulceration of this tissue. Concerning the manifestations of this condition, we refer the reader to the chapter on tracheal stenosis. Cystiform degenerations of the mucous glands are sometimes observed in the trachea in chronic inflammations, and these may readily be mistaken for adherent mucus, on superficial laryngo- scopic examination; but their constant appearance at the same points, on repeated examinations, suffices to correct the mistake. As is self-evident, the symptomatic features of the disease would be as little altered by tliese degenerations as by slight erosions, epithelial exfoliations, hemorrhages, and the like, for which reason we will not present any special description of these affections of mere pathologico-anatomical interest. As already mentioned, the exact determination of delicate BRONCHIAL CATARRH. 385 alterations of the tracheal mucous membrane is better accom- plished by tracheoscopy than by auscultation and other methods of exploration ; while by auscultation alone we are able to detect the implication of certain portions of the bronchi, and the limits to which the disease has extended. The symptoms of chronic bronchitis coincide, in all essential points, with those of the acute form. As in acute catarrh, so here, also, numerous variations occur, which are in part due to the seat and extent of the disease, but more so to the nature and quantity of the secretion. The course of these forms varies in a measure according as the affection is of a genuine inflammatory nature, or secondary to some other disease, such as the various chronic affections of the lung, valvular insufficiency, and the like. We shall describe merely the more essential forms, inas- much as the symptomatic picture, upon which exclusively the diagnosis rests, is the same for both varieties, and the modifica- tions in the course of the latter are practically occasioned by the fundamental affection only. Chronic bronchial catarrh, which is one of the most widely distributed affections among the working classes, may have its seat in the larger medium-sized, or smallest bronchial tubes. It is as a rule uniformly extended over both lungs, and especially over the lower and middle portions of the lungs, and principally in their larger and medium-sized bronchial tubes. It occurs in middle and advanced life more especially, and is observed in men much more frequently than in women. The most prominent symptoms are cough and expectoration. The differences in the expectoration afford the chief basis upon which a series of varieties of the disease may be estab- lished. Thus there are cases in which there is hardly any expec- toration ; others in which moderate quantities of sputa are dis- charged ; others, again, in which considerable quantities of puri- form sputa are expectorated. Not only do the auscultatory manifestations depend upon the consistence and quantity of the secretions, but also, in part, upon the frequency and severity of the paroxysms of cough, the manifestations of dyspncea, and even the general condition of health. The expectoration may be almost pure mucus, or more puru- vol. rv.-2.5 386 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. lent or more vitreous in consistence ; it may be serous, it may be fetid, and so on. The amount and severity of the cough change in like manner. In many cases there is no characteristic dysp- noea at all; in others, especially in the more dry forms of catarrh, it is often considerable, and increases at times, even to severe suffocative or asthmatic paroxysms. The course of these chronic bronchial catarrhs is most fre- quently as follows: Coming on either stealthily, as it were, without having been preceded by any special acute period, or else developed from an acute catarrh, the chronic bronchitis of adults occasions no special disturbances for a long time, even perhaps for years. It is only in the morning after waking that the patient experiences a more or less decided disposition to cough, attended with a slight sensation of constriction and op- pression in the chest. He then coughs for a length of time, until the breathing has again become freed by the expectoration of a larger or smaller quantity of bronchial secretion. Occasionally, and then only in cases of very mild character, and at the commencement of the disease, there is an entire absence of cough or further disturbance of any kind during the remainder of the day. In most cases, especially after a somewhat longer duration of the affection, a very slight degree of dyspnoea continues during the remainder of the day also. Any decided muscular effort will be pretty sure to excite dysp- noea at once. The cough is also repeated from time to time during the day, although to a moderate degree only; and expec- toration is always followed by relief. In the more severe and farther advanced forms, on the con- trary, the disposition to cough and a moderate degree of dyspncea persist almost continuously; so that the patient is annoyed day and night. Palpitations of the heart, and especially pains in the epigastrium, in consequence of enlargement of the liver, due to the disturbance of the circulation, are frequent causes of com- plaint in the severer and protracted forms of this catarrh. At a relatively early period most patients with chronic catarrh complain of shortness of breath, which becomes espe- cially troublesome on rapid walking, going up stairs, and so on. In the early stages the patient still feels tolerably comfortable BRONCHIAL CATARRH. 387 during the summer; and periods of complete health occur, especially if the patient is in a condition to take proper care of himself. The working classes, therefore, suffer much more, in consequence of such chronic catarrhs, than people of the better classes. In winter the catarrh undergoes exacerbation again ; palpita- tion of the heart becomes gradually superadded; the face, lips, nails, knee-pans, and other peripheric portions of the body gradu- ally become more and more cyanotic ; the cervical veins become swollen, and show undulating and even pulsating movements. At a later stage the feet swell, so that the patient cannot leave his apartment; and still later, when the dropsy gradually spreads lower down, and ascites occurs, he cannot even leave his bed. The urine gradually furnishes more or less decided evi- dences of the presence of albumen. Finally, a fatal termina- tion ensues under increase of the dropsy and dyspnoea. With reference to the results of physical examination, they hardly differ in any essential points from those mentioned in connection with acute catarrh, with the exception of a few con- secutive alterations. Percussion, of course, not unfrequently shows deviations from the normal resonance; but these are not so much due to the chronic catarrh, as such, as to a very com- mon resulting affection, emphnsema. Chronic bronchial ca- tarrh, as such, never exhibits any deviations from the normal results of percussion. Auscultation reveals sometimes rough and harsh respiratory murmurs, sometimes weakened murmurs, and sometimes the murmurs are indistinct or fail altogether at certain localities. All these conditions may change, even within a very short space of time; and they are in no wise characteristic. The different sorts of rales, sometimes moist and sometimes dry, are of much greater importance. Their favorite seats in chronic catarrh are in the posterior and inferior portions of the lungs. Coarse and medium-sized bubbling rales are heard most frequently, and, to a certain extent, fine moist rales also. Sometimes these rales, as well as the characteristic respi- ratory murmur likewise, disappear temporarily over a larger or smaller portion of the lungs, especially when the principal com- 388 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. municating bronchus is temporarily filled with secretion and occluded. Under these circumstances a forcible respiration, or a couple of powerful efforts of cough will often suffice to remove the obstructing secretion, and thus render the previous ausculta- tory manifestations again audible. In other cases only dry, whistling, and sonorous rales are heard, occasioned by severe swelling of the mucous membrane, and the presence of tena- cious, scanty secretion. Simple, chronic, bronchial catarrh is therefore distinguished from the tuberculous processes by its seat, and also by the man- ner of its extension. In its further increase it always appears to extend from below upwards; and it is especially the posterior inferior portions in which numerous rales can be discerned, while the anterior superior portions, especially the apices of the lungs, still maintain their normal conditions. In this manner the disease progresses for years with frequent remissions, and even short intermissions. Even all the symp- toms of disease may completely recede temporarily, as in sum- mer, so that the patient considers himself cured. With the return of the unfavorable season, however, the catarrh begins anew, or undergoes exacerbation; and then it continues per- manently, even in a more severe degree. With bronchial ca- tarrh, however, in contradistinction to the tuberculous process, the general nutrition hardly ever suffers in an appreciable man- ner, even when the disease continues for years. The nutrition begins to suffer only upon the onset of severe cyanotic manifes- tations, dropsy, enlargement of the liver, and the like. Of the remaining attendant manifestations, fever is still to be mentioned; and this, though by no means of regular occurrence, is sometimes observed, temporarily, in the course of chronic catarrh. Febrile movements, of course, do not belong to characteristic, chronic, bronchial catarrh as a rule. Not infrequently, however, acute exacerbations are observed in its course, which are sometimes associated with moderate febrile movements. Of the remaining symptoms, especial mention must be made of the frequent occurrence of moderate painfulness in the right hypochondrium and in the epigastric region. Pressure in this BRONCHIAL CATARRH. 389 region also becomes painful in catarrhs of long continuance. This epigastric pain, which is a not infrequent cause of com- plaint, is connected with enlargement of the liver due to venous hypera3mia. Slight manifestations of dyspepsia, of chronic gas- tric and intestinal catarrh, are also sometimes observed in the later stages, as a result of the disturbed relations of the circula- tion. The appetite is often poor at this time, and the bowels are inactive. Occasionally diarrhoea is observed. The moderate albuminuria which often occurs in the later course of the disease is also to be regarded as associated with these disturbances of circulation. Other pains—severe thoracic pains especially—do not belong to the characteristic symptoms of ordinary chronic bronchitis. Sometimes there is pain in the chest in the region of the respira- tory muscles, especially those of expiration, in consequence of the severe straining in coughing. If pleurodynia exists, there is reason to suspect some complication. With regard to the further course of chronic bronchitis, its termination in complete recovery is observed only in very mild forms, and in cases of relatively short duration. Termination in complete recovery must be regarded as the exception, and not as the rule. On the other hand, the temporary intermissions not infre- quently observed in the course of chronic catarrh during favor- able seasons of the year must not be regarded as actual recov- eries ; for, under the influence of some slight injury, a slight cold, a wetting, or even without the influence of any special cause, merely with the approach of the inclement seasons of the year, all the symptoms promptly recur. There remains, there- fore, even in very favorable cases, an unusual predisposition to such catarrhal affections. The prospects of recovery are, as a matter of course, rela- tively more favorable in strong, youthful subjects than in weak individuals and those in the decline of life. The severest forms of chronic bronchitis rarely terminate in recovery, but frequently enough lead, finally, to a fatal termina- tion through a series of secondary affections ; although, for the most part, not until after very long duration. It is especially 390 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. through the disturbances of the circulation, which the bronohitis occasions—the hypertrophy of the heart with fatty degeneration at a later period, the dropsy, the albuminuria, and the like- that life is endangered. Like emphysema, so, also, diffuse chronic catarrh of the air- passages becomes associated, as a rule, after long continuance, with hypertrophy and dilatation of the right ventricle of the heart. Concerning the manner in which this hypertrophy and dilatation take place, there is as yet no uniformity of opinion. The cause assigned by Traube, however, that the absence of any very marked alteration of volume of the lungs in inspiration and expiration, as must necessarily be the case where the bronchi are obstructed, gives rise to unusual resistance to the pulmonary circulation, is likewise of impor- tant significance in the production of the latter condition. If, in the course of chronic affections of the bronchial mucous membrane, there occurs a continuous and constantly increasing cyanosis, then it may be concluded with great plausibility that there is molecular alteration, in fact fatty degeneration of the muscle of the heart, especially of the right ventricle (Traube). The latter circumstance is due to insufficient oxygenation. The supply of oxygen to the walls of the right ventricle is impaired in a double manner: first, by the distention which the walls suffer with the increasing dilatation, which must diminish the calibre of the capillary blood-vessels in the walls, and thus the number of colored blood-corpuscles which pass over any one portion of the muscular fibres in a given space of time; and second, by the impoverished condition of the blood in oxygen, resulting from the impediment to respiration (Traube). We have already spoken of the altered respiratory rhythm and the dyspnoea which constantly attend chronic catarrhs. We have here but to mention the hypertrophy of various muscles, especially the sterno-cleido-mastoids, the scaleni, and others, which not infrequently results from the severe exertion of the respiratory muscles. The scaleni often become prominent as thick cords, alongside of which the much dilated and not infre- quently undulating jugular veins course as thick bluish cords. These hypertrophied muscles are usually in a condition of mode- rate contraction and tension. The neck appears short and thick, BRONCHIAL CATARRH. 391 a condition which, in its higher grade, as is well known, is best observed in emphysema. Having described the most important features and symptoms of chronic catarrh, it remains to pay special attention to some of its varieties. There is a great series of variations dependent upon the nature, quantity, and other peculiarities of the sputa ; and with these changing conditions of the sputa there is a change in the clinical picture, as could hardly be otherwise expected from what has been said above. Under the designation " dry catarrh,'1'' Laennec was the first to describe a form of bronchitis, which is distinguished symp- tomatically by severe paroxysms of cough and but a trifling amount of expectoration, despite exhausting and painful cough. Its seat is chiefly in the minuter bronchi, the mucous membrane of which is very hypersemic, and swollen to a very great degree. The secretion is scanty, tenacious, sometimes translucent, but mostly grayish and turbid. The more extended this hyperseniia, the more considerable is the dyspnoea, and the severer the par- oxysms of cough and the asthmatic troubles. This form is gen- erally associated with the greatest distress, which is proportion- ate to the severity and extent of the affection. This form, after long continuance, is frequently, if not al- ways, combined with emphysema. It is not a difficult matter to comprehend the relations which associate emphysema with this chronic catarrh of the minuter bronchi. The most important symptom is the unusually severe and straining cough, which often exhibits even a spasmodic charac- ter. Expiration especially is most markedly impeded. The paroxysms of cough are often so severe and associated with so much straining as to occasion vomiting. During tliese parox- ysms of cough, the countenance often exhibits a dark bluish- red cyanotic color ; the jugular veins swell into thick, bluish cords; but, despite the severe paroxysms of coughing, it is only after prolonged and painful efforts that a little viscid mucus can be expelled, owing to its tenacity and its deep seat in the minuter bronchi. The laborious respiration is especially pronounced in children with dry bronchitis. The respirations are often as frequent as 392 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. from forty to eighty in the minute; and there is great anxiety and restlessness with it, as in croup; so that the children will not remain in bed. Expiration is chiefly affected, and is accom- plished in jerks, or is more prolonged than natural. Asthmatic paroxysms often occur. All the respiratory muscles are in strained activity. There are frequent paroxysms of cough, sim- ilar to those of whooping-cough, and there mayr be either no expectoration at all, or only a very little. Auscultation reveals no mucous rales, but only harsh respiration, and dry rhonchi. There may be but slight fever, or none at all. Symptoms of hypersemic stasis of the brain may occur in cases of long con- tinuance. The disease usually terminates fatally in children, after a chronic course of at least several months. The physical symptoms of this form of catarrh are often associated with those of emphysema, inasmuch as it becomes complicated with the latter condition after long continuance. Sibilant, whistling, dry rhonchi, with sometimes harsh, and sometimes diminished respiratory murmur ; forced respiration with preponderating, prolonged expiration, extending beyond the normal limits of the lung in cases of marked dilatation of the vesicles ; sonorous resonance on percussion, which, especially in the lower, posterior, and lateral portions of the lung, in cases of vesicular dilatation consequent upon excessive disten- tion of the alveolar tissue, often exhibits that modification des- ignated by Biermerl "bandbox-tone" (Schachtelton); excessive development of the expiratory muscles, even barrel-shaped dis- tention of the thorax under some circumstances ;—these are the most important symptoms observed in severe cases complicated with emphysema. This dry catarrh is a very obstinate affection, and may persist for many years, although there may be remissions. Almost every variety of catarrh undergoes certain changes in the course of time, and so in this form the character and the amount of the secretion are apt to change. Thus for a longer or shorter period there will be produced an abundant secretion richer in cells, or more serous, in the place of the scanty, tenacious sputa usually 1 Ueber Bronchialasthma. Sammlung klinischer Vortrage, herausgegeben von R. Volkmann, 1870. (See also Vol. V. of this Cyclopaedia, p. 387.) BROHCIIIAL CATARRH. 393 secreted. As already mentioned, this form, when of long dura- tion, becomes readily combined with pulmonary dilatation and emphysema. When, on the other hand, the occlusion of the minuter bronchi is complete, atelectasis and collapse of the alveoli ensue. It is advisable, in the second place, to distinguish a so-called mild form of chronic bronchitis with moderate mucous expec- toration, in which the symptoms are much milder in character than those of the first-mentioned form. This form is observed at every period of life, but most frequently in middle and advanced age. It is an especially frequent disease of the work- ing classes in middle life, and it is chiefly those employments previously mentioned as attended with the development of dust which frequently occasion it. It is also observed in childhood, especially in scrofulous, rachitic, and poorly nourished children ; and it readily occurs in the wake of acute infantile diseases, especially measles and whooping-cough. Manifold variations are observed according to its etiology, the age of the patient, his constitutional vigor, and so on. Its course is, in general, by no means violent. Such patients cough in spring, winter, and autumn, especially, while they have little or no cough in summer. They cough up moderate quantities of mucous sputa, and expectoration is generally easy. Apart from the cough, such patients are tolerably well; their general health does not suffer, at least for a long time. Febrile move- ments do not occur, or are only observed when some acute exacerbation becomes suddenly manifested. Physical exploration reveals no alteration of the normal type of respiration, and no alteration of the percussion pitch; only at times are more or less numerous rhonchi heard in the coarser and medium-sized bronchi. This form of the affection may retrograde in its course, but more frequently it continues for years; and it may gradually extend to larger sections of the bronchial tract, and readily become combined with diseases of the pulmonary parenchyma. Besides the forms of bronchial catarrh already mentioned, there are others, which, in contradistinction to those described, are distinguished by an excessive amount of expectoration. 394 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. In view of the special differences in the expectorated masses, two further forms may be distinguished, namely, the characteristic broncho-blennorrhcea and the serous bronchorrhcea (the pitui- tous catarrh of Laennec). First, as regards the characteristic broncho-blennorrhcea. It is characterized by the discharge of copious quantities of puri- form mucus, and this discharge has been improperly designated as purulent flux of the bronchi. It usually occurs in a chronic form, but is sometimes encountered as a more acute affection. Broncho-blennorrhcea is observed in its most pronounced form in bronchiectasis. The symptoms, for a long time, are chiefly those of an ordi- nary chronic bronchial catarrh. After the prolonged duration of such a chronic catarrh, or after repeated acute catarrhs, the pronounced features of broncho-blennorrhcea become developed. The muco-purulent secretion gradually becomes more copious and purulent, the cough more frequent and severe, and then, from time to time, larger quantities of these purulent sputa are expectorated. The sputa thus expectorated may amount to a very considerable quantity. The patient suffers most from' shortness of breath, which from time to time reaches an aggra- vated degree. After successive expectorations there is usually more comfort, and the dyspnoea diminishes. The patient soon becomes emaciated. There is usually impaired appetite and disturbed sleep. Febrile movements frequently occur. The emaciation is explained by the great loss of fluids occasioned by the copious expectoration; and it has long been known as a fact that pus stagnating in the bronchi may give rise to fever. The stronger the affected individual is originally, the more readily and the longer can he sustain this great loss of fluids; but eventually he nevertheless becomes emaciated, a more or less severe degree of ansemia and cachexia becomes developed, and finally, even a fatal termination may ensue, often after the development of dropsical manifestations. In rare cases the broncho-blennorrhoea may be cured, all the symptoms under- going gradual amelioration, and giving place to a simple chronic catarrh. The second form of bronchorrhcea, which we have designated BRONCHIAL CATARRH. 39j as serous bronchorrhcea, has already been described by Laennec under the name of "pituitous catarrh.'''' The characteristic of this form of chronic bronchial catarrh is the copious serous secretion, poor in cells, which is expectorated under severe par- oxysms of cough. The expectorated matter consists of a toler- ably colorless, thready fluid, containing but few cells, which, when observed in the spittoon, bears a good deal of froth on the surface, and has but a few flakes of mucus mixed with it. The expectoration of these masses, which often amount to a consid- erable quantity, is usually accompanied with very severe and straining efforts of cough ; and at the same time there is a good deal of dyspncea, which is somewhat relieved after the discharge of the masses. On account of the very marked want of breath and the asthmatic difficulties, this form has been described as a special form of asthma,—humid asthma. Pituitous catarrh occurs, as a rule, as a chronic affection, which becomes gradually developed like the other forms of catarrh already mentioned. Severe attacks of dyspnoea and paroxysms of cough are observed, as in characteristic broncho- blennorrhcea. They recur at irregular intervals, most frequently during the morning. The paroxysm of cough and the dyspnoea moderate or cease entirely after the expectoration of sputa in large quantity ; but in most instances the patient is at least not entirely free from all dyspnoea during the intervals. Physical examination reveals nothing beyond the results already mentioned. Numerous rales are heard, chiefly the moist, coarse, and fine bubbling ones. Febrile symptoms are not ob- served, as a rule, in this form of chronic bronchial catarrh. As already mentioned, the quantity of the expectorated secretion is in many cases very great; it may amount to several pounds daily. Despite this, the resulting emaciation is often but slight, even after long continuance of the trouble. Laennec narrates the case of a patient seventy years of age—also cited by Biermer—who for ten or twelve years expectorated about four pounds of such sero-mucous sputa daily, and yet continued to be tolerably well. Only after a long time does emaciation occur, and then usually it is not very considerable. Complete recovery is rarely 396 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. observed. The fatal termination is usually occasioned by super- added complications. As the last variety, we have to mention, finally, fetid or putrid bronchitis, which sometimes occurs as a chronic affection and sometimes as an acute one. Fetid expectoration is observed most frequently in gangrene of the lungs, in saccular bron- chiectasis, and in perforating ichorous empyema of the lungs. There are also fetid sputa in cases in which none of tliese condi- tions exist. Even in diffuse bronchial dilatation, the secretion from the bronchial mucous membrane may undergo fetid decom- position under certain circumstances; and even without this condition the bronchial secretion may in certain cases acquire the character mentioned. In what follows we are concerned only with tliese latter forms. As especially stated by Lebert, the knowledge of fetid bron- chitis is not confined to recent times, as is generally supposed; indications concerning it are to be found in older literature. Observations of the kind are to be found recorded by Laennec,' Andral,2 and Briquet.3 Lay cock,* in 1857, reported several cases of putrid bronchitis. Our knowledge of fetid bronchitis, how- ever, has been most enlarged by Traube,5 who first showed with special distinctness that the expectoration of putrid masses is by no means alwayrs associated with the existence of bronchiectasis, gangrene of the lung, and the like, and that it may also be observed in simple bronchitis. Lebert, also, who has devoted a special description to putrid bronchitis, in his recent manual of diseases of the chest, relates that he has observed fetid bronchitis under very different condi- ditions, sometimes as a primary affection, sometimes as a secon- dary one, sometimes only as a temporary accident in bronchitis, bronchopneumonia, and diffuse pneumonia, and sometimes as an essential form of bronchitis, without any other differential 1 Traite de l'auscultation. Paris, 1819. 4. edit., 1887. 2 Clinique medicale. Paris, 1834, T. III., p. 2, 131. 3 Archives gener. de med., III. Scrie, T. XI. Paris, 1841. 4 Med. Times and Gazette, May, 1857. 5 Deustche Klinik, 1853, p. 409; 1861, No. 50; and Gesammelte Abhandlungen, II. Bd., 556 and 684. BRONCniAL CATARRn. 397 character than the foul odor of the sputa. On the whole, the fetid condition of the secretion is but occasionally observed in the idiopathic; variety of bronchitis. Concerning the etiology of this form, it is worthy of mention that the disease comes under observation in the summer months chiefly. It is frequently observed as a secondary complication of pulmonary affections, especially tuberculosis, chronic pneu- monia, bronchiectasis, and the like. On the other hand, pulmonary gangrene proceeds not infrequently from putrid bronchitis, from erosion and mortification of the bronchial walls and the surround- ing pulmonary parenchyma. Sometimes the pulmonary gangrene leaves behind it secreting cavities, communicating with the bronchi, in which the secretions stagnate or undergo putrefaction ; in other words, the gangrene of the lungs, after becoming healed, leaves behind a sort of chronic putrid bronchitis (Leyden). The final grounds why putrefaction of the bronchial secretions should take place within the bronchi in the variety of the affection under consideration, is not satis- factorily explained by the deserving labors of Leyden and Jaffe,1 nor by the hypothesis of the influence exerted by animal or vegetable organisms in the manner indicated by Pasteur. Neither can the dilatation of the bronchi and the stagnation of the secretion be regarded as the sole inciting causes. Concerning the expectoration, its great similarity to that of pulmonary gangrene is to be especially noticed. We believe it best to describe it here in Traube's own language :2 " The foul smell of the sputa, their great quantity, their turbid greenish- yellow color, their disposition, in consequence of the great fluidity of the menstruum, to separate after a time into three layers (an upper greenish-yellow, non-transparent, frothy layer; a middle transparent, albuminous layer of serous consistence; and a lower yellow, non-transparent layer, which having all the appearances of a pure purulent sediment, consists of swollen pus-corpuscles and their detritus), and finally, the presence in the sputa of soft, turbid, yellowish-white plugs, varying from the size of a millet-seed to that of a bean, with smooth surfaces and of exceedingly foul odor, in which microscopic examination reveals putrid animal substances and needles of sebacid acid, as first described by Virchow,—all these are manifestations which may occur in bronchial catarrh with dilatation of the bronchi, as well as in gangrene of the lungs. The presence of such sputa merely shows that a process of decompo- sition is taking place within the respiratory apparatus. The question is, however, whether this putrefactive process takes place in the interior of intact bronchi, or whether it is associated with destruction of the pulmonary parenchyma. Only where the latter condition can be determined with certainty can we come to the 1 Ueber putride Sputa nebst einigen Bemerkungen uber Lungenbrand und putride Bronchitis, Deutsches Archiv fiir klin. Medicin, Bd. II., p. 488. 2 Deutsche Klinik, 1853, p. 410. 398 RIEGEL—DISEASES OF TRACHEA AND BRONCHI. conclusion that there is a process of decomposition in the parenchyma of the lun«-s, analogous to putrefaction or identical with it; that is to say, that there is gangrene of the lung." Leyden1 speaks concerning this point, as follows: "The evidence of destruc- tion of the parenchyma of the lungs is afforded by the presence of parenchymatous detritus, that is, portions of the decomposing lung-tissue. They are, as described by Traube, enclosed in grayish-yellow masses, with shreddy borders, of a dirty aspect, consisting of an elastic, transparent, colorless ground substance, in which there are to be found a good deal of finely granular detritus, numerous yellow fat globules, here and there masses of free black pigment, and numerous large needles of sebacic acid. Elastic tissue is nowhere to be found (Deutsche Klinik, 1859, No. 46; and G-esammelte Abhandlungen, II., pp. 451 et seq.). The plugs of Dittrich also occur in the sputa of pulmonary gangrene, as well as in putrid bronchitis. These con- sist microscopically, according to Traube, of a detritus composed of extremely fine granules with larger fat globules. Not infrequently, as first described by Virchow, they contain needles of margaric acid." Traube2 distinguishes four stages of these plugs: 1, At the commencement of the affection they are white, still consist in great part of pus-corpuscles, with which the masses of detritus mentioned above are mingled; 2, At a more advanced stage the plugs show a dirty gray color, and numerous particles of a detritus strewn with larger fat globules are disseminated throughout a purulent mass; 3, In the third stage the clots have likewise a dirty gray color, and consist in greater part of the same sort of detritus as in the second stage; in addition, short, delicate needles, besides the fat-globules already mentioned, are distributed throughout it; 4, In the fourth stage the clots are still dirty gray, and the detritus contains large fat globules, and long thick needles, mostly united in bundles, which become vari- cose by pressure exerted upon the glass cover. This gradual internal development of the clots favors the hypothesis advanced by Traube, that special animal or vege- table organisms must be contained within them, which induce the process of putre- faction in the bronchi in the manner shown by Pasteur. Of especial importance as regards the origin and nature of the putrefactive processes under consideration, is the constant occurrence of certain fungi in the shreds of gangrenous lung-tissue, and in the putrid clumps, as principally authen- ticated by Leyden and Jaffe\ A recent observation of Rosenstein * is worth mentioning in this connection, and that is, that he has found the threads and also the lancet-like cells of Oidium albicans in the sputa of a patient with putrid bronchitis. Inasmuch as a patient with thrush lay near this patient, the influence of the fungus of the Oidium appeared to be the direct occasion of the putrescence. 1 Ueber Lungenbrand. Sammlung klinischer Vortrage, No. 26, p. 200. 2 Gesammelte Abhandlungen, II., p. 686, 3Deutsches Archiv f. klin. Med., 1866, Bd. II., pp. 488-519. 4 Berlin, klin. Wochenschrift, 1867, No. 1. BRONCHIAL CATARRH. 399 The chemical examination of the sputa, instituted by Jaffe, revealed volatile fatty acids, especially butyric and valerianic acids, ammonia (though not constantly), sometimes hydrosulphurous acid, leucine, tyrosine, and traces of glycerine. Thus the analogy between this process and the ordinary process of decomposition seems to be substantiated. In considering more closely the remaining clinical symptoms of fetid bronchitis, the fetid breath of the patient is to be men- tioned in the first place. The patient's breath often exhales a still more penetrating odor than the sputum already expecto- rated. Concerning the first appearance of the fetid condition of the sputa and the breath it is to be remarked that this meta- morphosis is stealthily and imperceptibly developed out of an ordinary bronchitis. It occurs more suddenly only in rare cases. Physical examination of the thoracic organs gives no other results than those corresponding to ordinary bronchitis; but this very circumstance furnishes an important differential point in contrast with pulmonary gangrene and other diseases. As a rule, there is always a reaction of the putrefactive pro- cess upon the general constitution. In most instances fever occurs within a short time, with considerable elevation of tem- perature and acceleration of pulse; and the strength may diminish to a considerable degree in a very short time. In mild cases the fever and other general symptoms subside, after a short time, with the improvement in the local process. It must not be forgotten, however, that in not a very small number of cases this putrefactive process may be sustained by the organism for some time without occasioning any very serious disturbances, as also happens in certain cases of undoubted gangrene of the lung which pursue their course without any febrile movements. A further danger of this putrid bronchitis resides in the pos- sibility of its extension upon the parenchyma of the lungs, in which case the entire picture of veritable pulmonary gangrene becomes developed. In other cases only the bronchial walls become irritated by the putrid secretion, and then inflamed, superficially excoriated, and necrosed. The putrefactive pro- ducts in the bronchi may even give rise to diphtheritic processes in the bronchial mucous membrane (Traube). Accordingly, with the exception of the expectoration, there are no further positive 400 RIEGEL.—-DISEASES OF TRACHEA AND BRONCHI. characteristic manifestations of fetid bronchitis. The micro- scopic examination of the sputa is specially important, as fur- nishing the results already described. Discrimination of this affection from empyema perforating the lung, is easier than discrimination between pure putrid bron- chitis and gangrene of the lung. The symptoms previous to the rupture, the sudden appearance of large masses of sputa, the quality of the expectoration, the sudden change in the physical symptoms, all protect against such a mistake. Discrimination of simple putrid bronchitis from bronchi- ectatic cavities is more difficult. The sputa furnish no indica- tions ; but the physical symptoms are a better guide; for in the former instance the signs are only bronchitic, while they are cavernous in the latter. As a matter of course, circumscribed dulness or cavernous symptoms are only found when consider- able bronchiectatic conditions are situated close to the thoracic walls. Another and more important sign for discriminating between them exists in the nature and manner of the expectoration. In bronchiectatic cavities, severe accesses of cough, repeated at shorter or longer intervals, by means of which considerable quan- tities of putrid sputa become ejected at once, are almost pathog- nomonic. These patients cough but little in the intervals as a rule, and sputa then expectorated are often of a simple catarrhal nature only. It is otherwise in fetid bronchitis, whether it is associated with diffuse bronchial dilatation or not. Here there are no severe paroxysms of cough, repeated at shorter or longer intervals and attended with the copious discharge of fetid sputa; but little sputum is discharged at a time, the individual spasms of cough follow at relatively short intervals, and the sputa thus discharged always show the same consistence as already described. In the mild forms recovery often takes place after a short period. Slight grades of fetid mucus are not infrequently observed as a temporary condition in various affections. Severe grades may terminate fatally in a very short time. In the genu- ine forms, when secondary gangrene of the lungs, or some other complication does not occur, the course is often protracted. BRONCHIAL CATARRH. 401 Concerning the ultimate cause of fetor of the bronchial secre- tion, we must again repeat, in conclusion, that it is not yet suf- ficiently explained, despite the valuable contributions of Traube, Leyden, Jaffe, and others. We can, therefore, only coincide with Lebert, when he says that from a clinical standpoint fetid bron- chitis can only be classified as a characteristic variety of pul- monary catarrh, and that the putrid decomposition of mucus resembles more a general pathological occurrence than a special form of disease. "Its fundamental character is fetid mucus, which may occur under manifold conditions, and the products of which we know tolerably well chemically and microscopically, but concerning the ultimate cause and special occasion of which we know tolerably little." Complications and Sequelae. We have already alluded to the most important consecutive diseases and complications in describing the individual forms, so that their special elucidation appears unnecessary. We, therefore, recall attention only to the frequent complication of the different forms of bronchitis with analogous diseases of the throat, and especially of the larynx and trachea ; further to the hypertrophy and dilatation of the right heart, developed second- arily, as a result of the disturbed relations of the circulation ; to the swelling of the liver, the secondary affections of the kid- neys, dropsy, and so on. All the last-named complications are to be regarded only as the direct and necessary results of the disturbed circulation. Their occurrence is favored by the impeded return of the venous blood in consequence of the prolonged and difficult expiration, and the frequent spasms of coughing ; as well as by the absence of any considerable alteration of volume of the lungs in inspira- tion and expiration, in consequence of the bronchial obstruction. At first there is but slight cyanosis, which becomes specially marked during severe paroxysms of coughing. Gradually, how- ever, the jugular veins become more and more distended, and exhibit undulating, or even pulsating movements. These dis- turbances, which result from over-filling of the pulmonary artery VOL. IV.—26 402 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. and the right heart, are compensated in great part, for a time, by eccentric hypertrophy, to which dilatation of the right ventricle and auricle becomes superadded. Soon, also, the results of the disturbed circulation become evident in the domain of the lower vena cava. The evidences of obstruction in the liver are recognizable by the physically demonstrable enlargement of the organ. The consequences of the disturbed circulation may also extend to the kidneys, the digestive tract, and the like. The quantity of urine becomes diminished, its color darker, its solid constituents relatively increased, and its specific gravity higher. With a still greater degree of obstruction the urine becomes albuminous, and contains blood-corpuscles, casts, and even fatty- degenerated epithelium. These consequences of the disturbed venous circulation appear in a marked degree, when, as occurs in the latest stages, the commencing fatty degeneration of the hypertrophied right ventricle acts as an obstacle to the perfor- mance of the increased amount of work. The alimentary canal also evinces signs of the disturbed cir- culation. Loss of appetite, regurgitation of food, meteorism, and irregularity of the stools are symptoms frequently observed at this time. Gradually, too, dropsy becomes superadded, beginning at the ankles, and always extending from below upwards ; even ascites, hydrothorax, and the like, gradually make their appearance. In severe cases these results of the disturbed circulation may exert an influence upon the brain. This is shown in syncope, noises in the ears, flashes before the eyes, indisposition to intel- lectual exertion, headache, and so on. In the last stage tliese symptoms of overfilling of the brain with blood may even increase to actual coma and stupor. We have learned, further, that catarrhal pneumonia, and collapse of the lung are among the most frequent complications of capillary bronchitis. Inflammatory affections of the pleura are less frequently observed as consecutive diseases or complications. If an individual is predisposed to tuberculosis, this disposi- tion is increased by repeated catarrh. Bronchiectasis and emphysema are to be mentioned, further, BRONCHIAL CATARRH. 403 as frequent sequelse. The nature and mode of their occurrence offer no further difficulties after what has been previously stated. Spasm of the glottis is also observed as a temporary trouble, in most instances lasting only for a brief time and favored by the severe paroxysms of cough. On the other hand, I must decidedly deny that the severe manifestations of stenosis, such as are sud- denly occasioned by spasm of the glottis, are ever occasioned by a sudden paralysis of the dilators of the glottis. The latter leads to manifestations of dyspnoea only after a long time, inasmuch as the antagonistic contraction of the closing muscles of the glottis is always developed gradually, as I have had oppor- tunity to demonstrate clinically as well as experimentally. That with the frequent recurrence and prolonged duration of such catarrhs, the disposition to analogous affections, especially of the pulmonary parenchyma, becomes greater, requires no further mention. Diagnosis of Tracheitis and Bronchitis. The diagnosis of tracheal and bronchial catarrh presents, in general, no special difficulties. Pure tracheitis, confined to the trachea alone, is, on the whole, very rarely observed. As a rule, the catarrhal inflammation extends from the trachea to the primitive bronchi, or the tracheitis occurs as an extension of catarrhal laryngitis. The discrimination between a laryngitis and a tracheitis is chiefly based upon alterations in the voice, and upon the appearances found by a lar}mgoscopic examin- ation. A laryngoscopic, that is to say, tracheoscopic, examin- ation can alone enable us to distinguish with certainty between a simple catarrhal inflammation of the trachea, hypertrophy of the mucous membrane, in which the mucous glands especially are often hypertrophied to a great degree, hemorrhages, slight forms of syphilitic disease, and the like. The latter, especially in their earlier stages, can only be safely diagnosticated by the aid of the mirror; while, in their severer forms, they are very apt, as is well known, to be associated with well-marked evidences of stenosis. The absence of a special symptomatic picture of these light forms of disease makes it impossible for us to devote any 404 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. separate description to them ; the same is true of the secondary congestions, swellings, nodular, pustular, and even ulcerous for- mations occurring in the wake of various infective diseases. How important the examination with the mirror is for the recog- nition of tliese mild syphilitic and other diseases of the trachea, is particularly shown by the knowledge of the occurrence of con- dylomata which was first acquired by Seidel.1 Small, soft ulcers, analogous to the slight superficial ulcerations which affect the pharynx and larynx in the secondary period, occur in the trachea also. Very frequently, indeed in most instances, tliese manifestations are combined with similar evidences of laryngeal disease. In contradistinction to the secondary forms mentioned, which are recognized in part by aid of the mirror, and in part by the evidence of other symptoms of the affection, the diagnosis of tracheo-bronchitis, as well as of the other forms of bronchitis in general, offers no special difficulties. The diagnosis rests upon the physical symptoms, the character of the sputa, the absence of dulness on percussion, the various forms of rales, and similar indications. The discrimination of this affection from purely nervous paroxysms of cough, and those occasioned by diseases of the larynx, does not present any special difficulty. The decision of the question whether a bronchial catarrh is to be regarded as an independent affection, or as a symptomatic and secondary one, is often more important and more difficult. Here, at least when the secondary diseases of the heart, liver, kidneys, and the like, are strongly developed, the careful con- sideration of each indication, especially when taken in connec- tion with the history of the case, can alone lead to accuracy in diagnosis. The discrimination from commencing tuberculous processes is also of great significance. Concerning the discrimi- nation between these forms we must refer the reader to the dif- ferential diagnostic data laid down in the chapter upon phthisis. In such cases the most scrutinizing examinations, the careful observation of the temperature, the observation of the condition of the general system, the consideration of the weight of the 1 Jenaische Zeitschrift, II., 4. BRONCHIAL CATARRH. 405 body, etc., are requisite to lead to a proper conclusion. Exam- ination with the spirometer and the pneumatometer may also be of use here. Space does not permit me to go any further into the con- sideration of these affections, and I must therefore refer the reader to the appropriate chapters. The physician will not be likely to confound the disease with laryngeal affections and with whooping-cough if he makes a careful examination and gives due consideration to all the symp- toms. He will be more likely to confound a capillary bronchitis with catarrhal pneumonia. The special points of significance here are: a further increase of temperature, coincident with the onset of the pneumonia (Ziemssen); the absolute elevation of temperature ; the degree of dyspnoea; a stronger inspiratory retraction of the lowest portion of the costal arch; the evi- dence of circumscribed dulness of slight extent; and so on. On the other hand, the differentiation of the individual forms of bronchitis, with reference to seat and extension, presents no difficulties. As regards the differential data of fetid bronchitis, on the one side, and pulmonary gangrene and similar forms, associated with putrefaction of the sputa, on the other, we have already made reference to them in describing the s}Tmptoms of the first of these forms of disease. The frequent complication of chronic bronchial catarrhs with pulmonary dilatation and emphysema, presents no special diffi- culties as regards the diagnosis. Terminations, Prognosis. The prognosis of the individual forms of tracheitis and bron- chitis varies very much. Tracheal affections offer in general a favorable prognosis, as long at least as they are limited to the mucous membrane alone. Simple catarrh of the mucous membrane of the trachea never (/ires rise to severe manifestations of stenosis. Severe manifes- tations of stenosis can be occasioned only where the sub-mucous tissue, and the cartilages, are simultaneously diseased ; these conditions furnishing a correspondingly less favorable prognosis. 406 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. In simple acute bronchitis, especially when limited to the coarser and medium-sized bronchi, the prognosis is almost always favorable. This form of the disease can only prove dangerous in very small children, in nurslings, in aged subjects, and in persons much debilitated by previous diseases. Capillary bronchitis, on the contrary, is always a serious affection, which may frequently lead even to a fatal termination in small children and in aged subjects. It may be said, in general, that the younger a child affected with capillary bron- chitis, the greater the danger. In the same manner the danger increases in small children, in proportion to the extent of the catarrhal inflammatory processes, and the height of the fever. While, however, the acute fever mentioned hardly entails danger to life, < except in children and the aged, the question as to complete restoration of health can hardly be answered in general. A great disposition to relapse very frequently remains as a residuum of such acute attacks of tracheo-bronchitis or diffuse catarrhs, from which chronic bronchitis may become eventually developed. In chronic catarrhs the genuine forms must be separated from the secondary ones ; in the latter, as a matter of course, the fundamental disease determines the prognosis. In general, the prognosis in chronic catarrh is on the whole unfavorable, in- asmuch as it is usually severe and often incurable ; but at the same time it may continue for years and decades without entail- ing any important injurious influence upon the general system. As in many other affections, here, also, the external condition of the patient is of great significance, inasmuch as people in the better conditions of life, who are able to avoid external injurious influences, and to protect themselves from them, are able to with- stand the secondary consequences for longer periods than the less favored and poorer working classes, of whom, as is well known, a great number finally perish from these affections; usually, however, in consequence of further morbid changes, due to the disturbed activity of the lungs, especially in the heart, kidneys, liver, and other organs. Such chronic bronchial catarrhs may also become dangerous, by leading to emphysema, bronchiectasis, and so on. BRONCHIAL CATARRH. 407 The general vigor and age of the patient are of not less importance, as regards the prognosis, than his external sur- roundings. Nurslings and small children are by their age seri- ously endangered by bronchial catarrh, and the danger increases with the volume and extent of the catarrh, and with its spread into the smaller and smallest bronchi. The danger of even a simple bronchitis increases in like manner in the later stages of life, and in the lungs of old persons it may even lead to a fatal termination. In individual cases the amount and proximity of danger are always to be judged of by the degree of the manifestations of poisoning by carbonic acid gas. As long as tliese are not present, no immediate danger is to be apprehended. On the other hand, the symptoms of acute poisoning by carbonic acid gas may often become developed in an exceedingly short time, as, for example, in the capillary bronchitis of children. In indi- vidual cases, the following signs may be considered as especially unfavorable: small and empty pulse ; superficial, but much accelerated respiration; severe degrees of cyanosis, sopor, deli- rium, and severe cephalic symptoms in general; the absence of expectoration, or at least difficult expectoration. TREATMENT. Prophylaxis. Important as prophylaxis may appear in view of the great extent and frequency of bronchial catarrh, yet the avoidance of many injurious influences which are known to often give rise to it, and to keep it up when already existing, will always remain a pium desideratum with certain classes of people. This is the case, for example, with those who are frequently compelled to face inclement weather in the pursuit of their avocations. Another set of injurious influences, those connected with the presence of dust and other impurities in the air, can hardly be completely overcome by the means at our disposal. An important advance in this respect has been made in modern times by the closer study of the connection of individual avocations with certain diseases; and, 408 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. as is well known, the study of diseases due to the inhalation of dust has occupied special attention. It is not our province here to mention all the precautions required in individual employments against the respiratory diseases occasioned by them and against the various forms of thoracic catarrh. We refer the reader, on this head, to the admirable monograph of Hirt.1 It cannot be denied, on the other hand, that, from another point of view, there are a series of important prophylactic meas- ures, which certainly tend to strengthen the organism in general and render it better able to resist such influences. Tliese pro- phylactic measures are to be employed from early youth. I must here again recall the observations of Geigel,2 already cited, which show that comparatively more well-born children die of respiratory affections in the first year of life than those less favored; while the latter class die in greater numbers from diseases of nutrition. The deaths from respiratory diseases are more frequent in the months of March, April, and May, while diseases of nutrition sacrifice most of their victims in the months of June, July, and August. The latter circumstance is due, without doubt, to the influence of depraved nutrition, to which children born under the least favorable conditions of life are naturally more exposed than are the well-born, and especially so in the warm season. On the other hand, the preponderance of respiratory diseases in the more favored children of the better classes can only be referred to their greater effeminacy. This conclusion might perhaps be objected to on the ground that these children of well-to-do people are naturally feebler, and therefore exhibit an increased dispo- sition to respiratory diseases. Tliis objection may, it appears to me, be justly dis- missed. We are not contrasting the children of the peasantry, on the one hand, and the children of residents in cities on the other. Here the objection is certainly true that the greater resistance of country-people depends not only upon their hardiness, but still more upon their naturally stronger constitutions. The distinction referred to here is between children of well-to-do parents, on the one hand, and, on the other hand, the children of poor people, likewise living in cities, but under the worst external conditions. If these latter, despite their unfavorable external rela. tions, and despite their poor nutrition, suffer much less from respiratory diseases than those of the former class, the conclusion previously mentioned, that the cause lies in the greater effeminacy brought about by anxious mothers is certainly justifiable. In this sense a certain, but, as a matter of course, not too vigorous toughening of the children must be recommended even at a relatively early period of life. This toughening must be 1 Hirt, Die Krankheiten der Arbeiter. Breslau, 1873. 2 Deutsche Vierteljahrsschrift f. offentl. Gesundheitspflege, III., 520. BRONCHIAL CATARRH. 409 regulated in accordance with the condition of strength of the child ; and where a naturally feeble constitution has occasioned a greater proneness to catarrhs in general the so-called harden- ing method alone will not accomplish the purpose. Here, cor- roborant treatment is much more important. Special toughening methods are not suitable during the earliest childhood, at least during the first year of life, in the case of children naturally very feeble. Here the prominent indication is for strong nourishment and protection from exposure to taking cold, and other external injurious influences. The children should not be taken into the open air in raw, wind}', and rainy weather ; and they must be care- fully protected from draughts. On the other hand, a judicious strengthening by means of cold washing, douching, rubbing, and the like, when carefully practised, is much to be recommended when the children are somewhat further developed, and the stronger they are naturally, the earlier may it be practised. So long as such children have not attained a certain degree of vigor, so long as their feeble constitution affords them but little power of resistance against ordinary external injurious influences, the greater is the indication for improved nutrition. On the other hand, at a somewhat later period, the various methods of invi- goration, by cold baths and cold washings, especially in the mornings, pla}T an important part. As with children, so with adults also, tliese are invaluable means for strengthening the external integument. It is by no means to be said, however, that invigorating measures shall not be employed with small chil- dren. The contrary is the case, only we should begin with the milder procedures and gradually pass to the more powerful ones. With small children we should use douches, made gradually cooler and cooler, in the tepid bath. At a later period—and tliis applies also to adult age—cool washing of the entire body should be practised every morning, and this can still later be superseded by cold sponging, the cold douche, and the like. The chief use of these invigorating measures lies, therefore, so to speak, only in strengthening the cutaneous surface. Inasmuch, however, as chilling of the surface of the body plays an import- ant part in the etiology of respiratory diseases, and especially in catarrh of the chest, a greater power of resistance to sudden 410 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. cooling, atmospheric influences, and the like, is secured by greater invigoration of the skin. That improvement of the nutrition comprises the second important indication in feeble, scrofulous, rachitic, and similar constitutions, hardly requires mention. Experience shows suf- ficiently that with the improved nutrition of the individual, the power of resistance to external injurious influences increases also. Like delicate children, so must the aged also be carefully protected from taking cold, from sudden change of temperature, and from the injurious influences of the weather, on account of the increased disposition to bronchial diseases in advanced life. The diminished tone of all the tissues in advanced life renders it possible for the same influences to which the body was sub- jected without injury in the prime of life, to easily produce dis- turbances at that advanced age; disturbances which, from the same cause, are attended with much greater danger. On the other hand, it is not to be denied that there is a class of individuals who, despite all precautionary measures, always become affected with catarrhs after the slighest exposure and at every sudden change of weather. For such persons, with exces- sive liability to catarrhs, the choice of a tolerably mild residence of equable temperature often affords the only certain prophy- lactic. The same applies to the so-called idiosyncratic catarrhs. We recall here only hay-asthma, asthma idiosyncraticum. Here, often, nothing suffices but to leave the locality in which the disease has been acquired ; and experience shows that in many such cases simple change of locality suffices to cause the imme- diate disappearance of the malady ; while all other therapeutic measures remain unsuccessful. In this sense residence in a southern, mild, uniform climate during the inclement seasons cannot be sufficiently recommended to people who suffer from bronchial catarrh. We cannot enter more closely into further prophylactic measures, belonging more to the domain of general sanitary science. It is only too well known how much is wanting in this direction in daily life. We recall here only the importance of a constantly equable, but not too elevated, temperature of the chamber during the BRONCHIAL CATARRH. 411 winter season. How frequently, however, we see the grossest disregard of this Biinple hygienic rule! And truly it need be no wonder that a person who, after remaining for hours in an overheated room, suddenly exposes himself to the cold, moist air, contracts a catarrh; or that, when he exposes himself anew to such sud- den changes of temperature again and again, he is unable to get rid of it. In the section on etiology we have already endeavored to explain the process of taking cold when the body is heated, on the sudden transition from an overwarm room to a very cool atmosphere; and the reader is referred to what has there been said in this connection. Concerning the regulation of the temperature of the apart- ment in cases of acute or chronic bronchitis, it may be taken as a rule that the temperature of the sick-chamber should never be higher than 14° R. (63^° F.). Ordinarily a much lower temper- ature than this is not to be recommended ; but under circum- stances, however, in which pure air is not otherwise attainable than at the cost of some cold at the same time, as is not rarely the case in the confined apartments of the poorer classes, pure ah, though it be cool, is to be preferred to that which is warmer but tainted. The degree of moisture of the air is likewise one of the most frequently neglected points. Large vessels of water should always be kept in the chambers of bronchitic patients to main- tain sufficient moisture of the air. The same end may be obtained by the use of atomizers. The prophylactic measures relating to clothing, residence, heating, and the like, to be taken by those who are liable to catarrhs, need no further mention here. With reference to clothing, it may be remarked briefly that the constant use of flannel next to the skin cannot be sufficiently recommended to such persons. Treatment. In discussing the special treatment of bronchitic affections we have to discriminate, in the first place, between such general measures as aim at warding off external pernicious influences, or removing remote causes of disease existing in the individuals themselves, and such measures as are directed against the disease itself. The first two coincide with the causal indication. They 412 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. are based upon well-known principles, and need be but briefly adverted to here. The fulfilment of these two indications, to ward off external pernicious influences, and to remove the individual causes predis- posing to disease, is hardly possible in many cases. That where these two indications can be met the first and most important duty is to meet them, requires no demonstration. External sources of injury which irritate the bronchial mucous membrane, and which keep up bronchial irritation already existing, must of coarse be removed as far as is practicable. This is requisite not only at times when such catarrhal inflammations exist, but also at times when the health is sound. In many cases this indica- tion cannot be fulfilled. In our remarks on etiology we have already mentioned a considerable series of occupations which exercise a direct irritation upon the bronchial mucous mem- brane. Many thus engaged, however, are not in a position to give up their employments, and resort to others which do not expose to similar danger. Where this first indication can be satisfied, the removal of these external sources of injury must of course be regarded as the first step to be taken. This indication is also fulfilled if bronchitic patients are cau- tioned against exposing themselves to atmospheric changes dur- ing inclement seasons ; or if such patients, especially in cases of acute catarrh, are forbidden to leave their apartments, in which an equable temperature should always be maintained. The same regimen is strongly to be recommended not only in acute ca- tarrhs, but in chronic catarrhs also. In primary catarrhs of not too long standing such a treatment, by which the patient is kept for weeks together in an equably warm and pure air, often suf- fices to remove the malady entirely. As justly remarked by Memeyer and Seitz, who highly recommend such a practice, its value is evinced by the expe- rience of patients with chronic bronchial catarrh who, after having been confined to their rooms for a long time on account of other intercurrent maladies, express the opinion that the dis- ease through which they have passed has exercised a critical influence upon their chronic complaint, so that they cough less than formerly and feel freer in the chest. BRONCHIAL CATARRH. 413 Where it is not practicable to avoid these external sources of injury, it is very difficult to institute really useful treatment. Where chronic bronchial catarrh occurs in consequence of a raw climate, it is advisable to send the patient to a milder climate during the inclement season. For persons who suffer from bron- chial catarrh every winter, nothing can be recommended more urgently than resort to a milder climate for several winters. Many localities are suitable for this purpose, and in general those are to be recommended which have been found suitable as winter residences for consumptives. As such winter resorts Nice, Mcntone, Hyeres, Venice, Pisa, Pau, Ajaccio, and Cannes are especially to be recommended, and we may add Palermo, Algiers, Cairo, Madeira, Catania, Davos, and so on. A sojourn on the Lake of Geneva, or some- where about Meran, is advisable during the autumn, but these places are not suita- ble for the winter itself. Concerning summer resorts and the use of mineral springs, we shall speak hereafter, when describing measures directed against the diseases themselves. We have designated as a further indication, and the one next in importance, the removal of the injurious influences existing in the individual himself which excite and keep up the bron- chial catarrh. Thus, for example, those forms of tracheitis and bronchitis which occur under the influence of the syphilitic dys- crasia require an antisyphilitic treatment. The same holds good for scrofulosis and for rachitis, which, as is well known, engen- der a certain disposition to catarrhal inflammations generally, and to bronchial catarrh especially. In children! with such a diathesis, a treatment directed against the diseased process itself, that is, the bronchitis, does not suffice. It is here essential first to attack the existing d}Tscrasia, and thus to remove the greater proneness to catarrhal affections, which, while being also a proximate or remote cause of origin, acts continuously as an obstacle to recovery. While in these cases all the expectorants and other remedies directed against the bronchitis fail as long as the existing dyscrasia is not eradicated, it often happens that these catarrhs are promptly cured when the children are better nourished and subjected to an anti-scrofulous and anti-rachitic treatment. In many cases, as a matter of course, it is not possi- ble to satisfy the causal indication sufficiently. This is espe- 414 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. cially the case in secondary bronchitis resulting from valvular disease of the left heart. The same principle holds good with other injurious causes which excite a collateral fluxion to the lungs. The more we are able to remove the fundamental cause or to ameliorate it, the more likely is the secondary bronchial catarrh to diminish in intensity, or even to disappear entirely. This plan of treatment succeeds especially in people of mid- dle age, who take but little exercise, lead a luxurious and more sedentary life and consequently have a sluggish circulation. Such patients often suffer at the same time with hemorrhoids, gastric disturbances, frequent congestion of the head, and the like. Here a treatment directed solely against the bronchial catarrh hardly meets with any success worth mentioning. The mode of life must be regulated first, the disordered circulation excited, and the digestion improved. Such persons, distinguished by marked corpulence, do much better under the use of saline-alkaline spring waters, than under an expectorant treatment. Patients of this kind are sent to Kissingen, Homburg, Marienbad, and the like, and are soon cured without the use of any expectorant or local respiratory treatment. While the methods of treatment thus far mentioned have as their object only the proximate or remote causes of the disease, there is a large class of cases in which these methods do not suffice because they act only upon external or internal causes, and cases also in which these indications cannot be satisfied, as, for example, in catarrhs occasioned by certain avocations. With the promotion of favorable external or internal conditions, the conditions for recovery become more favorable, but the cure of a disease which has once become established is by no means always obtained. In all these cases—and they form by far the greater number—a special treatment directed against the disease itself is requisite. The remedies to be employed will vary according to the different forms and stages of the catarrh, the hypersemia and swelling of the mucous membrane, the consis- tence of the secretion and its amount, and so forth. Unfortu- nately we must premise the remark that many of these indica- BRONCHIAL CATARRH. 415 tions are hardly to be satisfied by means of the remedies under our control. Thus we have hardly any certain means to remove hypersemia and swelling of the mucous membrane ; hardly any that will overcome the thickening and induration of the mucous membrane which occurs especially in chronic catarrhs. Often we are compelled to limit ourselves to removing, or even only ameliorating, the annoying symptoms, such as to relieve the cough, to facilitate the expectoration of the bronchial secretion and the like. It will be judicious, before turning to the treatment of the in- dividual forms of bronchitis, to treat briefly in general of the more important remedies and methods which are directed against the disease itself or against its most important symptoms. To these belong first: Local treatment in the form of inhalations of atomized liquids, vapors, and gases. In diseases of the windpipe and lungs, the inhalation of atomized liquids, and of vapors and gases, form, as stated by Waldenburg' in his excellent manual on respiratory therapeutics, the only general method of local treatment. Experiments with other methods, such as injections by the aid of catheterization of the trachea (Green), and insuffla- tion, that is to say, inhalation of solid medicaments in the pul- verized form, have likewise been made, it is true, but they have as yet met with little encouragement; and justly so, because, on the one hand, injection by means of catheterization of the trachea can only be accomplished by very experienced hands, and acts very powerfully"; while, on the other hand, both by injection and by insufflation, the locality to which the medica- ments are applied cannot be determined accurate^ enough to permit one to be certain that the diseased parts chiefly, and not rather the sound parts alone, are brought into contact with them (Waldenburg). Treatment by inhalation finds employment in both acute and chronic bronchial catarrh ; and although it is not to be denied that the value of this method in the affections under consider- ation was much over-estimated at the beginning, it is not to be 1 Die locale Behandlung der Krankheiten der Athmungsorgane, 1872, p. 454. 416 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. disputed, on the other hand, that it has effected many good results. Waldenburg warmly recommends this method of treat- ment in recent bronchial catarrhs especially, and considers it desirable that it should hereafter be generally pursued at once in acute catarrhs; he thinks that catarrhs would then be less frequently neglected and allowed to become chronic. Although this latter opinion may perhaps appear too sanguine, yet the good.results of this method in many cases is not to be denied. At the same time it should not be forgotten that many acute catarrhs often recover spontaneously under a suitable dietetic regimen, and that other methods also are competent, in like manner, to cure acute catarrhs in a short time. In the same manner this method is also to be recommended, under proper circumstances, in the treatment of chronic ca- tarrhs ; partly against the chronic catarrh itself, and partly for the relief of individual symptoms. We will return to the spe- cial indications for this treatment, and the principal remedies to be employed in its use, in discussing the measures applicable to the separate forms of the disease. In acute catarrhs, and in chronic catarrhs with but little secretion and difficult expectora- tion, emollients and resolvents chiefly are chosen, and sometimes narcotics also. In chronic catarrhs, on the other hand, with copious secretion, astringents, balsams and resins, and, in certain conditions, carbolic acid, are the chief remedies employed. The second class is formed of the special expectorants, to which the nauseants and emetics may be added. Frequently as expectorants are employed in practice, their value, on the whole, is to be considered as but slight. In their administra- tion two objects are kept in view: the one merely to expel the masses of secretion adherent in the bronchi, and the other to combine with this the transformation of the tenacious secretion, poor in cells, into a loose secretion rich in cells. Whether this latter object can be accomplished in this manner must remain uncertain. Above all other remedies belonging to this class of expecto- rants, in the wider sense of the word, to which is attributed also an anti-catarrhal action—that is, one which will make the secretion richer in cells, and thereby increase the facility of BRONCHIAL CATARRH. 417 expulsion of the product — we must place the antimonials, Kermes mineral, golden sulphuret of antimony, tartar emetic, and muriate of ammonia especially. Sal-ammoniac, particu- larly, is one of the remedies most frequently employed and most highly valued. It is employed chiefly in acute catarrhs during the period of defervescence ; when the cough is still dry, the secretion still scanty, and the tenacious mucus difficult to detach. Although its employment is sometimes justified in chronic catarrh, in the treatment of which its improper use is only too frequent, it is so only in cases in which the secretion is temporarily inclined to be stagnant, the expectoration becoming more tenacious and more difficult to detach. But even in the cases mentioned, it is not so valuable and indispensable a remedy as would be supposed from the frequency with which it is daily prescribed. With these milder expectorants, to which a certain anti- phlogistic action is likewise attributed, calomel also is classed, and has received an immoderate and unjustifiable employment, especially in infantile practice. Apomorphine has been recently recommended as a good expectorant.1 It is employed in doses of from one-sixth to one-half of a grain. The results of its action thus far reported are very favorable, the tenacious mucus always becoming more easily detached, the sputa more copious, and expectoration much easier. My own experience is also in favor of the expectorant qualities of this remedy ; though I must state that the number of cases in which I have thus far employed apomor- phine as an expectorant is comparatively small. Of the stronger expectorants, whose use is indicated in cases in which the patient can with difficulty and only incompletely cough up the abundant secretion, senega, benzoic acid, and ammoniacal solutions are the principal; to which may be added camphor and the like. To these may be added the actual emetics, which are espe- cially indicated in the suffocative forms of tracheitis, in which numerous bronchial branches are more or less occluded by mucus. They also come into use very properly in cases in which the tone of the bronchial muscles is so deteriorated that 1 Centralblatt f. d. med. Wiss., 1874, No. 32. VOL. IV.—27 418 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. the secretion can no longer be expelled from the bronchi; cases which are often designated in common parlance as " paralysis of the lungs." In these cases an emetic is the best expectorant, provided the strength of the patient is still sufficient to justify its use. Tartar emetic and ipecacuanha are most frequently employed in these cases ; and the latter, used in smaller doses, is likewise frequently employed as a milder expectorant. Muriate of apomorphia is a much more safe, trustworthy, and prompt remedy, and, as I first proved by numerous experiments,1 is best administered subcutaneously, in doses of from one-thirteenth to one-sixth of a grain. Apart from its certain and unfailing action, an important superiority of apomorphine over all other emetics yet employed exists in the promptness of its action. In from four to six minutes after its introduction the desired result is produced, and is attended with but very slight and temporary unpleasant effects ; and, furthermore, in special contrast to other emetics, it does not exert any paralytic effect upon the heart. It is therefore specially applicable to those cases in which the danger of "paralysis of the lungs" is imminent, and in which it is necessary to secure readmission of the air as promptly as possible to the bronchi rendered impervious by accumulated secretions, and thus to the alveoli. Derivatives and revulsives are to be mentioned as a third method of treatment, although they play but a subordinate part in the management of acute and chronic diseases of the trachea and bronchi, and are able to fulfil only certain special indica- tions. These derivatives, by means of which it is sought to remove or diminish the disturbance in the pulmonary circula- tion, are partly such as act upon the skin, and partly such as act upon the intestinal canal; much less frequently, or hardly *wer, such as act upon the kidneys. The external integume^c is selected most frequently for this purpose. The diaphoretic method of treatment deserves to be employed in those cases, especially, in which the bronchitis is recent, and associated with but little or no febrile movement. Whether the catarrh can be actually aborted by this method must remain 1 Riegel and Bbhm, Deutsches Archiv f. klin. Med., Bd. IX. BRONCHIAL CATARRH. 419 undecided; but it is certain, however, that cases of acute bron- chitis often undergo rapid and marked improvement under this treatment. So far as the method is concerned, it is, in general, a matter of indifference by what means copious perspiration is produced, whether by the administration of the ordinary diapho- retics, or by means of vapor baths, hot baths, and the like. The value of the leaves of jaborandi,1 recently praised as an unusually energetic diaphoretic, must be determined by further observation. My own limited experi- ence with this remedy is strongly confirmative of its diaphoretic action. In severe forms of bronchitis, associated with intense fever, on the other hand, and in chronic bronchitic affections also, the dia- phoretic method is no longer indicated. Mustard plasters, vesicants, dry cups, and irritating lini- ments are frequently used in the treatment of bronchial affec- tions. The effects produced by them are only temporary. It is especially in cases in which there is considerable swelling of the mucous membrane, and in which the secretion stagnates so as to cause considerable dyspncea, that severe irritation of the skin will produce momentary relief. The longer-continued employ- ment of such cutaneous irritants is in no wise to be recom- mended. Purgatives are, on the whole, seldom resorted to to produce revulsion from the lungs, or rather from the bronchial mucous membrane. At any rate this method is confined to certain cases, and principally to that form of bronchitis which occurs in ple- thoric subjects who lead a luxurious and sedentary life and take but little exercise. The above remarks are still more applicable to the use of diuretics. Of these remedies only such are employed as have at the same time a certain effect upon the bronchial secretion, as turpentine, for example. As to narcotics, they are never employed in combating the bronchitis itself, but only with the object of alleviating or reliev- ing certain symptoms. Their use is especially indicated in bron- chitic affections in which there is such severe irritation of the bronchial mucous membrane that the patient is almost continu- 1 Bull, de ther., 1874, LXXXVL, 6, 282-283; Hnion med., 1874, No. 45 ; Gaz. hebd., 1874, Xo. 15. 420 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. ously harassed by his cough. These severe paroxysms of cough- ing always irritate the bronchial mucous membrane afresh ; and with the subsidence or alleviation of the irritative cough these new and constantly recurring sources of irritation are removed, and thus a condition more favorable to recovery is produced. In such cases, especially in those forms of catarrh associated with great swelling and little secretion, but with severe cough, narcotics are employed; and they are better adapted to loosen the cough in these cases than any expectorant. This form of catarrh is associated in many instances with a spasmodic contraction of the bronchial muscles which tends to increase the dyspnoea still more, even to the production of asthmatic paroxysms. These bronchial asthmatic paroxysms likewise indicate the administration of narcotics, as we shall see hereafter in describing bronchial asthma. The use of nauseants is urgently recommended by many in such cases, as is also that of the iodide of potassium by Seitz. This latter remedy, as is well known, forms the most important ingredient of Aubree's house remedy, so highly extolled in asthma. Gazeol' has re- cently been recommended repeatedly in bronchial catarrh on account of its influence in diminishing the irritable cough. The special narcotic remedy to be employed is, on the whole, indiffer- ent, so far as there are no special grounds in individual cases contraindicating the employment of one or another. There is sometimes an additional indication, which is to diminish the excessive secretion of the bronchial mucous mem- brane. For this purpose astringent remedies especially are re- commended, tannin, acetate of lead, rhatany, and the like. Apart from their uncertain action there is an objection to their use in their alterant effect upon other secretions also. The desired effect can be much better secured by the employment of balsamic and resinous remedies, such as the balsam of Peru, copaiba, the compound mixture of iron, and oil of turpentine especially. These remedies are now most frequently administered by inhala- 1 A preparation introduced by Burin-Dubuisson. The formula for it is as follows : Ammonia (20° Beaume), 1,000 parts ; acetone, 10 parts; benzine, 10 parts ; naphtha- line, 1 part; pix liquida (fresh), 100 parts. Dissolve the naphthaline in the benzine, then add the ammonia, and finally the other ingredients.—L'Officine, par Dorvault. BRONCHIAL CATARRH. 421 tion. Carbolic acid has recently been recommended for the same purpose, chiefly in cases of fetid condition of the bronchial secretion, and it has been employed with very good results. Antipyretics and antiphlogistics play but a subordinate part in the treatment of acute and chronic bronchitis. In the majority of cases there is but slight increase of temperature, and the employment of energetic refrigerants is as a rule not required. In the majority of cases the moderate fever, that accompanies acute catarrh at first, subsides of itself in a few days under simple dietetic treatment. In cases, however, of severe febrile movement, the use of cold in the form of baths and ice wrappings is indicated. The latter are capable of reducing the temperature of the body to a considerable degree. In severe fever cold baths undoubtedly take the first place, even in the treatment of acute bronchitis. Their employment is highly recommended for children with capillary bronchitis and intense fever, but it is better in these cases to use baths that are not too cold, but rather of a temperature of from 77° to 86° F. During the bath cold affusions can be made so as to excite deep respirations. According to circumstances such a bath may be prolonged from fifteen to thirty minutes or more. That quinine in large doses is sometimes indicated to control the fever, needs no further argument. Its employment is indi- cated on the same grounds on which it is employed to control fever in general. Antiphlogistics, on the contrary, are but slightly applicable to the treatment of acute or chronic bronchitis. But little, too, is to be expected from cold employed for its antiphlo- gistic effect. General venesection is never required in bronchitis as such. Whenever employed it can serve at most to combat some single dangerous symptom. In children, general venesec- tion is, as a matter of course, absolutely contra-indicated at any time. In general the indication for venesection has been placed in an excessive accumulation of blood in the lungs and in the right heart, as shown by intense cyanosis, severe and rapidly increasing dyspncea, great dilatation of the jugular veins, and so on. Many authors still favor this idea, and venesection is accord- ingly urgently recommended in the suffocative form of acute 422 RIEGEL.— DISEASES OF TRACHEA AND BRONCHI. bronchitis. The employment of venesection is advised even in chronic bronchitis, if suffocative symptoms are present in conse- quence of hypersemia of the lungs. In slighter cases dry cups or leeches, and the like, are recommended. It is thus seen that even by the adherents of venesection that practice is recom- mended only for those cases in which a passive oedema is threatened, occasioned by the momentary inability of the right heart to overcome obstacles in its circulatory system. How far the desired object can be accomplished by venesection, Jiirgen- sen' has explained clearly and convincingly in his excellent work on the treatment of croupous pneumonia. We can apply what is there stated to the question before us. That blood-letting by diminishing the amount of blood, may momentarily diminish the work that the heart has to do, is undoubted. This removes the danger of the moment, and experience proves, in fact, that the dangerous symptoms may be diminished for a short time by means of venesection. The obstruction to the pulmonary circulation is momentarily removed or diminished by the venesection, and the right ventricle so much unloaded that it becomes able to drive more blood into the left one. This diminution, however, has this result: that now the heart and the muscles of respiration have to work harder than before the blood-letting, in order to convey the proper quantity of oxygen to the tissues of the body (Jiirgensen). Though, therefore, in cases in which there is such a dangerous obstruction of the pulmonary circulation, and in which other remedies are not available, the abstrac- tion of blood may appear to be justified in robust individuals, it must not be for- gotten that this remedy conceals in itself a reproduction of the danger, and that stimulants which do not involve a similar danger in themselves accomplish the same end better and without subsequent injury. In young children and in debilitated subjects bloodletting is absolutely contra- indicated as a matter of course, even in such cases as those mentioned, and stimu- lants which remove the danger much better, are greatly to be preferred. At most a small local abstraction of blood by means of a few leeches, or the like, might be practised in these cases, a method, however, by which no important result is reached with any certainty. There is seldom any indication for the employment of internal antiphlogistic remedies, in addition to which the action of most of them is very uncertain and doubtful. Other remedies indi- cated in special cases, as for example, stimulants, tonics, and the like, need no special mention. The indication for their use in bronchitis is the general indication for that class of remedies, and they are employed only for the relief of symptoms. We 1 Volkmann's Sammlung klinischer Vortrage, No. 45. BRONCHIAL CATARRH. 423 shall return to this subject in describing the special treatment of the individual forms of bronchitis. It remains to mention briefly a method of treatment which is employed more extensively than ever at the present day. This is the treatment by mineral spring waters, the milk, whey, and grape cures, and to a less extent the use of the juices of certain herbs. If we should form a judgment of their efficacy from the frequency with which mineral spring waters are employed at the present day, the best results should be anticipated. But this is by no means the case, although it is not to be denied, at the same time, that the use of many mineral waters is attended with decided suc- cess, at least in the treatment of chronic catarrhs. It would be an error, however, to attribute the entire success of this treatment to the mere use of these mineral waters. In many cases the removal from the customary injurious influences, residence in a pure, healthy, oxygenated atmosphere, and similar factors occasion a goodly part of the favorable result. We refer the reader to the treatises and manuals on balneotherapeutics for the special indications for the use of the different mineral springs, and especially to the manual of Helfft,1 and content ourselves with briefly mentioning the principal resorts. The use of the springs at Ems, so rich in carbonic acid, is chiefly adapted to the more torpid class of patients with relaxed mucous membrane and abundant secretion, so long as there are no symptoms of large caseous pneumonic foci and the patients are not anaemic. For more marked anaemia, the alkaline springs of Kochel at Lake Kochel, in Upper Bavaria, are to be recommended. The use of the soda- lithia spring in Weilbach is especially suited for persons who have suffered from scrofulous affections in youth, and who are prone to contract catarrhal affections after changes in the weather ; particularly when they are full-blooded and disposed to congestions of the lungs. So, likewise, +he saline alkaline springs of Luhatscho- witz in Mahren are suitable to scrofulous constitutions. In old chronic catarrhs, with dry cough and scanty expectoration, the springs of Weisscnburg, in the Canton of Berne, may be successfully employed if the patients are still well nourished. In all chronic bronchial affections, where there exists a blennorrhoeic stage, the following-named alkaline and muriated alkaline mineral springs may be employed with advantage: Gieshubel, Bilin, in Bohemia; Geilnau, in Nassau; Fachingen, Gleichenberg, in Steiermark; the Tonnissteiner Springs, in Brohlthal; the Springs of Borszek, Elopatak, Ronda, and those of Selters, Ober- selters, and Roisdorf. Then, again, there are patients in a rather advanced period of life, who, with a general plethora, suffer from haemorrhoids, and circulatory disturbances in the abdominal vessels; and in whom chronic catarrh of the bronchial mucous mem- brane may become developed. For these patients the saline-alkaline mineral springs 1 Helfft-Thilenius, Handbuch der Balneotherapeutics, 8th ed. Berlin, 1874. 424 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. are indicated, especially the Oberbrunnen, in Salzbrunn; the Waldquelle, in Marien- bad, Lippspringe, etc. Soden is suited for irritable, feeble persons, with a torpid, atonic condition of their abundantly secreting mucous membrane. In pasty, phlegmatic individuals, who suffer at the same time with distur- bances of digestion, the cold and warm sulphur baths at Weilbach, Wipfeld, Lan- genbrucken, Nenndorf, and the like, are to be recommended. Catarrh is frequently developed in rheumatic subjects. If the patient is irrita- ble and of feeble constitution, Ems is to be recommended ; for plethoric cases the muriatic springs of Kissingen, Homburg, and even Wiesbaden, Baden-Baden, and the like are to be employed. Milk and whey cures are frequently employed in chronic bronchial catarrhs, especially in delicate subjects. Among the places especially suited for the whey- cure, the following are to be mentioned: Ischl, where patients may likewise avail themselves of the salt spray and vapor-baths, as well as the simple salt-baths; Reichenhall and Kreuth, in both of which places the juices of herbs can likewise be used; Interlaken, Reinerz, Weissbad, etc. A direct influence upon the bronchitis is not to be expected from these cures; the use of mineral waters, especially the alka- line-muriatic springs, is often associated with them. Finally, the grape-cure is sometimes employed in chronic catarrhs, more so recently than formerly. It is recommended for such bronchial catarrhs as are associated with great thickening of the mucous membrane, in which the tenacious secretion becomes clogged in the bronchi, thereby rendering expectoration diffi- cult. Special success is not to be anticipated from this method in most cases. The resorts most worthy of recommendation are: Meran, Diirkheim, in the Rhenish Palatinate; Neustadt, on the Haardt; Gleisweiler, Bingen on the Rhine, Vevey, Montreux, Clarens, and Vernex, on Lake Geneva ; and Aigle, Bex, and Sion, in the valley of the Rhone. Finally, we have to mention the pneumatic cabinet, the employment of condensed and rarefied air, as a more esteemed recent mode of treatment. The results thus far obtained in chronic catarrhs by sojourn in pneumatic cabinets, speak strongly in favor of this method; but it is at the same time to be regretted that the oppor- tunity for employing pneumatic cabinets is quite limited. It was therefore a con- siderable step in advance when, a few years ago, Hauke,1 of Vienna, first constructed a small portable apparatus, by means of which both condensed and rarefied air can be employed for respiration. The advantage of these portable apparatuses consists not only in this feature of transportability, which places them within easier reach of a large number of patients, but also in the circumstance that both the compressed and the rarefied air may be used separately, during either expiration or inspiration. They differ, how- 1 Ein Apparat zur kiinstlichen Respiration und dessen Anwendung zu Heilzwecken, with 2 wood-cuts. Wien, 1870. BRONCHIAL CATARRH. 42o ever, from the pneumatic cabinets in this, that the entire body is subjected to the influence of compressed or rarefied air in the cabinets, while in the portable appara- tuses only the inner surface of the lungs is subjected to this influence. After the impetus was once given by Hauke to the manufacture of such portable apparatuses, improvements were soon suggested, and new and more complete appa- ratuses were constructed for the same purpose, especially by Waldenburg, Berkart, Storck, Cube, Biedert, and others. Without entering into any special criticism of all these transportable apparatuses, I will simply remark, as the result of numerous personal observations, that, according to my experience, Waldenburg's apparatus ' amply fulfils all the requirements. With regard to the employment of condensed or rarefied air in chronic catarrhs, I must recall the fact, shown by my own stethographic as well by Waldenburg's pneumatometric investigations, that chronic bronchial catarrh, like emphysema, is chiefly associated with an impediment to expiration. The indication is therefore clear, to seek such remedies as first of all assist expiration; and with this object Gerhardt2 has recommended and introduced the practice of producing mechanical compression of the thorax during expiration, in cases of emphysema and chronic catarrh. Gerhardt has likewise observed favorable results from this treatment in febrile cases of bronchitis and dilatation of the bronchi with copious secretion,' and considers it in these cases as the most powerful expectorant; the fever was subdued or reduced by it, and the expectoration greatly facilitated. The favorable results obtained by Waldenburg from the use of condensed and rarefied air in emphysema and chronic catarrh, have been recently substantiated in every point by the recorded experience of Sommerbrodt * and Hanisch.6 Not only has the expiration into rarefied air been proven efficacious, but also the inspiration of compressed air. Sommerbrodt was especially attracted to the employment of the inspiration of condensed air, because, according to Waldenburg's investigations, the inhalation of condensed air increases the pressure and afflux of blood in the aortic system, impedes the flow of the blood from the veins into the right heart, and thereby diminishes the amount of blood in the lungs. While Sommerbrodt repeatedly saw every attempt fail to recall the lost expiratory power in old emphy- sema, yet, on the other hand, in more than fifty cases of recent emphysema (or rather of distended lungs), and especially of bronchial catarrhs of the most different and even very long periods of duration, he never saw the curative effects fail entirely, and in most cases they were complete. Similar favorable results have been observed by Hanisch, and demonstrated objectively, during the treatment and after it, by 1 Berliner klinische Wochenschrift, 1873, Nos. 39, 40, 46, and 47. 8 Berliner klin. Wochenschrift, 1873, No. 3. 3 Verhandlungen der phys. med. Gesellsch. zu Wiirzburg vom 21. Feb., 1874, and Deutsches Archiv f. klinische Medicin, XV. Bd. 4 Berliner klinische Wochenschrift, 1874, Nos. 15, 31. 6 Deutsche Archiv fiir klinische Medicin, XV. Bd. 426 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. graphic representations of the respiration with my simple stethograph. Storck' expresses himself in favor of this mechanical treatment, on the basis of numerous personal observations. Our own numerous personal observations only corroborate the successful results of this method of treatment in chronic bronchial catarrh, and we welcome in the portable pneumatic apparatus a remedial agent that deserves a more general accept- ance than it has yet received. We now turn to the description of the treatment of the indi- vidual forms of bronchitis, and we can be the briefer that the most important remedies coming under consideration, and the indications for their employment, have been already discussed. Treatment of Acute Bronchitis. Acute, genuine tracheo-bronchitis is almost always a benign disease in adults, in whom recovery usually ensues spontaneously within a short time. Very frequently no special therapeutic measures are required, beyond warding off all external injurious influences. The patient should be subjected to a proper dietetic regimen, and should always be kept in an equable temperature night and day, the apartment being well ventilated ; and for the first few days, especially if there is any fever, he should keep his bed. At the commencement, when the swelling of the mucous membrane is at all considerable, and the secretion scanty, some relief may be obtained by breathing warm vapor. The treatment of recent bronchial catarrh by inhalation is highly recommended by Waldenburg.4 Emollients and resolvents chiefly, and sometimes narcotics, are to be selected for this pur- pose. Diaphoretic drinks are a favorite remedy in acute catarrh, and hot spirituous drinks are also frequently employed in such catarrhs. An actual abortion of the complaint, as is often believed to be produced by these methods, is not to be expected. Rubbing the chest with warm fat or oil, and the application of a poultice of the same materials around the neck, are favorite 1 Mittheilungen iiber Asthma bronchiale und die mechanische Lungenbehandlung. Stuttgart, 1875. 2 Die locale Behandlung der Krankheiten der Athmungsorgane, 1872, p. 454. BRONCHIAL CATARRH. 42? popular remedies. When the cough is severe, narcotics are indi- cated. Of actual drugs, sal ammoniac is the one most frequently employed ; then come small doses of ipecacuanha, antimony, and the like. Special results are hardly to be expected from these remedies. The above-mentioned dietetic regimen is much more important, and is often sufficient by itself for recovery in mild cases. It is otherwise in severe cases. The treatment must vary here, according to the vigor of the patient and his period of life, and according as the severity of the affection in individual instances has been occasioned by this or that special influence. Thus, in cases of severe acute bronchitis, in which the fever becomes tolerably high, this symptom should be selected as the point to be attacked by therapeutic measures. It requires no argument to prove that cold takes its place here in the foremost rank. The indication for its use, especially in the form of cold baths, is just as strong in febrile bronchitis as in pneumonia. Quinine and other like anti-febrile remedies are to be employed as circumstances may call for them. In other cases the dyspnoea preponderates over the other manifestations, in consequence of great swelling of the mucous membrane and extension of the inflammation into the minuter bronchial ramifications. Even here the application of cold will be found useful under certain circumstances, particularly in children, in whom it will excite deeper respiration. The above- mentioned inhalations of warm vapor of water, of alkaline car- bonates, and the like, may be of important service, at least in adults, by alleviating the cough, and thus removing a source of continuous irritation. Venesection is rarely indicated in any case of acute bronchitis. Local abstraction of blood may produce momentary relief; but it is by no means competent to exercise a permanent influence upon the course of the disease. The same remark holds good with reference to the various cutaneous irri- tants, such as mustard-plasters and the like. In debilitated sub- jects eveiy depressing measure is contraindicated as a matter of course, especially the abstraction of blood. Here stimulant remedies are indicated, and in large doses. Depressing measures 428 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. in general cannot be too much warned against in acute bron- chitis. The course of such cases of bronchitis is often rendered more severe from the too diligent employment of such depressing measures. Expectorants are usually of little or no use at this stage. Emetics are applicable only when previous physical examination has demonstrated the presence of great masses of mucus within the bronchial tubes. When the cough is too severe, narcotics are to be employed : opium, morphia, Dover's powder, and the like. In children and aged subjects it is better not to give any direct remedy for the cough. At a later stage, in which the crude consistence of the sputa has already disappeared, and the secretion of the bronchial mucous membrane has become more copious, expectorants may be employed, and especially senega, ammoniacal solutions, and the like. So also inhalations, especially of carbonate of soda, lime-water, tannin, and the like, prove of the greatest service. In aged subjects all debilitating methods are contraindicated as a matter of course. The fever is rarely high, and therefore the use of powerful febrifuges—cold especially—is almost always unnecessary. On the contrary, a corroborant procedure is to be adopted in order to counteract the threatened exhaustion. Care- ful examination of the pulse is of the greatest importance in tliese cases, as it is in all severe cases of bronchitis, as well as in pneumonia; for the greatest danger is to be dreaded from the great disturbance of the circulation and the unequal and immoderate action of the heart. Besides, there is the danger of insufficiency of the heart. Special attention, therefore, is to be given to the nutrition and strength of such patients. Alcoholic drinks are to be administered from the commencement of the affection, even when there is high fever, the more so that, as shown by numerous experiments of Binz,1 myself,a and others, 1 TJber die antipyretische Wirkung von Chinin und Alkohol, Virchow's Archiv, Bd. 51, p. 6. 2 Riegel, Uber den Einfluss des Alkohols auf die Korperwarme, Deutsches Archiv far klinische Medicin, Bd. XII., p. 79. BRONCHIAL CATARRH. 429 the body-temperature is not increased thereby, but, on the con- trary, is diminished. Emetics, on account of their depressing after-effects, are to be limited, in aged subjects, to the most urgent cases, and to be avoided altogether when possible. Apomorphine is to be pre- ferred in these cases, as its administration is associated with the slighest after-effects. Powerful derivatives are to be avoided likewise, on account of their depressing influence. It is hardly necessary to add that care must be taken to secure regular evacuation of the bowels. Stimulant remedies, in a limited sense, are suitable in cases of threatened or already existing collapse, and must be employed as soon and in as concentrated a form as possible—chiefly strong old wine, champagne, musk, ether, benzoic acid, camphor, and the like; the latter deserves to be employed especially in the form of subcutaneous injections. In children, great care should be exercised in the treatment of the severe forms of bronchitis, and more especially of capil- lary bronchitis. The employment of certain special remedies is not so requisite as the careful consideration of each individual case and the accurate appreciation of every element in it. All external injurious influences should be removed with the greatest solicitude. The air should be kept fresh and pure, but not too dry; there shonld be a constantly equable temperature in the sick-room ; suitable nourishment should be provided ; the coverings of the bed should not be too warm, etc., etc. The treatmentx by inhalations also deserves to be employed in the manner already mentioned, provided that the children are suffi- ciently tractable. The question of nourishment should receive special attention. Wine plays an important role here also as an 1 In view of the difficulties encountered in pursuing the treatment by inhalations with nurslings and young children, Abelin (Hygiea, Marts, p. 121, 1868) has intro- duced, in the Hospital for Children in Stockholm, the methodic employment of in- halations of warm vapor of water, in the form of what might be termed a permanent vapor bath ; by this plan the atmosphere of the apartment is kept continuously satu- rated with vapor, the patients being confined in this atmosphere for days and weeks together until recovery has taken place. From the statistics reported by this author, it appears that the mortality among children with capillary bronchitis has diminished more than half since the introduction of this method. 430 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. invigorating remedy. For small children Nestle s infant-food, which is by far the best substitute for the milk of the mother, has recently been justly recommended as a nutritious and in- vigorating remedy. Care must be taken to secure frequent change of position, to prevent the accumulation of mucus in the lower lobes of the lungs or in other places, and thus to avoid hypostasis and its consequences. Cold douches and ablutions are to be especially recommended for the purpose of exciting deeper respirations. For the fever we employ cold wrappings, or even cold baths ; small doses of quinine also, under suitable circumstances; and the like. G-eneral abstractions of blood are always contraindi- cated in children. Even from local bleedings no special benefit is to be expected, and, when resorted to, they should only be employed in the cases of very vigorous and well-nourished children. Expectorants afford, on the whole, but little benefit. If the object is to get rid of mucus that has accumulated in the bron- chi, emetics may be used, either alone or in conjunction with the stronger expectorants. Narcotics should be employed with the greatest circum- spection, and only in case of severe irritative cough. When manifestations of collapse are threatened, or are already present, stimulants are required. Treatment of the Chronic Forms of Bronchitis. Chronic bronchial catarrh, which occurs with greatest fre- quency after middle age, presents but few salient points of attack to treatment in general. The same remedies and modes of treatment that have already been mentioned come into use here also. We have already alluded sufficiently often to the fact that these remedies can produce but little effect upon the inflammatory process of the mucous membrane; and this is especially true of the so-called expectorants. This impotence in tlierapeutics is evident in still greater measure in the treatment of chronic catarrh. BRONCniAL CATARRH. 431 The causal treatment—that is to say, the removal of all those sources of injury which have occasioned the catarrh, or which favor its continuance—is here of the greatest importance. Inas- much, however, as this first and most important indication can- not be satisfied in many instances, the successful treatment of these cases is impeded by difficulties in part insurmountable. This is true, for example, of those catarrhs which have become developed in consequence of valvular affections of the heart. In many catarrhs likewise which have occurred as the result of cer- tain avocations associated with the development of dust, there is no hope of successful treatment if the source of injury is not removable. It needs no argument to prove that wherever these causal indications can be followed, their fulfilment is the first object in treatment. In reference to the special treatment of chronic bronchitis in a more restricted sense, the therapeutic principles already men- tioned apply here in general also. These vary so greatly ac- cording to the special variety of the disease, the duration and severity of individual symptoms, the age, corporeal vigor, and other conditions of the affected individual, that we shall be jus- tified in giving a brief description of the special indications. We begin, first, with the so-called dry variety, the catarrhe sec of Laennec, for the treatment of which Laennec has already laid down the essential principles. We must recollect that the minuter bronchi are here the predominant seat of the catarrhal affection, and that a further characteristic exists in the scanty, but often extremely difficult expectoration, and in the severe paroxysms of cough. We have already made reference to its intimate relationship to emphysema. Here the object of treat- ment is to remove the hypersemia and swelling of the bronchial mucous membrane, and especially to detach and dilute the tena- cious bronchial secretion. For this purpose, alkalies are most deserving of trial, and they are frequently employed, especially at the present time, in the form of inhalations. In mild grades of the affection even the inhalation of warm vapor of water is competent to alleviate tlif severe paroxysms of cough and facilitate expectoration. The alkalies are also frequently employed in the form of mineral 432 RIEGEL.—DISEASES OF TRACHEA AND BROXCIII. waters ; the special selection of which should be made in accord- ance with the rules already laid down. The special expectorants are of but slight service in this form of catarrh. The employment of condensed and rarefied air is furthermore to be mentioned as a means of medication that has recently come into greater use. While increased atmospheric pressure in the pneumatic cham- oer has been employed in Germany as a remedial agent for more than twenty years, it is only since the introduction of trans- portable pneumatic apparatuses that any extensive employment has been made of condensed or rarefied air. The results, so far, are much in favor of the efficiency of this agent in the forms of disease under consideration. Great progress has recently been made in the knowledge of the physiological principles upon which its employment depends, chiefly by the investiga- tions of von Liebig,1 Quincke and Pfeiffer,2 von Vivenot,' Waldenburg,4 and others. As far as present experience indicates, the alternate employ- ment of condensed and rarefied air is most to be recommended in the drier varieties of chronic catarrh. This does not require an apparatus of such a kind that both kinds of air can be made simultaneous use of in the individual phases of respiration ; the arrangement provided in Waldenburg's and other similar appa- ratuses suffices completely for the purpose. It is best to let such patients make expiration into rarefied air, while inspiration is made with ordinary air only, and it is frequently advisable to follow this procedure by a series of inspirations of compressed air, expiration being made into the ordinary atmosphere. Numerous further observations are requisite, as a matter of course, in order to appreciate the indications and contraindica- tions of this method of treatment more minutely than is at present possible. Still the experience thus far gained with the 1 Deutsches Archiv f. klin. Med., Bd. X., Heft 3.—Deutsche Klinik, 1872, No. 21.— Mittheilungen und Auszuge aus dem arztl. Intell.-Blatt. 1 Ser., No. 4, 1874. 2 Reichert's und Dubois Reymond's Archiv, 1871, Heft 1. 3 Zur Kenntniss der physiol. Wirkungen und therap. Anwendung der verdichteten Luft, von R. vonVivenot, jun. Erlangen, 1868. 4 Berliner klinische Wochenschrift, 1873. BRONCHIAL CATARRH. 433 method is already so much in its favor that we need not hesitate to believe that in the portable pneumatic apparatus we have an extremely valuable remedial agent for the treatment of the dis- eases under consideration. The remaining remedies mentioned on previous pages are to be employed according to well-known indications. Thus, for example, emetics are to be employed, not when the swelling and hyperaemia predominate, but when an abundant secretion closes numerous bronchial tubes and thus occasions dyspnoea. Cutaneous irritants are in general merely of temporary benefit. Under certain circumstances they may be found of service to diminish manifestations of dyspnoea. Dry catarrhal bronchitis, as already mentioned, is not infre- ' quentiy observed in children also ; and it is always a very serious disease, frequently terminating fatally. As regards the treat- ment of the affection, the frequent inhalation of warm vapor of water, of alkaline remedies, of solutions of carbonate of soda, lime-water, tannin, and the like, play the predominant role. Emetics, in most instances, are of no special benefit. On the contrary, the indication is not infrequently for stimulants, when severe dyspncea and evidences of collapse are present. Expec- torants 'are of little use. Narcotics, opiates especially, are to be administered for the purpose of relieving the occasional severe paroxysms of cough. Wi liter-cough should be mentioned as another and a mild form of chronic bronchitis, associated with but moderate expec- toration. As the designation "winter-cough" indicates, the appearance of this form of the affection is coincident with the onset of the inclement season. This suggests in itself the proper treatment, to wit, certain prophylactic sanitary regulations. It is especially advisable for persons suffering with this form of bron- chitis to resort to a mild southern climate during the inclement portion of the year, so as to avoid the injurious influences which experience has shown to be the cause of the malady. The majority of patients suffering with this form of disease are not, however, in a position to avail themselves of some southern climatic health-resort. So far, then, as circumstances permit, care should be taken that the patient remain in an apartment VOL IV —28 434 RIEGEL.—DISEASES OF TRACHEA AXD BRONCHI. constantly maintained at an equable temperature; that he should be warmly clad, and that he should avoid every external source of injury, every risk of taking cold, and the like. Special treat- ment is to be directed in accordance with the principles applica- ble to bronchitis in general. The employment, also, of com- pressed and rarefied air in the manner already mentioned is to be recommended in these catarrhs. In those cases in which the bronchitis is associated with cer- tain dyscrasise, such as scrofnlosis, syphilis, and the like, the chief attention must, as a matter of course, be directed to these fundamental affections. Especially should it not be forgotten that, under the influence of syphilis, inflammatiory conditions, although less frequent than in the larynx, are sometimes estab- lished in the trachea and the bronchi, and that they may even progress to ulceration, and finally to the production of constrict- ing cicatrices. The clinical picture of this condition, however, does not vary from that of simple inflammatory conditions, so long as it has not progressed to stenosis. We have already learned to regard fetid bronchitis as an additional form of chronic bronchitis. Here, it is self-evident that the first indication in the treatment is to suppress the putrid decomposition of the bronchial secretion. Inasmuch as* the pro- longed retention of the secretion within the bronchial tubes favors its putrid decomposition, the object of treatment, in cases in which the secretion stagnates for a long time, is to prevent this stagnation. This indication often can only be fulfilled very incompletely. The ultimate cause of the stagnation is often to be found in conditions which are not removable, such as bron- chiectasiae, paralysis of the bronchial muscles, diminished sensi- tiveness of the mucous membrane, and the like. To prevent the long retention of the secretion within the bronchial tubes, by the administration of emetics, is a method which in any instance can only be temporarily employed, and in no instance can be re- peated with sufficient frequency. Powerful expectorants are likewise only partially competent to satisfy this indication. Therapeutic efforts, therefore, have long been directed to- wards preventing the decomposition of the bronchial contents. Inhalations of oil of turpentine were first recommended for this BRONCHIAL CATARRH. 435 purpose by Skoda, and they have long been accepted as the exclusive method of treating these affections. Other disin- fectant substances recommended by various authors, such as clilorinated water, permanganate of potassa, and the like, have proved of little value. Inhalations of carbolic acid, in a solu- tion of from two to four per cent., have been recently especially recommended by Leyden.' I can fully substantiate the exceed- ingly favorable results reported by Leyden. Leyden recom- mends masking the unpleasant odor or taste, in sensitive patients, by means of mint-water, and also the internal administration of the same remedy in a solution of from one quarter to one per cent., in tablespoonful doses. Leyden also speaks favorably of the use of alcohol in tliese cases, on account of its disinfectant properties. Of internal remedies we have yet to mention quinine, inas- much as, according to Binz, it not only acts antipyretically, but also disinfectantly upon putrid processes ; and further, acetate of lead, tannic acid, and the like, recommended by Traube. Frequently, also, a corroborant treatment is required, with bitters and tonics, iron, strong diet, and the like. To lessen the fetor the apartment should be kept well venti- lated, and powdered charcoal, chlorinated lime, and the like should be placed in different parts of it. The remaining symp- toms are to be treated according to well-established therapeutic principles. We have already spoken of broncho-blennorrhoza and serous bronchorrhcea (the pituitous catarrh of Laennec) as further sub- varieties of bronchitis. In the first variety^, which is characterized by the discharge of copious quantities of muco-pus, treatment is directed to two principal objects : first, to prevent the formation of this purulent mucus; and, second, to facilitate its expectoration. The first object is best fulfilled by the balsamic remedies, of which oil of turpentine has been the most extensively employed, most fre- quently by inhalation, less frequently by internal administra- tration. Copaiba, balsam of Peru, and balsam of Tolu, myrrh, 1 Ueber Lungenbrand, Sammlung klinischer Vortrage, herausgegeben von R. Volk- mann. 436 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. anjd ammoniac are also recommended for this purpose. Carbolic acid, in addition to its disinfectant properties, has also the prop- erty of restricting the secretion of pus. As further remedies of the same sort, though far less effective, acetate of lead, tannin, rhatany, and similar desiccating and astringent remedies may be recommended. The second indication of treatment is to facilitate the expec- toration of the secretion. As this is impossible without cough, and as, on the other hand, the activity of the auxiliary muscles in the act of coughing is an important condition for the expul- sion of this secretion, the abatement of the disposition to cough by narcotic and sedative remedies is here contraindicated. On the contrary, it is essential to employ remedies which excite the efforts of coughing. When, therefore, the cough is in itself not sufficiently powerful to accomplish the expulsion of the secretion in the bronchi, the employment of such remedies is demanded as are calculated to effect this result. Under certain circumstances, therefore, even emetics are to be recommended to this end. In other cases powerful expectorants, as senega, ammoniacal solu- tions, benzoic acid, and the recently introduced muriate of apo- morphia are applicable for the purpose. Mechanical compression of the thorax during expiration is also to be recommended in these cases (Gerhardt). It is scarcely necessary to add that ample nourishment must be provided to supply the waste occasioned by the copious bronchial secretion. The administration of alcoholic and cor- roborant remedies are frequently demanded in these cases. We have mentioned bronchorrhcea, the pituitous catarrh of Laennec, as the last variety of bronchitis. The characteristics of this variety consist in the abundance of the sputa, in the pau- city of the cellular elements which they contain, in their serous consistency, and in the fact that they are expectorated after severe paroxysms of cough. This variety is usually developed out of other forms of chronic bronchial catarrh, and is very fre- quently associated with affections of the heart which lead to stasis in the bronchial veins, or with pulmonary emphysema, and the like. Inasmuch as the disturbed conditions of the cir- culation play an important role in the production of bronchor- BROXCIIIAL CATARRH. 437 rhoea, the first indication in treatment is to regulate tliese con- ditions. It is not practicable, however, in the majority of cases, to satisfy this indication completely. Regular modes of living, the removal of all external sources of injury, the avoidance of every strong exertion, precautions against taking cold, care for regular evacuation of the bowels, and the like are to be men- tioned as tending to promote the object in view. In addition to this, derivatives towards other organs are to be employed, in the hope of exciting increased secretions from them in order to relieve the bronchi. Derivatives to the bowels and the kidneys are employed most frequently. The benefit from this practice? is usually but very slight or quite temporary ; or else it fails completely. In addition to these measures, astringent remedies may be employed, in order to limit the bronchial secretion in a more direct manner ; such are, for example, alum, tannin, lead, chlo- ride of iron and the like. These remedies are employed most frequently in the form of inhalations. The pneumatic treatment is also to be recommended in tliese cases in the manner already mentioned Narcotics, in general, are but seldom to be used, for the same reasons as those advanced in speaking of broncho-blennorrhcea. Powerful expectorants, emetics, and excitants also, are em- ployed in tliese cases, according to the same rules as have been briefly sketched for their employment in broncho-blennorrhoea. 438 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. PSEUDO-MEMBRANOUS, CROUPOUS, OR FIBRINOUS BRONCHITIS; BRONCHIAL CROUP; BRONCHITIS WITH THE FORMATION OF FIBRINOUS CASTS. Prefatory Remarks. The subject before us, concerning which, on account of its general rarity, hardly an individual observer is in a position to acquire great personal experience, has already been worked up with great clearness by Biermer in Virchow's Manual.' Biermer has based his study upon clinical material, comprising fifty-eight cases, of which two occurred under his own observation. In addition to this, Biermer has in the most commendable manner gathered together a complete bibliography of the subject, old and recent. Lebert has recently presented an analogous study of the subject, based on a careful analysis of all the cases hitherto reported. Lebert has published, both in a separate essay (Deutsches Archiv f. klin. Med., Bd. VI.), and in his recent work entitled "Klinik der Brustkrankheiten," an accurate description of this form of disease, based upon the clinical material which he has found recorded in medical annals. Biermer, in his work on the subject which forms the basis of our own study of the topic, includes under the name of bronchial croup only those cases in which the croupous process is limited to the bronchi, or has at least taken its starting- point in these tubes. On the other hand, those observations in which the croup extended from the larynx to the bronchi are not included, nor those in t\ hich casts have formed in the bronchi during the progress of a croupous pneumonia. But he does take into consideration the secondary bronchial croup which is sometimes observed as a result of chronic affections of the lungs, tuberculosis for example. Lebert also excludes those cases in which the fibrinous bronchitis is a continua- tion of fibrinous laryngitis. On the other hand, he includes among his examples of fibrinous bronchitis, the cases in which casts have formed in the bronchi in the course of croupous pneumonia, and then distinguishes the following six categories: 1. Incomplete observations; 2. Cases of acute fibrinous bronchitis without un- mistakable signs of the condition during life; 3. Cases of acute bronchitis, with characteristic manifestations, such as, in particular, fibrinous expectoration; 4. Cases of acute pneumonia with extensive formation of membrane, without charac- teristic expectoration, and cases of acute pneumonia with expectoration of extensive fibrinous formations (smaller specimens are expectorated in almost every case of diffuse pneumonia); 5. Chronic essentially fibrinous bronchitis; 6. Chronic symp- 1 Virchow's Handbuch der speciellen Pathologie und Therapie, 5. Bd. Biermer, Krankheiten der Bronchien und des Lungenparenchyms. CROUPOUS BRONCHITIS. 439 tomatic fibrinous bronchitis. In the following remarks we shall adopt Biermer's division, and describe in the first place only that form of croupous bronchitis which commences primarily in the bronchi. On the other hand, we shall exclude from con- sideration both that form in which croupous laryngitis has extended into the trachea und the bronchi, and also that form in which the croupous inflammation of the alveoli of the lungs has been secondarily transplanted upon the terminal ramifica- tions of the bronchi. Although the bibliography of this subject is to be found collected in the manuals of both Biermer and Lebert, and we have but few new observations to add, it appears desirable to premise the discussion of our theme by a brief survey of what has been thus far written upon it. In doing this we will only include those cases which belong to our subject, in accordance with the definition given above. Galenus, De locis affectis, Lib. I., Cap. 1. (He relates that he has seen a pulmo- nary vessel expelled; apparently this is to be regarded as a bronchial cast.)— Murcellus Donatus, De medica historia memorabile, Lib. VI. Mantua, 158G.— Hiller, Bibliotheca anatomica, I., 263.—Morgagni, XXL, 20. edit, nona Lute- tin;, 1821, T. IH, p. 35. (He speaks of a small venous tube expectorated.)—N. Tulpius, Observation, medic, Lib. II., Cap. NIL, p. 115. Amstelodami, 1641. (Two cases with good representations of the expectoration, which are designated as Surculi vcna> arteriosa? expectorati).—Th. Bartholinus, Histor. anatom. r., Cent. HI., hist. 17 and 98, 1657. (Two cases.)—Moellenbrock, Ephemer. natur. curios., Dec. 1, An. II, Obs. 91, 1671.— Yerzascha, Obs. med. Cent. Basil, 1677, Obs. 25.—Bonnetus, Sepulchrct, Lib. II., Sect. 6, and Lib. I., sect. 22. Genev., 1679.—D. B. Observ. singul., etc. Act. erudit, 1683, p. 281.—Mack, Ephem. Natur. cur. Dec, II., An. X., Observ. 102, 1691.—Ruyschius, Resp. ad Epist., probl. VI., Fig. 4, Museum anatom., p. 122. (Describes the expectorated masses as polyps.)—Clarke, Philos. Transact., Vol. XIX., 1697, p. 779. (First accurate description of a case of chronic fibrinous bronchitis.)—BussiereT. Philos. Transact,, Vol. XXII., 1700-1, p. 545. (A case observed in a boy five years of age, with autopsy.)—lemery, Histoire de TAcademie des Sciences, 1704, p. 23.—Sambrr, Philos. Trans., 1727, p. 262. (Htemoptysis and expul- sion of an enormous polyp, having many ramifications. Illustrated.)—Struve, Acta Med. Phys. Nat. Cur., Vol. I., November, 1727, Obs. d6.—Nidiolls, Phil. Trans., Vol. XXXVII.. p. 123, 1731-32.—Pasta, Epistol. de Cord, polyp, n. 11, Bergam., 1737 ; Morgagni XXL, 20.—Kaaw Boerhave, Perspiratio sic dicta Hip- pocratica, etc. Lugd. Batav., 1738, p. 114. (Case of chronic fibrinous bronchi- tis.)— Kellner, Acta natur. Cur., Vol. V, 1740, p. 283, Obs. 14.—De Haen, Ratio medendi., T. II., c VII., 1758. (Pleuritis with expulsion of polypus; autopsy.)—DaTby, Journal de Med., etc, T. XL, pp. 42 and 370, 1759.— Morgagni, De sedibus et caus. morb., Epist. XXL, Cap. 20, 1760.—Senac, Traits du cceur, I., 4, ch. 3 and 2.—Leboeuf, Memoires de Facademie de chirurgie, 1764.—Marcorelle and Butler, Acad, des Scienc, 1762.—Van Swieten, Comment, in Boerhave Aphorism., Tom. IV, p. 31, aphorism. 1199. Hildburgh., 440 RIEGEL.—DISEASES OF TRACHEA AXD BROXCUI. 1765. — Warren, Med. Trans., Vol. I., p. 407, 1767.—Murray, Opusc, Vol. I., p. 255. De polypis bronchior. Commentatio soc. scient. Gottingcnsi pia>- lecta d. 6. Mart. a. 1773.—Michaelis, De angina polyposa. Gotting., 1778. Sect. II. de polypis asp. art. in genere.—Dixon, Duncan's medical Commentar., Vol. IX., 1783-4, p. 254. (Describes a marked case, and already recommends lime-water as the best solvent.)—Mogle, London Med. Journ., Vol. VI., 1785, p. 252.—John Hunter, A Treatise on the Blood, etc. London, 1794. (Report of a case and illustration of a bronchial cast.) Brennan, London Medical and Physical Journal, Vol. VIII., 1802-3, p. MO.—Cheyne, On Bronchial Polypus, Edinb. Med. and Surg. Journ., Vol. IV, p. 441, 1808; and The Pathology of the Membrane of the Larynx and Bronchia. Edinb., 1809.—Ascherius, London Medical and Physical Journal, Vol. VIII., 1802-3.—Raikem, Bull, dela faculty de mgdecine, T. IV., 1814-15, p. SS.—Chaussier et Louyer Villermay, Bull. de la faculte de medecine de Paris, T. IV, 1814-15.— Fr. Mutter, Beschreibung eines merkw. Falles von wahren Fleischpolypen in den Bronchien. Dissert. Giessen, 1818.— lllif London Med. Repos., Vol. XVIII., 1820, p. 207.— Gendrin, Histoire anatomique de i'inflammation, T. I., p. 608. Paris, 1826.— Reynaud, Mem. de Tacad. de med., T. IV, 1835.—Cazeaux, Bull, de la soc. anat., No. 17, III. ser., p. 337, Jan., 1836.—Casper, Wochenschrift fiir die gesammte Heilkunde, No. 1, 1836. 1837, p. 33 der med. Wochenschrift.— Andral, Clinique medicale, T. III., p. 222. Paris, 1834.—Sander, Casper's Wochenschrift, No. 32, 1836.—Hervez de Chegoin, in Cazeaux, Bull, de la societe anatomique de Paris, T. XL, p. 343, 1836.—Schwabe, Casper's Wochen- schrift, No. 20, 1837. (Chronic case.) Nonat, Recherches sur la grippe, etc. Paris, 1837; Arch, gen., 3. ser., T. II., Juin, 1837.— North, London. Med. Gaz., Vol. XXII., 1838, p. 330. — Car swell, Illustrations, etc. London, 1838.—Fasc. analog. Tissues, Plate 1.—Starr, London Med. Gaz., Vol. XXV, 1839.— Fauvel, Memoires de la soc mgd. d'observation, T. II.—Cane, Observations on Plastic Bronchitis, or Bronchial Polypi, The Dublin Med. Jour., Vol. XVII., 1840, p. 116.—Albers, Erlaiiterungen zu dem Atlas der pathol. Anatomie, 1833. —Brummer, Casper's Wochenschrift, No. 6, 1841.— Baillie, A Series of Engrav- ings, etc., to illustrate the Morbid Anatomy of the most important Parts of the Human Body. London, 1799-1802.—Middendorp, De bronchiorum polypis. Dorpati, 1835.—Hayn, Casper's Wochenschrift, 1842, No. 56.—Ranking, London Med. Gaz., Vol. XXVIIL, p. 832. (Schmidt's Jahrb., Bd. 37, p. 164.)— Rizzi, Gaz. med. di Milano, No. 27, 1844.—Franz Simon, Beitrage zur physiolo- gischen und patholog. Chemie. Berlin, 1843, p. 115.—Heinrich, Haeser's Archiv, Bd. VI., p. 245. (Describes only the microscopical structure of a fibrinous expectoration).—Hayn, Konigsberger medicinische Zeitschrift, 1844; Prager Vierteljahrschrift, 1844; I. Analekten, p. 85.—Corrigan, Dublin Journ., Vol. XVII., 1840, p. 116.—Reid, London Med. Gaz., June, 1844, p. 411; Froriep'sNotizen, Bd. 33, p. 108. (Two chronic cases.)—Albers, Rhein.-westphal. Corresp.-Bl., Nos. 13 and 15,1845.—Meerbeck, Annal. de la soc. d'Anvers, Avril, 1846.— Watts, London Med. Gaz., May, 1847.—Puchelt, Jr., Ueber Bronchitis CROUPOUS BRONCHITIS. 441 mit Bildung von Bronchialgerinnseln. Heidelb. med. Annalen, Bd. 13, Hft. 4, pp. 479-535, 1848. (A good monograph, with almost complete bibliography.) —Barrier, Traite1 des maladies de I'enfance. Paris et Lyon, 1845, T. I., p. 105. —Berliner, De polypis bronchiorum. Diss. Regiomont, 1848.—Thore,fils, Arch. ggn., Juill. 1849. (Schmidt's Jahrb., 65. Bd., p. ri2.)—Laffiley, Bull, de la soc. anat., T. XXIL, p. 332, 1847.—Bezeth, Merkwaardig geval van bronchialcroup big een twee-entwintigjarigen man. Nederl. Weckbl., J. IL, p. 181.— Von Gumocns, Schweiz. Zeitschr. f. Medicin u. s. w., 1854, 3 u. 4. Hft. (Three chronic cases).— Thierfeldcr, Bronchitis crouposa. Archiv f. physiol. Hcilk., XIIL, 2, 1854. (Presents eighteen collected cases and one original obser- vation.)—Peacock, Med. Times and Gazette, Dec. 1855, p. 658.—Lasserre, Archiv gen. de med., 4. serie, 1849, Vol. XX.—Nicholl, The Lancet, Feb., 1855.—Leudct, Gaz. hebd., Nos. 5, 8, 1855.—Biermer, Die Lehre vom Auswurf., pp. 49 and 106. Wiirzburg, 1855. (One chronic case.)—Fuller, Trans. Path. Soc. London, Vol. V., p. 41, 1854. — Oppenheimer, Verhandlungen d. naturhist. med. Vereins zu Heidelberg, 21. Dec, 1857. (One chronic and one acute case.) — Watson, Lectures, London Med. Gaz.—Lebert, Traite d'anat. pathol., Vol. I. Paris, 1857. (Description of the anatomical relations, illustrated.)—Samuelson, Konigsberger med. Jahrbiicher, 1. Heft., 1858.—Hirsch, Klinische Fragmente, 2. Abthlg. Konigsberg, 1858, p. 165.—Oppolzer, Allg. Wien. med. Zeitg., 4, 1858.— Xunneley, Trans. Path. So., Vol. XL, p. 23.—Ogle, Ibidem, Vol. XL, p. 23.—Hyde Salier, Ibidem, Vol. XL, p. 36.— Walshe, Diseases of the Lungs. London, 1860, p. 222.—Giraudet, Gaz. des hop, No. 82, 1864.—ScJmitzler, Wien. Med.-Halle, V. 44, 46, 1864. — Parmcntier, Bulletins de la societe anato- mique, T. XXXVI., p. 324, 1861.—Ilillton Fagge, Trans. Path. So. London, Vol. XVI., p. M8.—Rollett, Wien. med. Woch., XVI., 20, 21, 1866.—Triponel, De la bronchite plastique. These. Strassburg, 1866.—Spaeth, Med. Corresp. Blatt d. Wi'irttemb. firztl. Vereins, Bd. XXXVL, No. 8, 24. Miirz, 1866.— Paulicki, Wien. med. Woch., XVII., 86, 1867.— Sklarck, Deutsche Klinik, 32, 1865.—Croca, Presse m£d., XIX., 17, 1867.—Bonmariage, Presse med., No. 17, 1867.—Biermer, Krankheiten der Bronchien, 1867, in Virchow's Handbuch der speciellen Pathologie u. Therapie.— Oppolzefs Vorlesungen iiber specielle Pathologie u. Therapie, Bd. I., 1868.—Prahl, Et Tilfaelde af akut Bronkial- krup, Hop.-Tid., 12. Aarg., p. 29, 1869.—Douglas, The Edinb. Med. Jour., July, 1868.—Lebert, Ueber das Vorkommen fibrinoser Entziindungsproducte in den Bronchien und Lungenalveolen, D. Archiv f. klin. med., Bd. VI., pp. 74, 126.—Baumgarten, St. Louis Med. and Surg. Journ., Jan. 10, 1869.—Laure, Lyon medic, Sept. 12, 1869.—Richard J. Hallon, Dublin Jour., XLVIL, p. 369, May, 1S69.— Waldenburg, Berliner klinische Wochenschrift, No. 20, 1869. (Case of chronic croup of the bronchi in a girl eight and a half years of age, with termination in recovery.—Roth, Deutsches Archiv f. klinische Med., Bd. VII., p. 151, 1870.—Tuckwell. Trans. Path. So., XXL, Organs of Respira- tion, 10, 1S71.— Stage, Tilfiilde af akut kroupos Bronkitis, Hosp.-Tid., pp. 189, 193, 1S71. — Thegerstrom och C. A. Blix, Fall af croupos bronchitis, Hygiea, 442 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. 1871, Sv. lak. sallsk. forh., p. 122, 1872.— Commandre, Soc. de Med. de Lyon, Avril, 22, 1872.—Kretschy, Zur Bronchitis crouposa, Wien. med. Woch., 1873, 14,15,16. Rundschau, 1874, Miirzheft.—Bettelheim, Casuistische Mittheilungen iiber Bronchitis crouposa. Mittheilungen des arztlichen Vereines in Wien, 1873, Bd. IL, No. 23.— Chvostek, Wien. med. Presse, XIV, 32, 1873.— Austin Flint, Fibrinous Casts of Bronchi, Medical Record, Jan. 15, 1874. Consult, in addition, the manuals and treatises on pathological anatomy and on special pathology and therapeutics. Introductory Remarks and Etiology. The form of disease under consideration has been discussed by individual authors under very different appellations. It is sometimes designated as bronchial croup, sometimes as fibrin- ous bronchitis, and sometimes as pseudomembranous bron- chitis. In olden times the term bronchial polyps was fre- quently employed to designate the pathological products. Lebert designates the disease as fibrinous bronchitis, "because the fibrinous nature of the inflammatory product constitutes its chief characteristic; the fibrine, in this affection, exuding as such from the bronchial capillaries or the pulmonary capillary vessels, in company with the white corpuscles, or perhaps escap- ing as fibrinogen which promptly coagulates on exposure to air." The term croupous bronchitis is still employed by most authors. As already mentioned, we shall take into consideration here only those cases in which the croupous process has originated in the bronchi. From an anatomical standpoint, we must include under the term croupous bronchitis all those cases in which fibrinous products in general are deposited upon the bronchial mucous membrane, whether they occur there as a primary dis- ease, whether the croupous process has become secondarily extended upon the trachea and the bronchi, or whether it is as- sociated with croupous pneumonia and the like. From a prac- tical stand-point, on the contrary, tliese individual forms possess each a very different significance. As we shall take into consideration here only the form men- tioned above, the remark must be premised that a large number of observations are recorded in medical literature which are valueless for any accurate analysis, on account of their incom- CROUPOUS BRONCHITIS. 443 pleteness or want of details. Lebert,' in the careful compilation made by him, found thirty-two such cases recorded. Croupous bronchitis, as a genuine primary form of disease, is a very rare affection, and one which occurs more frequently in the chronic than in the acute form. Its occurrence is so infre- quent that even in large hospitals years and decades may pass before a single case of the kind comes under observation. Of acute fibrinous bronchitis, with fibrinous expectoration, Lebert could find but seventeen observations,3 after a careful analysis of all the cases known at the time of writing. As regards the etiology of this form of disease, we are in possession of hardly a single well-established fact. The dis- ease, in both its acute and chronic forms, is observed more fre- quently in males than in females. In the acute form, according to Lebert, the proportion of men to women is 11:6, or nearly as two to one ; in the chronic form, according to the same author, it is nearly 3 : 2. Biermer,3 who has analyzed fifty-eight cases, records nineteen in females and thirty-nine in males. As to the age of the patient, the disease is observed far more frequently in youthful subjects. On the other hand, it occurs tolerably seldom in childhood, and still less frequently in ad- vanced age. Most of the cases observed occurred between tiie tenth and the thirtieth years of life ; below this period it was always less frequent, and it occurred in but few instances at advanced age. Only a couple of cases have been observed in early childhood. The oldest subject was seventy-two years of age; and with reference to this case it is to be remarked that this individual had already had fibrinous expectoration, from time to time, for seven or eight years (Goumoens' case, 1. c). As to precious health and vigor, it is to be remarked of the subjects affected with the disease, that in many cases no special injurious influence had been previously apparent, and the state of constitution had been good. On the other hand, in the greater number of the cases the appearance of real bronchial croup was preceded by repeated attacks of acute or more chronic J Klinik der Brustkrankheiten, I. Bd., 1 Halfte, p. 110. 2 L. c, p. 117. 3L. c, p. 718. 444 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. catarrh; so that a predisposition to catarrh seems to be a favor- ing preparatory condition for the occurrence of bronchial croup. In other cases, physical debility from previous disease has been noticed, and this, perhaps, has increased the predisposition to the affection. According to some, pregnancy and menstru- ation have had, in a few cases, a certain though very remote relation to the occurrence of the disease. Of interest, in this con- nection, is the case reported by Schnitzler,l in which the attack followed the menstrual period. In several cases the disease occurred during pregnancy. Besides this, there seems to be a special predisposition to this disease in many families. A num- ber of observations are on record in which several members of the same family became affected with the disease. Position in life does not appear to exert any influence. The disease has been observed both in the well-to-do classes and in the poorer classes, and any special preponderance of cases in one or the other station of life has not yet been established. Just as little special preponderance is known as regards local- ity or nationality. In general, however, the frequency of bronchial croup ap- pears to have borne a certain relation to the frequency of bron- chitis. Whether the greater frequency of bronchial croup in Switzerland, spoken of by Biermer, is simply accidental, or actually due to local conditions, can only be determined by a large series of statistics. As yet the reports of cases of bron- chial croup are so scanty, that the fact that most of the known cases have occurred in Germany and in England cannot justify any conclusion as to the greater frequency of the disease in these countries. On the other hand, as advanced by Biermer, the in frequency of croup in southern climes seems to apply to croupous bronchitis also. Unfortunately, in the cases reported, the data regarding the frequency of occurrence of the disease at different seasons are too scanty for statistical purposes ; nevertheless, it seems highly probable that the majority of cases were observed in the spring, especially towards the end of spring, that is, at the same period in which pneumonia most frequently occurs. Hence, croupous 1 Wien. Med.-Halle, V., 44, 46, 1864. CROUPOUS BRONCHITIS. 445 bronchitis, like pneumonia, probably owes its development in a measure to the great daily variations of temperature and the like which occur at this period. Atmospheric influences, and taking cold, have generally been regarded as playing the same part in the production of this disease that they do in the production of catarrhs of the respira- tory organ, and especially of pneumonia. Exactly what is the association between these sources of injury, and the croupous bronchitis thereby occasioned, is by no means clear. On the other hand, there are at least an equal number of observations in which the disease became developed without any evidence of the influence of any such cause. While the disease begins suddenly in one series of cases, without being preceded by any disturbance on the part of the organs of respiration, especially by catarrh, yet in a much greater number of cases the appearance of the disease is pre- ceded by simple catarrh for a longer or shorter period. There is so much reason for considering the latter as the rule that bron- chial croup appears to take its origin from an ordinary bron- chitis. This bronchitis preceding the croupous exudation is sometimes acute, sometimes more chronic. In many cases it is of such short duration that the symptoms of bronchial croup follow almost immediately upon the commencement of those of bronchitis. These symptoms, as we shall see later, are espe- cially characterized by very severe suffocative paroxysms. In not infrequent instances, as in one of Biermer's cases, the mani- festations of bronchial croup are preceded for a long time by those of tuberculosis. Haemoptysis has also been observed as a precursor of bronchial croup, and on this account a closer connection has been supposed to exist between tuberculosis and croupous bronchitis. It is to be remembered that croupous bronchitis itself frequently occasions haemoptysis, without tuber- culosis, and that, therefore, every haemoptysis that occurs is not to be referred to a tuberculous origin. According to the obser- vations thus far recorded, we must express the opinion, with Biermer, despite the opposite views of some, that an intimate connection between tuberculosis and bronchial croup in no wise exists, or at least has not as yet been proven. 446 RIEGEL.—DISEASES OF TRACHEA AXD BRONCHI. So, also, not even the remotest connection with croup has been proved in any of the different dyscrasic conditions. Nei- ther of syphilis, rachitis, scrofulosis, nor of other similar morbid processes has it been proven that they stand in any closer con- nection with the occurrence of bronchial croup. A rachitic shape of the thorax has been mentioned in the case of several children who were affected with bronchial croup ; but not in the remotest manner do they show any closer association between these two affections. On the contrary, numerous facts indicate a merely accidental coincidence. Rachitis, like scrofulosis, syphilis, chronic alcoholism, and similar affections, may well favor the occurrence of bronchial croup, in so far as it enfeebles the general constitution; but there can be no thought of any further relation between the two. From what has been said it is evident how defective our knowledge of the etiology of bronchial croup still remains. All the causes mentioned may play a certain part in the produc- tion of this form of disease, but only a very remote one. A special predisposition, or the influence of some special unknown agency, is always essential in addition. In what this consists the observations thus far made have not yet been able to determine. Forms and Course of Fibrinous {Croupous) Bronchitis in General. As already remarked in our introduction, bronchial croup progresses under two different forms, acute and chronic. By far the greater number of cases yet observed belong to the chronic form. On the other hand, the acute form of genuine bronchial croup has as yet been observed only in a small num- ber of cases. Lebert has been able to collect but seventeen instances, in a recent compilation made for the first time from the entire range of medical literature. We will first consider the acute form with reference to its course. The disease may begin in the form and manner of an ordinary acute catarrh, with slight fever, more or less dry cough, feeling of oppression on the chest, loss of appetite, increased CROUPOUS BRONCHITIS. 447 thirst, and similar symptoms. After these simple catarrhal symptoms have existed for some days, severe symptoms occur more or less suddenly, including intense dyspnoea, increasing to manifestations of suffocation, active febrile movements, dry, harsh cough, usually without any or with but scanty expectora- tion, severe oppression and feeling of anxiety, sometimes even slight haemoptysis. In other cases, on the contrary, the symp- toms of actual fibrinous bronchitis are not preceded for a longer or shorter period by the symptoms of simple catarrh, but the dis- ease begins at once with very urgent symptoms, sometimes even with a severe rigor, which may then be repeated several times, high fever, intense dyspnoea, and severe, tormenting, long-con- tinued paroxysms of cough. Great dyspnoza, associated with marked sensation of oppression in the chest and dread of suffo- cation, is almost never wanting in this form. In some cases the commencement has been just like that of a pneumonia (as a mat- ter of course, without the later development of this disease), ushered in, that is, with chill followed by heat, pain in the side, and similar symptoms. In other cases symptoms of angina have preceded all others. The cough is usually at first dry, harsh, and shrill; often extremely severe and tormenting; but not hoarse and muffled, for the larynx remains totally unaffected in this form of affection. If sputa are expectorated, they rep- resent, at first, merely ordinary catarrhal sputa. The expecto- ration frequently exhibits admixture with blood ; sometimes the amount of blood discharged is somewhat greater, amounting to a tablespoonful and more. In its further course, usually, how- ever, only after the lapse of several days, the characteristic fibrinous expectoration becomes manifested; the character of which we shall consider more closely in our analysis of- indi- vidual symptoms. Fibrinous masses, or fragments thereof, originating in the bronchi, are only exceptionally expectorated during the first fewr days of the disease. Their expectoration occurs almost always with very violent straining. The dis- charge of these masses is immediately followed by relief. Not infrequently the first expectoration of the casts is associated with haemoptysis. In other cases, on the other hand, the discharge of these fibrinous masses does not take place. In one case 448 RIEGEL.—DISEASES OF TRACHEA AND BROXCHI. (Oppenheimer) even the otherwise constantly observed and often very tormenting cough was absent. Symptoms referable to the larynx are wanting in this form, as are also the peculiar symptoms of stenosis of the larynx. Of the physical methods of exploration, auscultation, espe- cially, reveals important deviations from the normal condition. The respiratory murmur is always absent where large bron- chial casts are firmly adherent, while the sonority of the per- cussion sound remains. According as the bronchi are more completely and in greater number occluded by fibrous masses, so must the normal respiratory murmur be suspended over a greater surface. The course of this acute form is such in severe cases that the symptoms mentioned constantly increase ; soon symptoms of asphyxia, stupefaction, and somnolence become superadded, and with constant increase of these manifestations a fatal ter- mination finally follows. In many cases towards the end the process becomes extended upon the trachea and the larynx, so that the symptoms of stenosis of the larynx are superadded to those mentioned. This complication, however, is of rare occurrence. If the disease inclines towards improvement, then the mani- festations of d}:rspnoea gradually subside after the expectoration of larger or smaller branched casts, usually with the aid of very violent coughing, and with notable straining of all the forces of expectoration. Sometimes these casts are expecto- rated coiled together in a large ball; sometimes, again, in sepa- rate fragments. The duration of the acute form extends usually over only a few days in those cases which are to terminate fatally. The shortest duration was three days, the longest fourteen days. In cases which are not fatal the course of the disease is somewhat more protracted. In reference to the frequency of fatal cases it is to be remarked that, according to observations thus far recorded, nearly half the cases terminate fatally. The course of the chronic form of the disease is very differ- ent. As a rule, the symptoms of chronic fibrinous bronchitis are CROUPOUS BRONCHITIS. 449 preceded for weeks and months, even for years, by those of ordinary bronchitis. After a shorter or longer continuance of these catarrhal symptoms, severer symptoms become manifested, severe paroxysms of cough, intense dyspncea, and the like, the disappearance of which is coincident with the expulsion of the fibrinous masses. Much less frequently the commencement of this chronic form is the same as has been described for the acute form, so that the disease appears at first with the train of acute symptoms already described, and then in its further course acquires a sluggish character. Sometimes the appearance of the symptoms of fibrinous bron- chitis are preceded by symptoms of pulmonary phthisis with or without haemoptysis, of exudative pleuritis, and the like, so that, in other words, the fibrinous manifestations become superadded to one of the diseases just named. Slight attacks of haemopty- sis, especially, are not unfrequently observed as a symptom in this affection, independently of the existence of tuberculosis. In several of the cases acute laryngeal catarrh, with hoarse- ness, occurred in the commencement, at the same time as the prodromal bronchitis. TJie further course of this chronic form may vary very much. Those cases which are attended only with the symptoms of an ordinary bronchitis, in which the occasional expectoration of branched casts forms the only deviation, pursue a non- febrile course, as a rule. This form may continue for long periods, even for years, without affecting the general condition to any considerable degree. The symptoms undergo exacerba- tion from time to time, the catarrh becomes more severe, moder- ate dyspncea is superadded, and the cough becomes more severe by paroxysms, and after the expulsion in one of these par- oxysms of a larger or smaller cast the symptoms again subside, and the previous feeling of relative comfort returns. Some- times these casts are expelled with tolerable facility and without special straining. There are numerous transition forms between this mild form, progressing without any important injury to the general con- dition, and the severest form, in which the intense suffocative paroxysms set in, and in which, after a short time, the strength VOL. IV.-29 450 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. and the nutrition of the patient suffer in a great degree. In its higher grades the chronic form of bronchial croup presents an extremely tormenting affection, although usually not directly dangerous. Excessive want of breath, intense anxiety and sense of suffocation, tormenting paroxysms of cough, in short, the same train of symptoms that we have already seen in the acute form, characterize the severer grades of the chronic form also, so that in these cases the chronic form presents nothing but a series of acute or subacute attacks, with shorter or longer intervals of complete freedom, or simply of ordinary bronchitic manifesta- tions. These cases, then, like those of the acute form, are not infrequently attended with fever, sometimes slight, sometimes more severe. With the frequent recurrence of these severe attacks it is self-evident that the vigor and nutrition of the patient must suffer in a great degree. The duration of this chronic form is very various. As already remarked, in chronic bronchitis the affection does not consist so much of a single attack, as of a prolonged series of attacks which recur at intervals of varying lengths. Thus the duration of the entire affection, including the intervals between the attacks, may extend over many years. Cases have been repeatedly observed of seven and eight years' duration, and even longer. In a case reported by Walshe, the duration of the disease extended, with slight intermissions, over fourteen years. Just as the general duration of fibrinous bronchitis varies to a considerable degree, so also is the duration of the individual attaclcs very variable, and in like manner the length of the interval between the individual attacks varies notably. In many cases, chiefly mild ones, the expectoration of bronchial casts ceases after a few days, to recur only after a long period. It happens in infrequent instances that the entire process reaches its conclusion with one or two discharges of bron- chial casts. This takes place with greatest relative frequency in cases in which the croupous bronchitis has become established as a temporary complication in other chronic pulmonary affec- tions, especially tuberculosis. As a rule, the individual attacks in idiopathic bronchial croup continue longer than in the acute form; sometimes they last through several weeks, and even for CROUPOUS BRONCHITIS. 451 longer periods. It frequently happens, too, that at one time the attack will be a short one, and at another time, a very long one. Finally, it is worthy of mention, that the recurrence of the attacks always takes place in an irregular manner. Only in a single case has a certain regularity been observed. Anatomical Changes. The great rarity of the disease, and the greater infrequency of opportunity for post-mortem investigation, renders it not sur- prising that the anatomical relations of croupous bronchitis are not yet sufficiently elucidated in all their details. In the absence of personal knowledge of post-mortem conditions, we will describe the anatomical relations in accordance with the reports recorded in medical literature. Sometimes the croupous process in the bronchi attacks a part of the trachea and most of the ramifications of the bronchi, and sometimes it is confined to individual branches of the bronchial system. The first may be designated, according to Biermer, as the diffuse, the latter as the circumscribed form. The former extending from the trachea into the minutest ramifications of the bronchi, is chiefly encountered in the acute form. The croupous masses behave differently in different cases. Some- times they adhere firmly to the walls of the bronchial tubes, and sometimes they lie free within them separated somewhat from the walls by mucus or air. Sometimes they may be entirely absent in the cadaver, although croupous casts have been ex- pelled in considerable quantity during life. The fibrinous casts are either expelled alone, rolled up in the form of a ball, surrounded only with a little mucus, or they are enveloped in a considerable quantity of catarrhal, purulent, or sanious sputa. The latter condition is observed in the milder forms of croupous bronchitis, and recalls the appearance of similar fibrinous products of inflammation in pneumonia, the frequent occurrence of which was first indicated by Remak. The recently expelled bronchial cast usually forms an irregu- lar, skein-like mass, sometimes of a whitish-yellow, sometimes of a reddish flesh color. The latter color is usually due to admix- 452 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. ture of blood on the surface. For more careful inspection and separation from other admixtures, the entire stringy mass is to be washed in water and spread out upon a support. It is then at once seen how the original mass resolves itself into a series of branching ramifications, which are again resolvable into smaller and smaller subdivisions, accurately corresponding to the sub- divisions of the bronchi. In complete specimens casts of even the terminal bronchi and infundibula can sometimes be detected. In the latter case the ends of the casts are not sharp, but club- like. In cases in which the expectoration of these casts is often repeated within short periods, it can be readily demonstrated that the casts expectorated at different times, frequently ex- hibit exactly the same length and thickness of trunk, branches, and twigs. The length and thickness of the casts are different in dif- ferent cases. As Biermer justly remarks, we can, under cer- tain circumstances, learn from the form of tiie ramified cast, whether it originates from the upper short-branched divisions of the bronchi, or from the lower and more gradually branch- ing ones. Thus, casts from the upper bronchial divisions are marked with somewhat shorter branches, which promptly divide into numerous delicate prolongations; while in those from the lower portion of the lungs, on account of the greater length of the subdivisions of the bronchi, the change into smaller and smaller prolongations is more gradual. Their length is, there- fore, also of importance, inasmuch as we can determine with certainty, by a certain length of a cast, that it could not have come from the bronchi of the upper portion of the lung. These casts are on an average from three to six centimetres in length, but they sometimes reach the length of ten or twelve centimetres. Their thickness often does not entirely correspond with the calibre of the affected bronchial twigs. As a rule, the main stem is not thicker than a goose-quill. In less frequent instances it reaches the thickness of a lead-pencil or even that of a little finger. In a case recently reported by Kretschy,1 which terminated fatally, the length of the entire cast reached 1 Wieh. med. Woch., 1873, 14, 15, 16. CROUPOUS BRONCHITIS. 453 eleven centimetres ; and the thickness of the main stem was about one centimetre and a half. In the majority of cases the cast is not solid, especially in its thinner branches, but is hollow and filled with mucus and air. The thicker stems are usually solid and fibred longitudi- nally ; the thinner stems are much more frequently hollow ; and the thinnest stems again are delicate, solid threads. Even in preparations preserved in alcohol, the pearl-like rows of the air-bubbles can often be seen. On cross-section, especially in the thicker tubes, we can usually recognize a lamellar structure in concentric layers. This indicates that the deposit of fibrine has taken place at intervals. The innermost ring represents the oldest deposit of fibrine, on which, then, a second, a third, and subsequent layers have been deposited. This arrangement in layers can be best seen in alcoholic preparations. The individual layers differ greatly in thickness; internally there may be a tubular canal; sometimes, however, the cast is apparently solid. Thus the alcoholic preparations, in the case reported by Kretschy, showed four delicate, thin, transparent lamellae of different thicknesses, only in the larger pieces there was a central layer of membrane many times folded, which was connected with the lamellar wall by means of delicate horizontal folds. These relations, as a matter of course, may vary very much in individual cases, according to the rapidity with which the membranes are formed. As to their form, we have already mentioned that they do not usually present an entirely smooth surface. The expression, cylindrical in form, generally applied to these casts, does not fully describe their appearance. Bulging or knotty swellings are observed in places ; and the thicker stems are not always round, but are sometimes somewhat flattened (Biermer). These bulg- ing and spindle-shaped places are not ordinarily, according to Biermer, to be regarded as impressions of bronchiectatic dilata- tions, but are due to the circumstance that the croupous exuda- tion, in coagulating, finds obstacles at some places, and is thus prevented from being so completely drawn together. Mucus and air are usually enclosed in these bulging portions, just as between the different layers. The enclosure of air within these 454 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. layers is readily explicable by the rapidity with which they are often deposited. A second explanation of the formation of tliese thicker portions, when solid, is recognized by Biermer, in the secretion of unequal quantities of coagulable material at different points. Sometimes the casts exhibit small spiral turns about their axes, especially in their thinner branches. Spath' alludes to another special peculiarity of these casts. On nearly all the casts examined by him, the upper end, in the direction of the trachea, was obliquely cut off ; which indicates, according to him, that the croupous exudation is only partially continued from the bifurcation of a bronchus, the larger portion of the bronchus remaining free. Spath regards this as an im- portant point for the theory of the mechanism of the expectora- tion. He believes that the end of the cast thus projecting is torn loose by the expiratory current of air in the same manner as in embolism ; and that thus the entire cast, loosened more- over by the action of the bronchial muscles, can be forced out. The consistence of the bronchial cast is usually tolerably compact, and firmly elastic. The finer stems have sometimes a somewhat softer and gelatinous consistence. Frequently, the casts are no longer as firm towards the end of the disease as at the height of the attack. The color, as a rule, is milk-white, or yellowish-white ; some- times mother-of-pearl. The superficial surface, especially im- mediately after expulsion, occasionally shows a bloody tinge, sometimes more uniform, sometimes more in the form of sepa- rate stripes, which, by some observers, have been incorrectly regarded as capillary blood-vessels. Microscopic examination of the cast reveals, as a rule, a structureless, hyaline basement substance, between which cellu- lar elements are thickly pressed together, principally composed of pus corpuscles. In most instances but few or no red blood- corpuscles are enclosed within the fibrinous masses, though they are not infrequently found on the surface. In a case recently reported by Waldenburg,4 the thicker 1 Wiirtemb. Corr.-Bl., XXXVI., 8, 1866. 1 Berlin, klin. Woch., 1869, No. 20. CROUPOUS BRONCHITIS. 455 stems exhibited numberless fat globules and but very few mucus and pus corpuscles, contained in a slightly fibrillated but other- wise hyaline basement substance. The finest ramifications con- tained only a few small fat globules, but, on the other hand, numerous mucus and pus corpuscles. A good deal of fat was detected in the masses by chemical examination also. Sometimes a few cells of cylindrical ciliary epithelium, and like elements are enclosed in the casts. Connective-tissue ele- ments and capillary vessels are not found in them. The chemical relations of the casts correspond with those of coagulated albumen in general, viz., insolubility in water and table salt, and solubility in alkalies, especially in lime-water (the latter fact known to Dixon [1. c] in the last century [1783]). The addition of iodine tinges the cast yellow ; diluted muriatic acid makes it swell. The other masses, sometimes expelled simultaneously with the casts, are usually only simple catarrhal sputa, with san- guineous admixtures. In the majority of cases, as already mentioned in describing its course, a simple bronchitis is asso- ciated with the croupous exudation. TJie mucous membrane of the affected bronchi is sometimes deeply reddened and injected, and sometimes again it is pale. Accurate indications as to the condition of the epithelial layer are wanting in many cases. Biermer found, in the one case which he dissected, the epithelium still remaining beneath the loosely lying casts. In the expectorated casts often exam- ined by him he found only round cells, but no cylindrical epi- thelium enclosed. On the other hand, in the case reported by Kretschy, the epithelium had disappeared without leaving a trace at the place occupied by the plug in the corpse,—having either undergone metamorphosis or exfoliation. In this case also, contrary to what was found in Biermer's case, cylindrical and ciliary epithelium were found upon the plugs last expelled. According to Kretschy's view, the blood only can be the source of the rapid and inexhaustible supply of fibrine as the cementing substance for the croup-membrane, and not the epi- thelial cells; the escape of cells also taking place from the blood-vessels. Kretschy therefore, on the basis of his case, de- 456 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. cides that the croup-membrane is formed by the transudation of a fluid albuminous substance (fibrine), hardening rapidly after its secretion, and the exudation of white blood-corpuscles, and that it is not due to a peculiar metamorphosis of the epithelium of the bronchial mucous membrane, in wrhich the epithelium forms the cellular elements, by endogenous formation of new cells, and the fibrinous framework out of the remaining cellular substance. According to this, the deposit upon the mucous membrane in acute croupous processes would be the result of a formation of fibrine from transuded blood-plasma and exudation of young cell elements ; in short, the process would be exudative. The submucous tissue may, as in laryngeal croup, become swollen and infiltrated with serum. On the other hand, exten- sive ulcerations of the mucous membrane have not yet been observed. As to the condition of the parenchyma of the lungs, it may be remarked that only exceptionally does it remain entirely normal. In cases of long continuance of the affection, especially, alterations are almost constantly found; but even in the acute course some alterations are also found, at least in the majority of cases. A portion of the alterations found in the lungs at the autopsy are not to be regarded as the result of the bronchial croup, but as having preceded its appearance for a shorter or longer time. This applies, for example, to many cases with tuberculous complications. Among the peculiar consequences of bronchial croup we have to mention principally emphysema, or acute dilatation of the lung, and in addition atelectasis, lobular, and less frequently lobar thickening, cirrhotic induration, and circumscribed purulent inflammation. The pleurisy observed in several cases of bron- chial croup was not to be regarded as a secondary affection, but as a complication of the primary one. Symptomatology. Analysis of Individual Symptoms. Having already delineated the course of bronchial croup in CROUPOUS BRONCHITIS. 457 its main features, it now remains to give a short description of its individual symptoms. Among these the expectoration of bronchial casts presenting the form of the bronchial ramifications is the first one to be con- sidered. The quantity of these casts varies considerably in individual cases. Thus, instances are recorded in which from eight to ten and even more casts were expelled daily ; in one rase, indeed, the patient is said to have repeatedly expelled through mouth and nose several cupfuls of casts within a few hours (?). These casts are either expectorated alone, rolled up in the form of a ball, mostly enveloped in a little mucus, or they appear as admixtures in a mass of expectoration, which is some- times of a more mucous character, sometimes more purulent, and sometimes again more or less bloody. We cannot, as a matter of course, form any definite opinion from the quantity of casts expelled, as to the size and quantity of the casts formed within the bronchi. In those very cases in which the croupous product is extended over the largest portion of the bronchial tree, there is frequently no expulsion of casts, inasmuch as the current of air is no longer able to detach them, or is only able to do so partially. Thus, then, the expectorated casts furnish no correct indication of the extent of the croupous process. In view of the rapidity with which these casts appear, even when much subdivided, the fact above mentioned of the rela- tively great quantity of casts is readily comprehensible. Thus, in a case recently reported by Kretschy from the clinic of Duchek, a second plug was coughed out twenty-eight hours after the first expulsion of a bronchial cast; twenty-seven hours later another cast of the bronchial tubes was expelled, exactly like the previous one ; twenty-four hours afterwards another one, and so on. All these casts, seven in number, were of exactly the same length and thickness in trunk, stems, and branches, and had all been produced, as proved by the autopsy, in one and the same place (middle and lower lobes of right lung). With casts of a certain size, it is easily comprehensible how, 458 RIEGEL.—DISEASES OF TRACHEA AXD BRONCHI. with relatively slight force of coughing, their expulsion is only possible in the form of separate fragments, or no longer possible at all, especially when they adhere firmly to the walls of the bronchi. In this way a fatal termination often results in very acute cases, without the expulsion of a single cast. Besides the power of the muscles of expiration and the size of the cast, the connection of the separate lamellae with each other, and especially with the bronchial walls, has an influence upon the difficult or easy expulsion of these masses. The lamellar structure of tliese membranes, which frequently inclose bubbles of air, shows that the exudation occurs at successive periods. According to the rapidity with which the individual membranes appear, a greater or a less quantity of air can become enclosed between them. Thus, in one case the to- and-fro current of air is still competent to partially loosen one lamella from the others, while it is incompetent to do this in a second case. All these conditions, therefore, must vary according to the intensity and extent of the different factors mentioned. As already stated, these casts, are sometimes expelled by themselves, merely mingled with traces of mucus, sometimes with admixture of sero-mucous or muco-purulent sputa, and not altogether infrequently with bloody masses. In cases in which but scanty quantities of these casts are expelled, and in which they float in abundant sero-mucous or muco-purulent masses, they may be readily overlooked in a superficial exam- ination. The mucous masses, as a matter of course, are but the product of a contemporaneous acute or chronic bronchitis, with which, as previously observed, croupous bronchitis stands in intimate connection. It not infrequently happens, however, that bloody masses, even in large quantity, are mixed with the fibrinous masses. These bloody admixtures are usually due to rupture of blood- vessels during the severe paroxysms of cough occasioned by the casts, and by the loosening of these masses. Haemoptysis, therefore, is not infrequently observed in bronchial croup, even without the existence of tuberculosis. Sometimes it precedes the discharge of the cast, and sometimes it attends it. Only exceptionally is the haemoptysis severe. CROUPOUS BRONCHITIS. 459 The expulsion of the cast in most instances does not take place in the same manner as the expectoration of ordinary sputa, but almost always in the form of more or less violent paroxysms. These paroxysms may be exceedingly severe under certain circumstances, and attended with intense dyspncea and exceedingly tormenting and straining efforts to cough. They sometimes precede the expectoration of the fibrinous masses for a longer or shorter period, at times even for an entire day. When the extent of the croupous process is circumscribed and limited to a small surface, the dyspncea is correspondingly less severe, and attended with correspondingly less alarming manifestations. With the expulsion of these fibrinous masses, the picture usually changes at once. The dyspncea, the severe paroxysms of cough, the cyanosis thereby occasioned, and all the remaining symptoms usually disappear at once after the expulsion of the mass; and this relative feeling of comfort con- tinues until fresh casts have again been formed, when the same series of symptoms are occasioned as were excited before. The more quickly these masses are formed, the sooner the old severity of symptoms returns. The often rapid re-formation of these croupous masses renders it comprehensible how, in acute cases, the dyspncea may be almost continuous. While the train of symptoms is extremely stormy, as a rule, in severe acute cases, the expulsion of the casts being accom- plished only by very violent coughing, there is a series of cases, on the other hand, in which the expectoration is accomplished with tolerable facility. In the first place, there are cases in which the croupous process involves but a slight extent of surface. Here, therefore, the breathing is less impeded, and the provocation to cough is slighter. Then as a further favora- ble element comes the fact that these casts now remain longer in the bronchi, and may thus undergo retrogressive metamor- phosis, by which they are gradually softened, loosened, and raised from the bronchial wall. In these cases, slight coughing suffices to expel the casts. The voice, in the majority of cases, is slightly, if at all, altered. If there is hoarseness, there must be some complica- tion. Pure, uncomplicated bronchial croup, as such, never 460 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. causes any real alteration in the voice. Slight grades of laryn- geal catarrh, which are attended with a moderate enfeeble- ment and roughness of voice, are, of course, not infrequently associated with bronchial croup. It is fully in accordance with what has been mentioned that the so called croup-cough, con- stantly observed in laryngeal croup, is absent in bronchial croup. Febrile movements are usually present in acute cases only, or in cases complicated with other affections. Sometimes the attack is ushered in by an actual rigor, which often appears suddenly and unexpectedly. Such a condition, for example, was observed by Kretschy. In his case the patient, while promenading, was suddenly attacked with severe rigors, last- ing an hour and a half, having felt quite well until that moment. The rigor was followed by severe straining cough and dyspnoea, and then, but not until twelve hours later, a reddish, fleshy lump was expelled, which, on close examination, proved to be a bronchial cast. The paroxysms were repeatedly ushered in by rigors in this patient. In other cases there was nothing of the kind. The temperature sometimes indicated tolerably high figures. With the termination of the paroxysm the normal temperature usually returns, if there is no counteracting compli- cation. Sweating is not infrequent during the paroxysms, and espe- cially during the severe paroxysms of cough. Venous hyperemia and cyanosis are not infrequently ob- served ; but they subside with the disappearance of their cause of origin. Dropsical manifestations are only exceptionally observed as a result of the disturbed relations of the circulation. Severe grades of dropsy are always indicative of some compli- cation. In the decidedly acute forms the nutrition does not suffer, as a rule, or if so, only in an insignificant degree; it is only in very severe chronic cases that it suffers to any considerable degree. On the other hand, there is a series of chronic cases, although severe, in which the general nutrition does not suffer notably, despite long continuance of the malady. The subjective symptoms vary not inconsiderably in the dis- CROUPOUS BRONCHITIS. 461 i i ease under consideration. Stitches in the side are observed only i : in few cases, and are apparently due to complications with i inflammatory affections of the pleura. Sensations of pressure ; and soreness in the breast are not infrequently observed. On the other hand, severe pains are absent in the great majority of cases. When numerous bronchi are occluded, feelings of anxiety are by no means infrequently experienced by the patient, and these are nearly proportional to the severity and acuteness of the process. As to the special physical signs of bronchial croup in its lim- ited signification, they may be entirely absent under certain cir- cumstances, as when the process is limited to but few and very small bronchial twigs. All other symptoms may be wanting, save those of catarrh ; so that it may be impossible to determine the seat of the affection with certainty. It must, however, be borne in mind, that even the most accu- rate physical exploration is never competent to the recognition of bronchial croup as such, even in the severest cases. In pro- nounced cases the symptoms are similar to those more or less characteristic of bronchial stenosis, whether due to syphilitic cicatrices, or to the impaction of a foreign body, or to any other cause. Percussion shows no important diminution of resonance in pure uncomplicated cases, no matter over how many ramifica- tions the obstruction in the bronchi may extend. In cases of complication with atelectasis, lobular or lobar pneumonia, and the like, the percussion sounds will indicate the well-known changes incident to these affections. The respiratory murmur, as is self-evident, must cease at those places, the bronchi leading to which are occluded by casts. Hence it may be considered as a somewhat characteristic trait of this affection that while on the one hand the percussion tone is full and clear, the respiratory murmur, on the other, is absent. These symptoms of bronchial obstruction continue so long as the casts are not loosened from the bronchi and removed. When, therefore, after a paroxysm of cough, by means of which the coagulated masses have been expelled, the normal respira- tory murmur suddenly again becomes audible at a place where 462 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. previously the physical signs mentioned in the last paragraph were observed, it is justifiable to draw the conclusion that the casts were formed in this locality. Moist rales are not a special characteristic of the disease under consideration. Such rales are observed, temporarily, in almost every case of bronchial croup. On the other hand, an acoustic phenomenon has been repeatedly described, which is said to be due to the movements of the casts in the bronchi. This phenomenon, which has been considered to a certain extent as more or less characteristic, is sometimes described as a flap- ping valvular sound (Girandet), sometimes as a very loud whist- ling (Corrigan), sometimes as a bronchial friction-sound (Cane), and the like. That the cast, when it has become movable and oscillates to and fro in the respiratory current, may produce characteristic sounds, sometimes more of one character, and sometimes more of another, is easily comprehensible. Apart from the infrequency of the phenomenon, it cannot be considered as a pathognomonic manifestation. By means of inspection we may determine the diminished respiratory activity of that half of the thorax, the principal bronchi of which are occluded by casts. This diminished expan- sion of the affected half of the thorax, coexisting with the full and clear sound on percussion, and with the absence of the respi- ratory murmur, suggests the thought that the bronchi must be obstructed, and also that the obstruction is probably due to the presence of bronchial casts. Even with complete occlusion of the principal bronchi, total inactivity of the side implicated is never observed, nor is it so marked as when the lung is com- pletely compressed by pleuritic exudation, pyo-pneumo-thorax, or similar affections, but there is always an observable activity of the affected half of the thorax, though it is considerably diminished in comparison to that of the sound side. It is evident that the more acutely the train of symptoms sets in, the more likely will we be to suspect the presence of a bron- chial obstruction. The diagnosis, however, can only be made with certainty after the expulsion of the obstructing masses. CROUPOUS BRONCHITIS. 463 Diagnosis of Croupous Bronchitis. The most important and only diagnostic sign is the ex- pectoration of branching bronchial casts. All the remaining symptoms, individually or collectively, may readily mislead, and are never sufficient to establish the diagnosis with certainty. Bronchial casts may be mistaken even for coagula of blood, upon somewhat careful examination, in cases in which blood adheres to the bronchial cast. As long as no bronchial casts have been discharged with the expectoration, just so long the diagnosis remains uncertain. In the majority of cases, however, expectoration of bronchial casts takes place sooner or later, and so the diagnosis becomes firmly established ; it remains doubtful only in those cases in which no masses are expectorated during the entire progress of the affection. On the other hand, we may sometimes adopt the diagnosis of bronchial croup—with a very strong degree of probability in its favor—before the expulsion of the casts, in cases in which the symptoms described are present, and especially if the affected individual have already passed through one or more analogous attacks, which were followed by the expectoration of a bronchial cast. The disease is most readily mistaken for diffuse catarrhal bronchitis. Although the dyspncea, especially in adults, is not usually so great in the latter disease as in bronchial croup, this symptom has only a relative value, and hence very little weight can be attached to it. The absence, likewise, of the respiratory murmur, with preservation of full and clear resonance on per- cussion, may also be observed in these cases, though usually but temporarily. As a rule, the expiratory muscles are able, more promptly and readily than in bronchial croup, to overcome the obstacle existing in the bronchi. In those cases in which bronchial croup occurs quite acutely and suddenly, a certain value is to be attached to the fact that the affection is limited to a circumscribed portion of the thorax, that is to one-half of the thorax. This sign loses its differential 464 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. diagnostic significance, as a matter of course, if the bronchial croup is ushered in by an extended bronchitis, involving both halves of the thorax, as not unfrequently seems to be the case. To avoid the mistake of confounding this disease with occlu- sion of the bronchi by a foreign body, the history of the case should be very carefully considered. The physical signs of bronchial croup, and those of a foreign body in the bronchi, are very nearly identical. Where the history of the case cannot be ascertained, the affection may readily be confounded with the presence of a foreign body in the bronchi. On the other hand, it is hardly possible to confound the disease with a free pneumothorax, even upon only a superficial examination. It is also hardly possible to mistake the disease for laryn- geal croup. The simple observation of the thorax during the phases of respiration suffices, in the one case, to indicate that the obstruction exists in but one-half of the thorax, or is at least intrapulmonic, and in the other case that it is connected with the larger air-passages, the larynx or the trachea. As to the manner of distinguishing between tracheal and laryngeal steno. sis, we must refer the reader to the appropriate chapter on each affection. Both of them, however, are distinguished from bron- chial croup by the so-called inspiratory dyspnoea,—the form of dyspnoea which occurs in all the affections dependent upon con- striction of the upper larger air-passages. These two forms may also be distinguished from each other by numerous other symp- toms, the enumeration of which in this place appears to be unne- cessary. To mistake the disease for pneumonia or some other pulmonary affection is scarcely possible with careful physical exploration. Complications, Duration, Termination, and Prognosis. The acute form of bronchial croup, as already mentioned, runs its course in the majority of cases within from one week to at most several weeks; and in a relatively large number of instances leads to a fatal termination. In the majority of cases this acute form is not attended by any complications or morbid CROUPOUS BRONCHITIS. 465 sequelae. It is only in those cases in which nearly all the bron- chi in one lung are occluded that the sound lung, at least in many instances, becomes involved in disease, namel}T, in second- ary pulmonic dilatation. In like manner, in almost every in- stance of sudden impermeability of a large portion of the lung, we find the intact portions, especially the edges, acutely dilated, as, for example, in ordinary acute pneumonia. This vicarious acute dilatation of the lung occurs the more readily the more quickly the obstruction is produced, and the severe dyspncea and paroxysms of cough supervene, and it ceases with the dis- appearance of the cause of the injury ; that is to say, after the expulsion of the bronchial cast. The chronic form of croupous bronchitis leaves consecutive disease behind it somewhat more frequently. An exact answer to the question as to the frequency of these consecutive condi- tions, based upon accurate statistics, is hardly practicable, owing to the fact that many of the cases published, in fact most of them, were not long enough under observation to render a satisfactory reply to this question possible. As to the question whether bronchial croup does not lead to secondary tuberculosis, Biermer replies correctly that it is very rarely, or never, followed by tuberculous phthisis. He believes that the observations in wThich it is stated that the patients subsequently died of phthisis, plainly indicate that the patient was previously tuberculous. On the other hand, emphysema and chronic bronchial catarrh are among the somewhat more frequent sequelae of bronchial croup. Emphysema is to be regarded as occurring in the same manner as acute dilatation of the lung in occlusion of short duration. In rare cases infiltration of the parenchyma of the lungs is observed. Sometimes, furthermore, atelectasis of the affected portion of the lung ensues in consequence of the ob- structed condition of the bronchi. Bronchiectasis has been observed at the autopsy in but two instances; and in these it was not dependent upon the croup. Finally, Biermer mentions the obliteration of individual peri- pheric bronchial ramifications, with fibrous induration of the surrounding pulmonary parenchyma. VOL. iv.—30 466 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. As to duration, we have already stated that there are cases which run their course within a few days, and others which con- tinue for months, and even years. We therefore distinguish an acute and a chronic form. The chronic form is further dis- tinguished by often exhibiting very long intermissions, during which the patient feels perfectly well, and, at most, only the signs of a simple bronchial catarrh remain. Severe exacerba- tions recur from time to time. The duration of these exacerba- tions, again, may vary a great deal. The prognosis is in general doubtful in acute cases. Ac- cording to the observations recorded, death occurs in about half of the acute cases. On the other hand, the prognosis of chronic bronchial croup is much more favorable. Recovery takes place in by far the greater number of cases, in so far as there are no serious complications which of themselves threaten life. In making a prognosis, the acuteness of the process must be taken into consideration in the first place, and then the degree of its extent. Age and constitutional vigor are of influence ; and so, likewise, the existence of further complications, as tubercu- losis, for example. Acute cases, in which the process is extended over a great number of bronchi, and in which the fever is of a high grade, always demand a doubtful prognosis. The less the forced activity of the respiratory muscles succeeds in expelling the croupous masses, the graver the prognosis. The early ap- pearance of coma and marked cyanosis are always unfavor- able prognostic indications, especially in feeble and emaciated subjects. On the other hand, chronic cases which have become devel- oped from simple bronchial catarrh, even when associated with turbulent manifestations, usually justify a favorable prognosis; and this is the more favorable the smaller the section of the bronchial tract to which the croupous process is confined. Where, on the contrary, the patient is already enfeebled, where severe emphysema, tuberculosis, and other complications exist, the prognosis is much less favorable, as a matter of course. CROUPOUS BRONCHITIS. 467 Treatment. Two indications are to be satisfied in the treatment: first, to remove the fibrinous masses present in the bronchi; and sec- ond, to prevent their reproduction. The first indication, it appears, can be most simply satisfied by the administration of emetics. On the other hand, it is to be taken into consideration that the bronchial casts are sometimes, especially at first, so firmly adherent to the bronchial walls that even the most forcible exertion of the abdominal muscles, and of the other muscles associated in the act of emesis, are insufficient to remove the fibrinous masses out of the bronchi. As long as the cast is still firmly adherent to the bronchial wall, the employment of emetics is useless, as a matter of course. Where, on the other hand, the casts are already loosened, the use of emetics will be serviceable and afford im- mediate relief. In the majority of cases we are not able to determine whether the fibrinous masses are still firmly adherent or are already loosened. The objection, further, has been not unjustly made to emetics, that they always tend to produce a diminution of strength. In spite of all this, I wrould recommend the use of emetics in this stage, especially as we possess in the recently introduced and amply tested muriate of apomorphia (Riegel and BOhm,1 Siebert,2 Quehl,3 Jurgensen," and others) an emetic which, with a convenient method of administration (by subcutaneous injection), acts very promptly, is always certain, and is free from unpleasant attendant effects. It is always possible to produce emesis with this remedy within a few minutes, and without special nausea ; as I have proven in a great number of patients. Besides this there are no un- pleasant after-effects, the last trace of any unpleasant sensation caused by the remedy passing off in the course of a few minutes. Inasmuch, therefore, as this remedy does not produce the unpleasant effects which usually follow the administration of all other emetics, it should be employed experimentally even 1 Deutsches Archiv f. klin. Med., IX. Band. 8 Dorpater Inauguraldissertation, 1870. 3 Inauguraldissertation. Halle, 1872. This Cyclopedia, Vol. V., p. 233. 468 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. in cases in which it cannot be determined beforehand whether the casts are so far loosened that they can be readily expelled. The employment of emetics should always be preceded, when possible, by the use of those remedies from which it may be expected that if they do not loosen the fibrinous masses they will at least soften them, and thus relax their attachment to the bronchial walls. For this purpose inhalations of lime-water, lactic acid, and carbonates of the alkalies, and even of hot vapor of water, are especially to be recommended. Lime-water and the carbonates of the alkalies, in particular, are frequently employed to loosen croup-membranes. In mild cases this medication alone seems to be sufficient. Thus Waldenburg' reports the case of a girl, eight and a half years of age, who, for more than four years, had every few days expelled branched masses, the expulsion of which was accomplished only with great exertion; a whey-cure, however, and daily inhalations of lime-water, effected a recovery in the course of forty-five days. On the other hand, Waldenburg noticed that after the recovery from bronchial croup an impetigo of the scalp, which had existed for a long time, increased very much, thus suggesting the idea that possibly there was a certain nosological connection between the bronchial croup and the impetigo. In cases in which the diagnosis is certain, Biermer' recom- mends an energetic mercurial treatment (calomel and gray oint- ment) in addition to the inhalation of the vapor of hot wrater or of lime-water. The abstraction of blood is never called for in croupous bron- chitis, unless required on account of special complications. Finally, iodide of potassium has in recent times been re- peatedly employed with advantage (see the observations of Wun- derlich, Thierfelder, Sklarek, and others). In many of the cases reported, as in that by Sklarek3 for example, the expelled cast was much looser, even on the second day of the use of the iodide of potassium. ' Berlin, klin. Woch., 1869, No. 20. ' L. c, p. 732. Deutsche Klinik, 1865, 32. CROUPOUS BRONCHITIS. 469 The use of alkaline mineral waters is also to be recom mended in chronic cases of bronchial croup. The second indication of treatment is to prevent the recur- rence of the attacks. In cases in which the croupous bronchitis has developed in connection with an acute or chronic bronchial catarrh, it is advisable, first, to attack this bronchial catarrh. In addition to this, it is requisite, as a matter of course, to avoid all those sources of injury which experience has frequently shown to give rise to bronchial catarrh. The prophylactics recommended against simple bronchitis are therefore to be em- ployed here also ; but this is by no means to be understood in the sense that this affection is to be regarded in a measure simply as an increase of such an existing catarrh, rather than an independent affection. Where the general constitution is disturbed in any manner, as, for example, when there is scrofula, anaemia, and so forth, the use of the remedies applicable to these diseased conditions is indicated. The employment of corroborant and alterant remedies is to be chiefly recommended in those cases in which the remedies first mentioned have not been of benefit. A special enumeration of all the remedies which have been found apparently beneficial in a single instance by this or that author would be of no service here. There are no remedies, as far as is at present known, which are competent to prevent the recurrence of the attacks with any degree of certainty. 470 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. NARROWING OF THE TRACHEA AND BRONCHI; TRACHEOSTENOSIS ; BRONCHIAL STENOSIS. Albers, Erlauterungen, zum Atlas der pathol. Anatomie, II., p. 136; this author cites Kerkringii, Specilegium anatomicum, Obs. XXVII.—Boneti, Scpulchretum, Lib. I., Sect, XXIL, Obs. II.; Lib. IL, Sect. I., Obs. VII. and VIII.; Lib. IL, Sect. IL, Obs. IV. and X.; Lib. IV., Sect. I., Obs. XXXVIII. ; Lib. IV., Sect. III., Obs. I., II.; further, Ephemerid. Nat. curios. Dec. III. a. III., Obs. 115; an. VII. and VIII., Obs. 129; an. IX., Obs. 119, Centur. IX., Obs. 15.— Lieutaud, Historia anatomico-pract., Lib. IL, Obs. 845.—Rush, Med. Observa- tions and Inquiries of a Society of Physicians in London, Vol. V., p. 96.—Pet. Frank, Interpretationes clinicae, P. I., p. 71.—Heister, Med. chirurgische Wahr- nehmungen, No. 297, p. 843; Journal de med., chir. et pharmacie, 1792, Juin; Revue medicale francaise et etrangere, Juillet, 1816, p. 120.—Carmichael, Maga- zin der auslandischen Literatur von Julius und Gerson, Bd. II.—Saxe, in Ru- dolphi's sclrwedischen Annalen, Theil I.—Desault, Chir. Nachlass.—Malacarne, in Hufeland's und Harless neuem Journal der auslandischen med.-chir. Litera- tur, Bd. III.—Frank, Klinische Erklarungen. — Cassel, Dissert, de gland, bron- chialium morbis. Bonnse, 1838.—Bulletin des sciences medicales, Janvier, 1829. (Case of great narrowing of the trachea in consequence of swelling of the mucous membrane.)—Andral, Clinique med, 3 edit., T. III., p. 183, 1834. —Reynaud, M6moire sur l'obliteration des bronches, Memoires de l'academie de medecine, Vol. IV., pp. 117-167. Paris, 1835.—Stokes, Diseases of the Lungs and Windpipe. Dublin, 1837.—Hasse, Anat. Beschreibung der Krankheiten der Circulations- und Respirationsorgane. Leipzig, 1841.—King, A Morbid Flattening or Compression of the Left Bronchus, produced by Dilatation of the left Auricle, Guy's Hospital Reports, Vol. III., p. 175.—Rokitansky, Handbuch der pathol. Anatomie, III. Bd. Wien, 1842.— Worthington, Med.-Chir. Trans., 2. Ser., Vol. VII., p. 220, 1842. — O'Ferral, Dublin Med. Jour., Nov., 1843.— Schulze, Preuss. Vereinsztg., 23. Oct., 1844.—Gintrac, Bull. m6d. de Bordeaux, Juin, 1844.—Holscher, Hannov. Annal., Bd. V., Hft. 2, 1842.—Schillinger, Oesterr. Woch., 1847, No. 7'.—Dittrich, Prag. Vierteljahrschrift, 1849, I., p. 26. —Piorry, Traite de med. pratique, III., 64 et seq.— Wunderlich, Handbuch der Pathologie und Therapie, III. Bd., 1850, p. 384.—Bamberger, Deutsche Klinik, Marz, 1850.—Rokitansky, Wien. Ztschr., VII., 3, 1851.- Suchanek, Prager Vier- teljahrschr., X., 4, 1853.— Chassaignac, Compression de la trachee par les gan- glions bronchiques, tracheotomia; Nouveau signe de diagnostic des engorge- ments ganglionaires du mediastin, Gaz. des hop., 1853, No. 43.— Wilks, Con- striction of the Right Bronchus, Med. Times and Gaz., No. 335. 1856; Trans. Path. Soc. London, Vol. VIII., 1857.—Gross, Elements of Pathological Anat- STENOSIS OF TIIE TRACHEA AND BRONCHI. 471 omy. Philada., 1857.—Guntner, Prag. Vierteljahrschr., Bd. 66, 1857.—J. Mois- senet, L'Union, 128, 129, 1858; Gaz. des hop., No. 27, 1859.—Demarquay, Gaz. des hop., 146, 1858.—J. Neudbrfer, Wien. Ztschr., N. F., I., 13, 1858; Schmidt's Jahrb., 102, p. 96.— Virchow, Ueber die Natur der constitutionell- syphilitischen Affectionen, Archiv fiir pathologische Anatomie, Bd. XV., 3. u. 4. Heft., Nov., 1858; also as a separate pamphlet. Berlin, 1859.— Vigla, Ulceration syphilitique de la partie infC'rieure de la trachee; retrecissement de la trachee par la cicatrice, Gaz. des hop., No. 27, 1859.— Charnal, L'Union, 21,1859.—Miricourt, Tuberculosis of the Bronchial Glands, without Pulmonary Tuberculosis at the same Time. Death by Compression of the Trachea, VUnion, 85, I860.—Rokitansky, Lehrbuch d. path. Anat, III. Bd., p. 28, 1861.—JJemnte, Ueber Stenose der Trachea durch Compression, nebst Bemerkungen iiber Tracheo- stenosis im Allgemeinen, Wiirzb. med. Ztschr., II. u. III.—Betz, Geschichte einer Tracheostenose, Memorab., VI., 8. Aug., 1861.—Tungel, Klin. Mittheil., I860. — Tiirck, Allg. Wien. med. Ztg., VI., 8, 1861.— Mettcnheimer, Tracheoste nose durch eine compacte Geschwulst der Thyreoidea, nebst Bemerkungen iiber die Symptomatik clieser Krankheit, Wiirzb. med. Ztschr., III., 4. u. 5.—Fonssa grives, Schmidt's Jahrb., Bd. 113, p. 175.—Paulsen, Hospitals Tidende, 1862; Schmidt's Jahrb., Bd. 119, p. 174.— Turck, Clinical Researches on Different Diseases of the Larynx, Trachea, and Pharynx, examined by the Laryngoscope London, 1862. (Four cases of narrowing of the trachea, in one instance from cancer of the thyroid gland.)—Haldane, Edinb. Med. Journ., VII., p. 784. 1862.—An. der aorta transversa. Rupture into the Trachea.— Pridie, Edinb. Med. Jour., VII., p. 116, June, 1862.—Aneurism of the Arch of the Aorta, Lancet, Aug. 1, 1863, p. 128.-Wilks, Guy's Hospl. Rep., 3d S., Vol. 9, 1863. —Empis, On Striclulous Breathing, "Cornage Broncho-tracheal." L'Union, 1, 3, 5, 1862.—Turck, Ein Fall von Verengerung der Luftrohre, Allgem. Wien. med. Ztg., 1862, Nos. 6 u. ZL—Zeissl, Lehrb. d. constit. Syphilis, 1864.— Sottas, L'Union, 144, 1864.—Bourdon, Stenose der Luftrohre, Berlin, klin. Wochenschr., No. 10, 1864.—Demarquay, Ueber die Tracheotomie bei Erwach- senen, L'Union med., No. 21, 1864.—K'uchenmeister, Ztschr. f. Med., Chir. und Geburtsh., N. F., III., 5, p. 255, 1864. (Case of aneurism of the aorta, in which death was caused by pressure upon and ulceration into the trachea.)—Moissenet and Bourdon, L'Union 22, 1864. (On syphilitic narrowing of the trachea.) —Btstau. Fibroin im Mediastinum anticum mit Compression der Trachea, art. anonyma und Vena cava sup. ; Thrombose der Vena cava sup.; Untergang des Nerv. recurrens dexter in der Geschwulst., Virchow's Archiv, XXXIV., 1 u. 2, p. 236, 1865.— Hayem, Gaz. hebd., 2, Ser. IL, 6, 1865. (Tumor of Bronchial Gland with Compression of the Trachea in an Adult.)—J. Cyr, Anatom. pathol. des retrecissements de la trachee. Paris, 1866.— Russell, Cases of Syphilitic Thickening of the Larynx and Narrowing of the Windpipe, Brit. Med. Journ., Oct. 27, 18(\Q.— Verneuil, Syphilitic Narrowing of the Trachea and the Left Bronchus, Union med., No. 29, 1866, p. 462.— Mary, Retrecissement. des voies aerienncs. The3e. Paris, 1865.—Gerhardt, Ueber syphilitische Erkrankungen 472 RIEGEL.—DISEASES OF TRACHEA AND BROXCIII. der Luftrohre, Deutsches Archiv f. klin. Med., Bd. II., p. 535, Casuistische Mittheilungen iiber Krankheiten der oberen Luftwege, Jen. Zeitschr. f. Med., III.— Verneuil, L'Union, 29, p. 462, 1866.—Seidel, Condylom in der Trachea, Jenaer Ztschr. f. Med., p. 489. — Turck, Klinik der Krankheiten des Kehlkopfes und der Luftrohre. Wien, 1866.—Schrotter, Ueber eine operation in der Trachea mit Hulfe des Kehlkopfspiegels, Wien. med. Ztg., No. 47, 1867.— E. Wagner, Arch. d. Heilkunde, IV, 3, p. 222. 1863. (Case of diffuse syphiloma of the larynx, the trachea, and the bronchi). —Scholz, Wien. med. Wchschr., XV, 37, 1865.— Mackenzie, Paralysis of the Left Crico-arytenoideus-post, Trans. Path. So. London, XVII., p. 30, 1867.— Schrotter, Beitrage zur laryngoscopischen Chirurgie. Exstirpation eines Sarcoms aus der Trachea, Oesterr. med. Jahr- bucher, Nr. 1, 1868.-Koch, Ztschr. f. Wundarzte und Geburtsh., XXL, 3, p. 184, 1868. (Case of encephaloid of the trachea in a thirty-seven year old maid-ser- vant).— Oedmansson, Nord. med. Ark., I., 4, No. 18, p. 58, 1869.— Eibensteiner, Sitzungsbc. der Aerzte in Steiermark, VI. Jahrg., p. 49, 1869. (Syphilitic sten- osis of the larynx and trachea from diffuse inflammation of the mucous mem- brane and submucous tissue, with partial necrosis of the cricoid cartilage and ulcerating gummata.)—F. Riegel, Zur Pathologie und Diagnose der Medi- astinaltumoren, Virchow's Archiv, Bd. XLIX., Hft. 2, p. 193. — Trelat, Gaz. hebd., 2. Ser., VI., 17, 18, 19, 1869.— Job, Gaz. des Hop., 105, 1869. (Constric- tion of the left bronchus.)—Mackenzie, Trans. Clin. So. London, Vol. IL, p. 169, 1869.— Podrazky, Tracheo-stenosis, Tracheotomie, Tod wahrend der Operation, Zeitschrift f. prakt. Heilk., Nos. 13 and 14, 1870. (The stenosis of the trachea was caused by a large aneurism of the aorta, which had not been diagnosti- cated.)—J. Burnett, Philada. Med. and Surg. Reporter, XXIL, 1, p. 8,1870. (A case in which very decided encroachment upon the lumen of the trachea was produced by an aneurism of the aorta.)—Mackenzie, Constriction of the Tra- chea ; Syphilitic Deposits in the Liver and Kidney, Trans. Path. So. London, XXIL, p. 33. (The trachea was narrowed, at the point crossed by the inno- minate artery, to the size of a goose-quill, by a projecting cicatrix on the anterior and right side.)—Schrottefs Jahresbericht der Klinik fiir Laryngo- skopie an der Wiener Universitat fiir 1870. Wien, 1871.— Erichsen, Med. Times and Gaz., April 8, p. 394, 1871.—Langhans, Primarer Krebs der Trachea und Bronchien, Archiv. f. Pathol. Anat. u. Phys., Bd. 53, Hft. 4, Taf. Xni.— Hof- mokl, Aus der chirurg. Klinik von Dumreicher. Zur Casuistik der Laryngo- tomie. Wien. med. Presse, No. 6, p. 150, 1871.—Emele, Sitzungsbericht des Vereins der Aerzte in Steiermark, VII., p. 65, 1871.—Trendelenburg, Ueber einige Formen von Stenose der Luftwege und ihre Behandlung, Arch. f. klin. Chir., XIII., 2, p. 335, 1872.—Hiittenbrenner, Fall von syphilitische Narbe an der Bifurcation der Luftrohrer, Jahrb. f. Kinderheilk, N. F., V. 3, p. 338. 1872.—Balfour, Edinb. Med. Jour., XVIL, p. 1123, June, 1872.— Zurhelle, Eine isolirte Schleimhauterkrankung der Trachea, Berl. klin. Woch., 1872, No. 35.— Lbvi, H., Zur Casuistik der Trachealstenosen, Wien. med. Woch., 1872, No. 29.— Weil, Falle von Tracheo- und Bronchostenose, Deutsches Arch. f. klin. STENOSIS OF TIIE TRACFTEA AND BRONCHI. 473 Med., Bd. XIV., p. 82.—Lewis Smith, Enlarged Bronchial Gland Pressing on Bronchus, Medical Record, Dec. 1, 1874. — Thomson, Aneurism of Aorta Burst- ing into Trachea, Medical Record, Dec. 15, 1874. Consult further the bibliography on foreign bodies in the air-passages; also, especially Biermer, Krankheiten der Bronchien und des Lungenparenchyms in Virchow's Handbuch der speciellen Pathologie u. Therapie ; Article Bronchial- stenose, p. 770. — Lebert, Klinik der Brustkrankheiten, I. Bd., I. Halite, 1873, p. 320; also the well-known manuals and treatises on special pathology and therapeutics, and on pathological anatomy. Preliminary Remarks. In the following pages, in which a short description will be given of narrowing both of the trachea and of the bronchi, not only those forms of stenosis will be kept in view which are produced by intratracheal and intrabronchial alterations, but those, also, which owe their origin to processes external to the trachea and the bronchi. On the other hand, we exclude those stenoses which are due to the entrance of foreign bodies ; and likewise the stenoses occasioned by croupous bronchitis. Con- cerning the first, we refer the reader to the ensuing chapter; and concerning the latter, to the preceding section. So, like- wise, all stenoses and obstructions of the smaller and minut- est bronchi are excluded from consideration. We will first take up the stenoses caused by compression; then the stenoses and obstructions occasioned by neoplasms ; and, finally, the stenoses produced by disease of the tracheal and bronchial walls, by cicatrices, and the like. Stenoses of the larynx, generally described in common with those of the trachea, are excluded from consideration in the fol- lowing pages for reasons already stated; while those of the trachea and bronchi will be considered in common ; a separate description of either being made only in so far as the symptoms of the two forms of stenosis differ in important points. In the following pages only the general conditions occurring in stenoses of the organs mentioned, can be described. A detailed description of all the variations that may occur, and especially of all the diseases which lead to stenoses of the trachea or bronchi; furthermore, an account of all the forms of 474 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. neoplasm that occur in this locality, the special surgical treat- ment of these formations, and the like, cannot be undertaken for want of space. Concerning these points, therefore, we must refer the reader to the monographs and to the special chapters on these subjects. Etiology. Narrowing of the trachea or bronchi may occur in very different ways. From an etiological point of view tliese ste- noses in general may be separated into two chief groups: 1st, those in which the cause of the stenosis lies external to the trachea and the bronchi; and 2d, those in which the constrict- ing cause is to be found in the very walls of these tubes, or in neoplasms taking their origin in them (excluding foreign bod- ies, which, as a matter of course, give the most frequent occasion to manifestations of stenosis). The first group of tliese stenoses may be rudely comprised together under the name of '' stenosis of compression," inasmuch as they are chiefly due to compres- sion of the trachea or bronchi from without. This form is observed much more frequently than the second class. The fol- lowing are in general the most important and most frequent sources of these stenoses : Stenosis from goitre. This includes actual hypertrophy of the thyroid gland, the various forms of struma associated with an enlargement of this organ, hemorrhage, inflammation, sarcoma, carcinoma, and cystic tumors of the thyroid gland ; furthermore, the echinococcus of the thyroid gland, which is of very rare occurrence; and so forth. Of the latter affection Gurlt' has collected the histories of seven cases, in three of which there was great compression of the trachea. In most cases in which one of the causes mentioned occasions manifestations of stenosis, we find only the trachea compressed; but stenosis from goitre may sometimes involve even the bronchi. Cases of the kind have been recorded by Demme and Metten- heimer.2 In one of the preparations of the museum at Witrz- burg, described by Demme, the left bronchus was greatty com- 1 Ueber die Cystengeschwiilste des Halses. Berlin, 1S55. 2 Wurzburger med. Zeitschr., III. Bd. STENOSIS OF THE TRACHEA AND BRONCHI. 47.5 pressed by a cystoid tumor proceeding from the left lobe of the thyroid gland. The seat of the tracheal stenosis, when muscular pressure predominates, is, according to Demme, chiefly the upper portion of the windpipe. Substernal goitre, as a matter of course, com- presses the deeper portions of the windpipe. As further causes of stenosis we have to mention: swelling of the lymphatic glands at the hilus of the lungs and at the point of bifurcation of the trachea; and swelling of the lym- phatic glands of the anterior and posterior mediastinum. These glands may undergo enlargement in various ways. In addition to simple hypertrophy, chronic inflammations with their various terminations—calcification, tuberculosis, and car- cinomatous degeneration of these glands—have to be taken into consideration. The enlargement of the glands is sometimes very great, reaching the size of a hen'1 s egg, and even a greater volume. The position of these tumors has more to do with the degree of narrowing than their size ; in the same way, as is well known, that very large goitres occasion manifestations of steno- sis comparatively less frequently than tumors of relatively small size, but located in a certain manner. Thus, even the glands of the bronchi at the hilus of the lung may, under some circum- stances, when but moderately swollen, produce stenosis of one or the other bronchus ; and even the lower (md of the trachea, immediately at the point of bifurcation, may be compressed by such enlarged glands. Thus Aiken' narrates a case, in a girl four years of age, with tuberculosis of the bronchial glands, in which there were nightly paroxysms of suffocation. The largest gland, which had acquired nearly the circumference of a lien's egg, so compressed the trachea, at the point of bifurca- tion, that its calibre was diminished to about one-third of its former size. According to Demme's2 collection of cases of stenosis due to goitre, the swelling of the tracheal and bronchial glands is a not infrequent complication of struma. Suppuration of tiie glands mentioned, with perforation of 1 Schmidt's Jahrb., 1840, 28, Bd., p. 61. s Ueber Stenose der Trachea durch Compression, nebst Bemerkungen iiber Tracheo- stenosis im Allgemeinen, Wiirzburger med. Zeitschr., II. Bd., 5. u. 6. Heft, p. 390. 476 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. the abscess into the trachea or a bronchus, is to be mentioned as a very infrequent termination. Cases of the kind have been narrated by Frazer,1 Edwards,2 Graham Tice,3 Weil,4 and others. Aneurism of the aorta is a cause of stenosis of the larger air- passages not less frequent than swelling of the glands. Accord- ing to Rokitansky, it is principally aneurisms proceeding from the concavity or the posterior circumference of the arch of the aorta, which lead to compression of the trachea and primitive bronchi. There are also, however, cases of compression of the right bronchus by aneurism of the ascending aorta, and of the trachea by aneurism of the innominate artery. The biblio- graphy of aortic aneurisms contains numerous cases of this kind of stenosis, yet it should be borne in mind that every case of dyspnoea observed in patients with these aneurisms is not to be attributed to compression of the trachea or of a bronchus. On the other hand, pressure upon the left recurrent nerve, which, as is well known, is not infrequently paralyzed by aneurisms of the aorta, is hardly competent to produce real dyspncea. Although such a unilateral paralysis of the recurrent produces an alteration of the voice to which the older pathologists gave the inappropriate name of '' vox anserina,'' the cause of which was first laryngoscopically demonstrated by Traube0 to be a paraly- sis of the left vocal cord, shown by its taking the cadaveric position, nevertheless the constriction of the glottis thus pro- duced is hardly sufficient to occasion any severe manifestations of dyspnoea. The cadaveric position of the vocal cord thus produced, associated with failure of the movements to and fro, diminishes the glottis, at the most, but one-fourth of its normal dimensions. Very mild grades of this dyspnoea may, therefore, perhaps be confounded with that occasioned by moderate com- pression of the trachea. The differentiation of the two forms 'Edinburgh Monthly Journ., VIII., Jan., 1848. 2Med. Chir. Trans., Vol. 37, 1854. 3 Ibidem, Vol. 26, 1843. 4 Falle von Tracheo- und Bronchostenose, Deutsches Archiv fiir klinische Medicin, Bd. XIV., p. 82. b Deutsche Klinik, 1860, No. 41. STENOSIS OF THE TRACHEA AND BRONCHI. 477 is of course based upon the alteration in the voice, and especially upon laryngoscopic examination. Diseases of the mediastinum, mediastinitis, and especially mediastinal tumors, are to be mentioned as further causes of tracheal and bronchial stenosis. Mediastinal tumors which occur most frequently in the form of sarcoma or carcinoma, less frequently in the form of lipoma and fibroma, implicate in their subsequent course the contiguous organs also, especially the pericardium and the pleura, and when very large they may compress the different organs of the thoracic cavity, especially the trachea or bronchi. According to the seat and extent of the tumor it will compress sometimes the trachea, sometimes the point of bifurcation, sometimes again but one bronchus. Such a case of mediastinal tumor, in which the tracheal stenosis occasioned by it had been diagnosticated by the aid of the laryn- goscope during the life of the patient, has been described by myself.1 A similar case has also been reported by Pastau.2 A careful compilation of the cases recorded has led me to the con- clusion that tracheal stenosis in mediastinal tumors is one of the infrequent sequences. More frequently there is compres- sion of one or the other primitive bronchus, or of some of its brandies, with correspondingly increased activity of respiration in the other lung, and diminution of the expansibility of the affected side. The compression of the trachea, moreover, when it does occur, ordinarily is not very great. In like manner with mediastinal tumors, may the very rare affection, mediastinal abscess, lead to compression of the tra- chea or the bronchi. The same ma}T be said of hemorrhages, of abscesses, situated in the vicinity of the trachea or the bronchi, and having originated in the connective and cellular tissue sur- rounding the trachea or the bronchi. A case of the latter kind has been reported by Petrunti,3 and a second, apparently of the 1 Riegel, Zur Pathologie und Diagnose der Mediastinaltumoren, Virchow's Archiv, Bd. XLIX., Heft 2, p. 193. * Fibrom im Mediastinum anticum mit Compression der Trachea, Art. anonyma und Vena cava sup. ; Thrombose der Vena cava sup. ; Untergang des Nerv. recurrens dexter in der Geschwulst., Virchow's Archiv, Bd. 34, p. 236. 9 Filiatre sebez., 1838, Schmidt's Jahrb., 25. Bd., 1840. 478 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. same character, by Tiirck.1 So also even diseases of the pericar- dium, extensive pericardial exudation, particularly dilatation of the left auricle, may occasion manifestations of compression, especially of the left bronchus. King2 reports a case of this kind in which the left bronchus was compressed in consequence of dilatation of the left auricle, and Friedreich3 has reported a similar case. Tumors of the thymus gland appear veiy rarely to occasion tracheal stenosis, but usually to implicate principally the vas- cular and nervous trunks by compression. Congenital cystic hygromas, likewise, on account of their superficial supra-muscu- lar position, rarely exercise pressure upon the more deeply lying structures of the neck. Cases of compression of the trachea, by the sinking of the cystic lobes between the sternum and the ver- tebrae, have been recorded by Wulzer" and Hawkins5 (Demme). Finally, cases have also been known in which diseases of the sternum, the clavicle, and the vertebral column have occasioned stenosis of the trachea. Demme ° especially has reported cases of this kind. Stenosis by compression has also been produced by escape of air into the surrounding connective tissue. Demme mentions especially emphysematous tumors, which after wounds of a bronchus, rise along the trachea and compress the wind- pipe, chiefly in the region of the interclavicular notch of the sternum—the so-called air-goitres described by the older authors, which are observed as a consequence of wounds of the windpipe, after severe crying, vomiting, etc. Tumors of the oesophagus likewise occasion compression of the trachea in rare instances. Biermer7 mentions finally cancer of the lung. This disease, according to Biermer, is not only associated with closure of 1 Klinik der Krankheiten des Kehlkopfs und der Luftrohre. Wien, 1866. 2 Guy's Hospital Reports, No. VI. 3 Virchow's Handbuch der speciellen Pathologie u. Therapie, V. Bd., 2. Abth., p. 236. 4 Casper's Wochenschr. f. d. g. H. 1836, No. 17, p. 257. " Ibidem, p. 236. 6 Wiirzburger med. Zeitschr., 1861-62, 2. und 3. Bd. ' Bronchialkrankheiten in Virchow's Handbuch der speciellen Pathologie u. Thera- pie, V. Bd.,1 Abth., p. 772. STENOSIS OF THE TRACHEA AND BRONCHI. 479 the small bronchial tubes, but also compresses the large bronchi, as he himself observed in two instances. We mentioned at the beginning, as a second cause of stenosis of the larger air-passages, those forms in which the source of injury is internal, that is to say, is due to alterations in the tracheal and bronchial walls. Such stenoses occur in three ways : 1st, from cicatrices, callosities, and adhesions; 2d, from morbid growths; 3d, from inflammatory thickening of the walls. With regard to the cause first mentioned, cicatricial con- tractions of the trachea and larger bronchi are most frequently of syphilitic origin. The syphilitic process, as is well known, has the peculiarity in its severer forms, that the cicatrization following the ulcerations to which it gives rise usually leads to great contraction. This, which is true of the trachea and the bronchi, is likewise true of the larynx. Here, not infrequently, we can see strongly constricting cicatrices proceed from such ulcerative bases, so that considerable disturbance of function is thereby occasioned. The cicatrices thus produced usually consist of ridge-like projecting bands of connective tissue. In many cases these cicatricial cords can be seen extending over large tracts of the air-passages. In others we see near them ulcers not yet entirely cicatrized. Such cases of syphilitic steno- sis of the larger air-passages are rather numerous in medical literature. On the other hand, cicatricial narrowing of the tra- chea and the larger bronchi of other than specific origin is extremely rare. The case therefore observed by Demarquay,1 in which a stenosis of the trachea appears to have been occa- sioned by a chronic glanders ulcer, must be regarded as an exceptional rarity. Catarrhal ulcers never lead to cicatricial narrowing of the trachea and bronchi. On the other hand, it is exceptionally observed after diphtheritic, tuberculous, and typhoid ulcers ; examples of which are narrated by Demme. While, as is well known, morbid growths are by no means rare in the larynx, they are very seldom observed in the trachea or in the larger bronchi. They are observed in the larger bron- 1 Cyr, Anatom. pathol. des retrecissements de la trachee. Paris, 1866. 480 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. chi still less frequently than in the trachea. Those which have been observed are chiefly polyps, fibromas, carcinomas, and epi- theliomas. Carcinomas most often affect the air-passages sec- ondarily. Most frequently their point of origin is in the oeso- phagus or in the thyroid gland,—from whence the air-passage is secondaril}T implicated ; manifestations of stenosis being gradu- ally produced after the growths have acquired a certain bulk. Cancerous infiltrations of the bronchial wTalls and polypoid excrescences of a sarcomatous nature have produced stenosis of the bronchi in very rare cases only. Biermer cites a specimen of the latter kind in the Wiirzburg collection, which had already been mentioned by Virchow.1 Numerous sarcomatous nodules were disseminated throughout both lungs ; and the bronchi, in several places, were obstructed by polypoid sarcomas which had grown out from their walls. According to Forster, primary cancer of the trachea and bronchi has not yet been observed. Rokitansky describes a cancerous formation extending from a bronchial stem to its branches, by which the walls of the bronchi were thickened, rendered rigid, and diminished in their calibre, and their inner surface made uneven. He remarks, however, that carcinoma of the bronchial glands and extensive carcinoma of the costal pleura were present, and that the disease in question probably proceeded from these. So, likewise, the cases of carcinoma of the trachea, reported by Tiirck, were only secondary cancers. On the other hand, the case recently reported by Langhans 2 shows that the bronchi and trachea may serve as a point of ori- gin for primary cancer. This case, therefore, is not only of interest because it is the only one of primary cancer of the tra- cheal and bronchial wall, demonstrated to a certainty, but because it reveals with certainty the mucous glands as the point of origin of the entire cancerous formation. We have designated inflammatory thickening of the walls as a third cause of intra-tracheal and intra-bronchial stenosis. In general these stenoses from hypertrophy of the walls are exceedingly rare; but a few well-assured cases are on record. 1 Verhandlungen d. phys. med. Ges. zu Wiirzburg, Bd. VII., p. 207. 2Primarer Krebs der Trachea und Bronchien, Virchow's Archiv, Bd. LIIL, p. 470. STENOSIS OF TIIE TRACHEA AND BRONCHI. 481 Thus Andral (1. c) relates a case of chronic bronchitis, without further pulmonary complication, in which the principal bron- chial tube of the right upper lobe was so constricted from thick- ening of its walls that a fine probe could hardly be passed through it. Cyr ' also mentions similar observations by Demar- quay. Gintrac,2 likewise, mentions a case. At all events these stenoses, at least in their higher grades, are among the greatest rarities. Finally, we have to mention acute oedema of the tracheal and bronchial mucous membrane, which has been especially observed after the inhalation of chemical vapors, after perichon- dritic processes, abscess, and necrosis of the cartilages. The latter disease, as is well known, is observed much more fre- quently in the larynx than in the trachea. Anatomical Alterations. The anatomical alterations produced by stenoses of the trachea and larger bronchi vary very considerably, according to the duration and nature of the process. Thus there are a great number of stenoses in which the anatomical examination shows no further alteration than a more or less marked indentation of the walls. This likewise applies to a series of stenoses from compression, especially when they have existed but a short time. In other cases, on the contrary, especially in those of long-continued compression, there is a series of further altera- tions. Thus Demme frequently found hypertrophy of the mucous glands and submucous connective tissue of the trachea, in the neighborhood of places in the windpipe compressed by goitre. In addition to this he found the pachydermia de- scribed by Virchow as existing in the laryngeal mucous mem- brane, a condition which is characterized by a fissured and scab-like surface of the mucous membrane, and is dependent upon hyperplasia of the epithelial layer. While the thickening of the submucous connective tissue reached a high grade in several cases, he never found the muscular layer hypertrophied, though the perichondrium often was. 1 Des retrecissements de la trachee. These. Paris, 1866. 2 Bull. med. de Bordeaux, Juin, 1844. VOL. IV.—31 482 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. Further, Demme found the cartilage atrophied in most instances, as a result of the compression of the trachea. He even found it rarefied in cases in which the remaining coverings were still perfectly healthy. Sometimes there is even complete absorption of the walls, so that a rupture of the trachea ensues. Thus Paget has reported a case in which a cyst of the thyroid gland, after producing gradual absorption and atrophy of the walls of the pharynx and trachea, discharged its contents into these cavities, and thus caused death by suffocation. Similar cases have been reported by Lieutaud, Gooch, Demme, and others. The form of the stenosis, as shown by Bonnet and Demme, may vary extremely; it depends chiefly upon the anatomical relations of the parts and the consecutive alterations in the tissue of the walls. Thus compression from before backwards will make it a transverse slit. If the surfaces pressed upon are nar- row, it may happen that the walls of the windpipe will be in con- tact only in the middle, thus leaving more or less irregular pris- matic spaces of variable size arranged anteriorly and posteriorly. In other cases the contracted part acquires the form of a tri- angle with its acute angle directed forwards. Circular stenoses occur very rarely as the result of pressure (Tiirck). The anatomical alterations of the second group of cases, intratracheal and intrabronchial stenoses, likewise vary ex- tremely. As already stated, syphilis is much the most frequent cause of those stenoses produced by callosities and the formation of cicatrices. In reference to the special alterations occurring in these cases, the reader is especially referred to the excellent article of Gerhardt.1 Disregarding the milder forms, such as those produced by condylomas of the tracheal wall (Seidel2), small superficial ulcers and the like, we should next take into consideration well- defined syphiloma of the trachea and bronchi. This, according to Gerhardt, very seldom occurs in the form of projecting cir- cumscribed nodules, but usually in the form of a diffuse thick- ening of the entire tracheal wall, often covered internally with 'Deutsches Archiv f. klin. Medicin, Bd. II., p. 535. a Jenaische Zeitschrift, II., 4. STENOSIS OF TIIE TRACHEA AND BRONCHI. 483 papillae, folds and ridges, which present the characters of syphi- loma described by Wagner.1 There is also frequently an ulcer- ative process on the surface of the tracheal wall, which may involve the entire circumference of the internal surface at once or consecutively, producing a circumscribed annular ulcer; or the ulcers may be small, involving but a portion of the circumference. If these ulcers penetrate deeply, they lead to perichondritis, to denudation, ossification, and detachment of the tracheal ring or individual portions of them ; so that these are sometimes coughed out in the further progress of the disease, and some- times become bent, dented, thinned, and pushed over one another (Charnal).2 Sometimes the purulent liquefaction of the so-called infiltration, beginning in the interior, extends to the perichon- drium, or even towards the outside of the trachea (Wallman),3 and leads to abscesses. After a longer progress the process is then disposed to undergo a retrogressive metamorphosis in such a manner that callous, uneven folds, bands, and projections of cicatricial tissue bulge inwards. At places where cartilage has been destroyed or very much indented, annular strictures form, which not infrequently are so small as hardly to admit the passage of a crow-quill (Gerhardt). The seat of the disease may be the entire surface of the tracheal wall. This was the case in four out of twenty-two cases analyzed by Gerhardt. In six observations, the uppermost por- tion of the windpipe was affected, extending usually from just below the cricoid cartilage, down as low as the fifth tracheal ring, at the farthest. In twelve other cases the disease occupied the lower half of the trachea, generally in the region of the bifurca- tion, so that it often extended into the primitive bronchi. The bronchi were affected in three cases out of four of disease of the entire trachea, in six out of twelve of disease of the lower end, and not at all in six of disease of the upper portion of the windpipe. In all the cases of disease of the entire windpipe the larynx was at the same time narrowed. Morbid growths form a second intratracheal and intra- 1 Archiv der Heilkunde, TV., 222. 2 Notes from Vigla's clinique (Gaz. des hop., 1859, 21, Schmidt's Jahrb., OIL, 100.) J Virchow's Archiv, Bd. XIV., p. 201. 484 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. bronchial cause of stenosis. In general, morbid growths are observed in the trachea and bronchi much less frequently than in the larynx. The forms observed are, on the whole, similar to those which occur in the larynx, so that a special description of them seems to be unnecessary. Inflammatory thickening of the tracheal and bronchial walls constitutes a final cause of stenosis. This thickening may extend over a greater or smaller portion of tliese structures, sometimes affecting the different tissues uniformly, sometimes only certain of them. On the whole, such inflammatory thickenings leading to manifestations of stenosis are very rare. Wilks1 has reported a couple of cases of the kind. A case reported by Gibb, in which tracheotomy was performed on ac- count of dyspnoea, appears to have been one of hypertrophy in consequence of chronic inflammation of the mucous membrane and the deeper strata. The trachea was narrowed longitudinally by very great thickening of its walls. Similar stenoses of the bronchi, due to thickenings of the bronchial walls from chronic inflammation, have been but very rarely observed. A case of the kind has been related by Andral.2 The main bronchus of the upper lobe of the right lung was so constricted from thickening of its walls, that it was barely possible to introduce a delicate stylet. The submucous tissues were unaltered, but the mucous membrane was much thickened and reddened. On the whole, this last-mentioned form is of extreme rarity. Though chronic inflammatory thickenings of the walls of the bronchial ramifications are not infrequently observed, they sel- dom acquire such dimensions as to produce any considerable narrowing of the calibre of the tubes. As to the anatomical consequences of such stenoses, we have first to mention a dilatation of the bronchial twigs below the point of stenosis. This is absent only in rare cases, and then especially when the stenosis is so considerable and severe that respiration is entirely or almost entirely cut off from the corre- sponding section of the lung. 1 Guy's Hosp. Reports, 1863. 2 Clinique med., 3 Edit., T. III., 1834. STENOSIS OF THE TRACHEA AND BRONCHI. 485 The occurrence of this secondary bronchiectasis is chiefly favored by the severe and frequent cough. In the same manner an abundant bronchial secretion favors the occurrence of secon- dary bronchiectasis, inasmuch as the stenosis prevents the escape of the bronchial secretion, or at least impedes it to a very great degree. In addition to this, emphysematous expansion of individual sections of the lung is not infrequently observed as a direct result of the stenosis. In other cases, again, there are atelectatic portions of the lung. That catarrh, sometimes of the minuter, sometimes of the coarser bronchi, not infrequently exists in connection with the stenosis, requires no special men- tion. The same may be said of the terminal pneumonia, not infrequently observed in these cases. Symptomatology. In describing the symptoms of tracheal and bronchial steno sis, we may be brief, since a separate description of the differ- ent forms mentioned appears unnecessary. The symptomatol- ogy, as far as it has reference to the stenosis, is exactly the same whether it is due to pressure externally, or whether the cause of the contraction lies within the trachea or the bronchi. Only the degree of stenosis has any special influence upon the train of symptoms. The symptoms observed in tracheal and bronchial stenosis are therefore only in part due to the stenosis, the remaining part belonging to the fundamental disease which has given occasion to the stenosis. The symptoms belonging to the latter category may exhibit the utmost variety corresponding to the great variation of these causes, while the more restricted symptoms occasioned by the stenosis itself always exhibit a certain identity. We have to do only with the latter in this article. It is evident that according to the seat of the stenosis in the trachea or in one or the other bronchus, the symptoms, although corresponding in many points, differ not inconsiderably in others; for which reason a partly separate description of the symptoms of both varieties seems necessary. WJierever an essential obstacle to the passage of air exists 486 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. at any point of the larger air-passages, the type of breathing exhibits alterations. Taking for granted that the peculiarities of the type of breathing in normal respiration are well known, we need only recall that the inspiration is never longer than the expiration under normal conditions, but usually somewhat shorter ;' that the inspiration always passes into the expiration without pause, while a pause at the end of expiration, though not constant, is still observed with tolerable frequency. In contradistinction to this type, every constriction of the larger air-passages (larynx and trachea), let the cause be what it may, produces a special form of dyspncea, which we may, following Biermer and Gerhardt, designate as "inspiratory dyspnoea." As is seen by mere inspection, but as is better exhibited by the method of graphic exploration introduced by myself, inspi- ration chiefly is disturbed in all these cases. This form of dyspnoea is therefore readily distinguished from a second form observed in bronchial asthma, emphysema, and chronic bron- chial catarrhs. The latter form of dyspncea is distinguished from the other by the designation expiratory. In proportion to the magnitude of the obstruction the respiration is a forced one; and it is self-evident that obstructions which close the greater portion of the calibre of the trachea lead to a severer degree of dyspncea than those which implicate but one primary bronchus, even when they render it in great part or almost entirety impervious. If the obstruction is situated only in one- half of the thorax, therefore implicating only one of the primi- tive bronchi, then, as a matter of course, the altered conditions are manifested chiefly upon the side of the occluded bronchus. If, on the other hand, the obstruction is situated in front of the point of bifurcation, then the results are participated in by both halves of the thorax. Let us consider a case of the latter kind, and select an instance of great narrowing of the trachea. The anomalies of respiratory movements exhibited under such circumstances are so characteristic that the diagnosis of stenosis of the larger air-, passages can be made from them alone. Inasmuch, as stated 1 For details I refer to my monograph: Riegel, Die ^Athembewegungen, Eine physiologisch-pathologische Studie. Wiirzburg, 1873. STENOSIS OF THE TRACHEA AND BRONCHI. 487 already, it is chiefly inspiration which is attended with great difficulty, the patient, in order to overcome this obstacle, em- ploys all the muscles which can in any way facilitate the expan- sion of the thorax. In spite of all this effort, however, he does not succeed in securing the introduction of a sufficient quantity of atmospheric air in the same space of time as under normal conditions, and therefore expends considerably more time in effecting his inspiration; but nevertheless it is only gradually and with great difficulty that he can expand the thorax, and, as I have demonstrated graphically, the increments of expansion diminish with each additional interval employed in inspiration. * Expiration follows quite easily, and relatively promptly, in pure uncomplicated cases. This is readily comprehended if we consider, on the one hand, the relatively slighter inspiratory expansion, despite considerable exertion of force, and, on the other hand, the sum of the forces set free at the commencement of expiration. In other cases, more or less complicated, on the other hand, expiration also is sometimes impeded, though in a less degree than inspiration. In correspondence with tliese con- ditions the inspiratory action of the lower borders of the lungs is diminished or is held altogether in abeyance. A relative prolongation of the respiration must be men- tioned as a further peculiarity of stenosis of the larger air- passages. This prolongation is readily explicable because in- spiration requires a much longer time than in normal respiration. An analogous symptom is observed, under some circumstances, in diseases in which an obstruction to expiration is involved ; it differs only in this, that a considerably longer time is devoted to the expiration. This symptom can be explained most natu- rally by the beautiful experiments reported by Breuer.2 It lies, as demonstrated by Breuer, in the principle of self-regulation of the respiration by the pneumogastric nerve, that the individual respiratory obstructions can be combated by suitable modifica- tions. Insufficient filling of the lungs, therefore, occasions stronger and more continuous inspiratory efforts ; and impeded 1 Athembewegungen, 1. c. 2 Die Selbststeuerung der Athmung durch den N. vagus. Sitzungsber. der k. k. Akad. d. Wissensch. zu Wien., Bd. LVIIL, Abth. II., Nov., 1868. 488 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. emptying of the lung must strengthen and prolong the expi- ration. In spite, however, as above mentioned, of the activity of all the auxiliary muscles of inspiration, and the greater length of time devoted to the phase of inspiration, the respiratory obstacle is in no wise compensated for thereby. In all stenoses of this kind, the breathing presents the peculiarity of the forced costal type. In spite of all exertion, the necessary quantity of air is not drawn in, in consequence of which considerable rarefaction of that in the lungs takes place, which is, of course, most mani- fest at the points most remote from that of the entrance of the air. Thus it is explicable that in severe forms of stenosis the most yielding points are drawn inwards with each inspira- tion. A retraction of this kind occurs with each inspiration, especially at the lower portion of the sternum and the lowest ribs, and extends the higher upwards the greater the respiratory obstruction. At the same time the intercostal spaces, the jug- ular and the supraclavicular fossae sink inwards. Though hardly of diagnostic value, still the fact, first demon- strated by Demme, is worthy of consideration, viz., that the cir- cumference of the thorax is diminished in its upper portions as the result of long-continued stenosis of the trachea. In long- continued stenosis of one bronchus only, the corresponding chest wall sometimes sinks inward, and this sign may be of diagnostic value under some circumstances. Thus Mayne' observed a marked retraction of the left wall of the chest in a case of aneu- rism of the aorta, and based thereon the diagnosis of compres- sion of the left bronchus. I have myself had the opportunity of frequently examining a case minutely, in which there was a bronchial stenosis of the right side, apparently of syphilitic nature. Here there was distinct diminution of the circumfer- ence of the affected side; and, in addition, the difference between the circumference of inspiration and expiration was greatly lessened as compared with the healthy side. We have to mention, as an important sign with reference to its distinction from laryngostenosis, that in tracheal stenosis 1 Stokes, Dis. of the Heart. STENOSIS OF THE TRACHEA AND BRONCHI. 489 the larynx is but very little or not at all moved up and down in respiration. In laryngostenosis, on the contrary, as is well known, the larynx makes very marked respiratory excursions, in consequence of the pressure of the current of air above and below the point of narowing (Gerhardt).1 Furthermore, the stenotic respiratory sounds, the noisy, wheezing breathing, the "cornage," heard in the vicinity of the point of narrowing, are especially characteristic. These sounds are often of such intensity that they may be heard at quite a distance. The expiratory sound is considerably higher in pitch than the inspiratory sound, in contrast to the normal condition (Gerhardt). Gerhardt calls attention to still another circumstance worthy of consideration. If the attempt is made to discover the seat of this loud respiratory sound, with the stethoscope carried from the larynx to between the shoulder blades, it appears that it is by no means heard most strongly at the place of constriction. Some of the sounds that occur in the trachea can be heard the loudest in the larynx. This is explicable from the complexity of the conditions of transmission of sound. If the stenosis is located high up in the trachea the wheezing sound can be felt externally as a thrill. In stenosis of one bronchus a distinct thrilling of the chest-wall can be frequently felt on the side of the stenosis, both in inspiration and in expira- tion, corresponding to the more or less deep humming heard on auscultation. The voice in tracheal stenosis is frequently faint, weak, muf- fled, and of limited intensity, corresponding to the weakness of the current of air that strikes the vocal cords. The vesicular respiratory murmur is no longer audible in severe cases of tracheal stenosis. Sometimes it is considerably diminished and weakened, sometimes it is overpowered by the stenotic respiratory sounds above mentioned. If the seat of the stenosis is in one bronchus, the vesicular murmur of the half of the thorax supplied by this bronchus is feebler or entirely absent. At the same time the respiratory movements of this 1 Lehrbuch der Auscultation und Percussion, von Dr. C. Gerhardt, Zweite ver- mehrte und verbesserte Auflage. Tubingen, 1871, p. 219. 490 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. side are weaker, and sometimes, after long continuance, even the thoracic circumference of this side is diminished. Exploration with the sound, which was at one time more fre- quently practised, is very annoying to the patient, and not with- out danger, for which reason it has been given up.at the present time. Exploration with the laryngoscopic mirror, on the other hand, is of the greatest significance. Laryngoscopic examination is not only of great importance, owing to the fact that it estab- lishes with certainty the intact condition of the larynx in cases of tracheal stenosis, in which it cannot be otherwise decided whether the larynx or the trachea is the seat of the stenosis, but also because it often enables us to fully determine the special seat and the nature of the obstruction in the trachea. As a matter of course, examination of the trachea presents somewhat more diffi- culty than examination of the larynx ; nevertheless it is practi- cable, in by far the greater number of cases, to render the calibre of the trachea accessible to the eye, if the position of the head is but so arranged that a sufficiently broad rectilinear passage is maintained for the rays of light to pass through the larynx and the entire trachea as far as to the commencement of the bronchi.1 While, therefore, examination with the laryngoscope is of very great importance in tracheal stenosis, inasmuch as it demon- strates the exact seat and nature of the constriction, the diag- nosis of bronchial stenosis is principally based upon the follow- ing facts : Diminution of the thoracic movements of the affected side; absence or enfeeblement of the respiratory murmur of this side, with conservation of the full and clear sound on per- cussion ; wheezing, whistling, humming sounds audible at a distance, to which corresponds a palpable thrilling of the tho- racic wall of t?ie affected side both in inspiration and expiration (Friedreich,2 Weil3). The examination of the vocal fremitus has been frequently neglected in the diseases under considera- 1 Concerning the details of this method, we refer the reader to the instructions given by Tiirck in his excellent treatise on diseases of the larynx and the trachea. 2 Friedreich, Herzkrankheiten, in Virchow's specieller Pathologie und Therapie, V. Bd., 2 Abth. 3 Deutsches Arch. f. klin. Medicin, Bd. XIV., p. 82. STENOSIS OF TIIE TRACHEA AND BRONCHI. 491 tion. Nevertheless it is naturally to be expected that the pec- toral fremitus of the side affected should be diminished in cases of bronchial stenosis. In contrast with the diseased side, the half of the thorax, the main bronchus of which is intact, is immoderately burdened; and therefore one may frequently observe, often even after but a short continuance of the stenosis, a not inconsiderable expansion, increased respiratory movements, and depressed position of the half of the diaphragm of this side ; in short, the signs of acute dilatation of the lung. The increased labor thrown upon the healthy half of the thorax, on account of the sudden abolition of the function of the other half, is analogous to what is observed in other affec- tions. Thus, in simple pneumonia we not infrequently see the contiguous intact portions of the lung become dilated. And similarly, in chronic catarrh of the lower portion of the lung, we see the upper portion immoderately overburdened, and thus even an actual emphysema of this portion gradually produced. This secondary dilatation of the healthy portion of the lung occurs on all sides, in every sort of obstruction, with such regu- larity, that from its seat we are enabled to form an approxi- mate opinion as to the seat of the respiratory obstacle. That its occurrence is more or less dependent upon the yielding nature of the thorax is evident from the rapid appearance of the manifestations and the like. The same reason accounts, also, for the entire absence of this secondary acute dilatation of the lung in certain cases. The above-mentioned train of symptoms is so characteristic of stenosis of the primitive bronchus of one side, that the diag- nosis can always be made from it with certainty. The same is true of stenoses and obstructions occasioned by the presence of a foreign body. Concerning the aspect of the patient it is still to be mentioned that in the majority of cases the face presents an anxious and pale livid appearance. The pulse is often accelerated. In a case of stenosis of the trachea by compression, recently reported by Weil,1 in which the vagus was compressed at the same time, the 1 Deutsches Archiv f. klin. Medicin, Bd. XIV. 492 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. pulse exceeded two hundred beats in the minute. In cases of considerable stenosis, a remarkable smallness of the pulse is observed, as a rule, even within a short period. The temperature of the body exhibits no important variation as a direct consequence of the stenosis. Where any such varia- tion exists it is usually associated with the fundamental disease which has occasioned the stenosis, or with secondary affections. The subjective disturbances vary according to the severity of the stenotic manifestations, on the one hand, and the individu- ality of the patient on the other. Complaints of a feeling of oppression, or of pressure on the chest, are frequent enough. The patient is very rarely able to designate the seat of the affec- tion, as did a patient of Andral, in whom the primitive bronchus of one side was narrowed, who pertinently remarked that he felt as if he breathed with one lung only. Cough is not occasioned by the stenosis as such, unless there are further causes which give rise to paroxysms of cough. Quite frequently, however, the same process which has occasioned the stenosis gives rise to paroxysms of cough also. In like manner there is no general rule as to the expectoration which sometimes attends the cough. The further course of the stenotic manifestations is subject to manifold fluctuations. Not infrequently the disturbances occa- sioned by the stenosis itself are temporarily interrupted by paroxysms of severe dyspnosa. These paroxysms of severe dysp- noea, which are associated with noisy respiration, are most fre- quently due to acute swelling of the mucous membrane and increased deposit of mucus at the place of constriction. Such sudden paroxysms of intense dyspnoea can only be exceptionally traced to sudden increase of the actual cause of the narrow- ing, as the sudden dilatation of an aneurismal sac, and the like. Perhaps bronchial asthmatic paroxysms may be the cause of this suddenly increased dyspncea in many cases. The onset of spasm of the larynx, too, may readily increase the dyspncea to a very considerable degree. On the other hand, paralysis of the glottis, supposed by many to be the cause of these paroxysms, can hardly be so considered with any plausibility. Simple paralysis of the glottis, in the STENOSIS OF THE TRACHEA AND BRONCHI. 493 form of complete bilateral paralysis of the vocal cords, pro- duces no special dyspnoea, at least in the state of rest. Bilat- eral paralysis of the dilators of the glottis, on the contrary is, as a matter of course, always associated with severe dyspnoea. Apart, however, from the rarity of this affection (there are as yet but three well-established cases on record, one by Gerhardt,' one of my own,2 and a third by Pentzold3), it is hardly probable that the dilators of the glottis only should be suddenly paralyzed. Apart from these paroxysms, which are not in direct connec- tion with the fundamental disease, tracheal stenosis in its ordi- nary course may be divided into different periods. Gerhardt, who first accurately described tliese differences, recognized three periods. The first one is almost entirely free from disturbances ; in it, at most, labored respiration occurs only on physical exer- tion. The second is a stage of continuous and well-marked ste- nosis, which may extend over a great length of time, and which presents almost all the symptoms occurring in stenosis of the larynx, especially the audible respiratory sounds, the form of res- piration, and its relative prolongation. The voice of the patient is weak in this stage, and of limited volume, on account of the feebleness of the current of air which strikes the vocal cords. The third stage, according to Gerhardt, is apt to appear very rapidly. It commences with a paroxysm of suffocation, which soon passes over, and from which the patient apparently re- covers. Nevertheless the paroxysm recurs after a shorter or longer interval, and the patient either dies in the paroxysm, or succumbs consecutively to a rapidly extending pneumonia of aspiration. Although every case of tracheal stenosis by no means passes through the three stages mentioned, in the order we have given, still this may be regarded as the normal course in the majority of cases. The importance of the affections under consideration renders it justifiable to contrast the clinical train of symptoms, briefly, with those manifestations which are 1 Virchow's Archiv, Bd. XXVIL, p. 298. 2 Berlin, klin. Woch., 1872, Nos. 20, 21, 1873, No. 7. 3 Deutsches Archiv f. klin. Medicin, Bd. XIII., Hft. 1. u. 2. 494 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. observed in artificial constriction of the trachea in animals. Biermer, in his excellent essay on bronchial diseases, has already related some experiments on animals made by Fick and himself. I have frequently performed such experiments, even in my lectures; but employ another, and, as it appears to me, more suitable method. Biermer, in his experiments upon animals, either kept the nostrils closed, or com- pressed the trachea with the finger. My experiments, on the contrary, in which, at the same time, I desired to represent the breathing graphically, were performed in such a manner that after preliminary tracheotomy an ordinary tracheal canula was introduced, to which a tube was attached terminating in two limbs. One of the limbs of this tube was placed in communication with a rubber tube leading to the cardiograph, and the other was allowed to remain open. On this open limb, which carried a rubber tube at its end, an entire series of tubes of different calibres were placed one after another. The cardiograph was in connection with the rotating drum of a kymograph, and thus, without touching the animal in the least, the alterations of respiration following the different calibre given to the windpipe, according to the size of the glass tube inserted, were accurately represented graphically. It was thus shown that in proportion as the larger air-passages were constricted, there was an increasing prolongation of the breathing. At the same time the curve was the longer the slower the breathing, that is, the more the air-passage was con- stricted. The increasing slowness of the breathing, and the increasing size of the curve corresponded completely; so that with every further increase in the constric- tion of the tracheal tube, both became altered in the same way, and at the same rate. The remaining manifestations, such as the employment of all the auxiliary forces, loud, whistling respiration, increase in the number of pulsations, and the like, require no further description. In all important points the results of these experiments with animals coincide with the clinical symptoms. The symptoms described in the preceding pages relate only to what is directly occasioned by the tracheal and bronchial stenosis. In the majority of cases there are, in addition, a series of further symptoms, which belong to the fundamental disease that has produced the stenosis. These, as a matter of course, vary according to that disease. Concerning these symptoms, which belong to goitre especially, to mediastinal tumors, aneu- rism of the aorta, syphilis, in short to all the affections previ- ously mentioned in the article on etiology, the reader is referred to the appropriate chapters. The same remark applies to the symptoms of the conditions consecutive to the stenosis. These concern chiefly the organs of respiration and circulation, especially emphysematous dis- tention of individual portions of the lungs, secondary pneumo- STENOSIS OF THE TRACHEA AND BRONCHI. 495 nia, bronchiectasis, dilatation of the heart, and the like. A special description of them is not requisite in this place. Diagnosis. In establishing the diagnosis of a tracheal or bronchial ste- nosis, it is essential in the first place to determine the existence of a narrowing of the larger air-passages; and secondly, to determine the special seat and nature of the stenosis. The first point, the determination of the existence of a narrowing of the larger air-passages, should, with the help of the points above discussed, present no special difficulty. The points of especial importance are : relatively prolonged and extremely difficult breathing ; the predominant inspiratory dysp- ncea, at least in tracheal stenosis, with the special characters already mentioned; the epigastric retraction ; the absence or fee- bleness of the respiratory murmur, with relatively full and clear pulmonary resonance ; the stridor; the slight or negative impair- ment of the voice; the gradual occurrence and increase of the stenotic manifestations; the knowledge of the fundamental dis- ease occasioning the stenosis ; and so on. On the other hand, the distinction between tracheal stenosis and laryngeal stenosis presents some difficulties, at least in some cases. It is not so much here the acute affections of the larynx, such as croup, oedema, and spasm, which can give rise to mis- take, as certain more insidious anomalies of the larynx occurring at the same time. We have to consider, first, the signs previously mentioned as especially insisted on by Gerhardt. In tracheal stenosis the larynx, as a whole, moves but slightly up and down during breathing, or not at all. In laryngeal stenosis it makes very marked respiratory excursions. In spasmodic respiration and noisy breathing, slight respiratory movement of the larynx, not exceeding one centimetre, is a certain sign of tracheo- or tracheo- bronchio-stenosis (Gerhardt). A differential diagnostic sign of tracheal stenosis, as distin- guished from laryngeal stenosis, is evinced, as shown by Ger- hardt, in the position of the head. In most laryngeal stenoses, 496, RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. and particularly in those which affect the glottis, there is a bending of the head backwards, which is not observed in tracheal stenosis. In pure tracheal stenosis, on the contrary, there is a somewhat protruded and slightly depressed position of the chin. With regard to the employment of the sound as a diagnostic means of distinguishing laryngeal from tracheal stenosis, this instrument, as previously observed, is to be discarded. Laryn- goscopy, on the other hand, is always competent to distinguish with certainty laryngeal from tracheal stenosis. Special mention must be made of one laryngeal affection, which may readily lead to a mistake, despite examination with the mirror, on account of its apparently negative result, and that is, bilateral paralysis of the posterior crico-arytenoid mus- cles. While the forms of paralysis of the vocal cords ordinarily observed, and complete bilateral paralysis of the recurrent nerve, produce little or no dyspnoea, but always alteration of the voice, bilateral paralysis of the posterior crico-arytenoids leaves the voice intact, but always gives rise to very great dyspncea. The vocal cords in these cases do not present the usual cadaveric position, as in pure paralysis of the recurrent nerve, but they are approximated so as to leave but a small fissure between them, which becomes further diminished by each inspiration. It is therefore necessary, in order that this form may not be overlooked on account of the entire absence of alteration in the voice, that the vocal cords be examined laryngoscopically, not only during phonation, but also during both quiet and forced inspiration. Complete paralysis of the recurrent nerve of both sides can- not lead to any mistake, as it always produces absolute aphonia, but never any great difficulty in respiration. It must not be forgotten, moreover, that tracheal or bronchial stenosis is not infrequently combined with paralysis of the recurrent nerve. This paralysis of the recurrent is usually unilateral, and therefore has no important influence on the dyspnoea. The not infrequent association of tracheal or bron- chial stenosis with paralysis of the vocal cords, is readily expli- cable from the fact that, by pressure and the like, a series of STENOSIS OF TIIE TRACHEA AND BRONCHI. 497 affections, especially aortic aneurisms, mediastinal tumors, and the like, not infrequently injure the recurrent nerve and the trachea or a bronchus at the same time. It was stated in our introduction that we would exclude the subject of foreign bodies in the air-passages from the discussion before us. That foreign bodies may give rise to the symptoms of stenosis already mentioned requires no further comment. Their differentiation depends, above all other things, upon the history of the case, which in the majority of cases points with certainty to the pene- tration of a foreign body. A valuable sign, in many cases, is the movement of the body up and down within the great air-passages. In very rare instances the foreign body, which at first occluded the one bronchus, becomes forced by cough, or other violent movement, from its primary position, and lodges in the other bronchus, or in some other situation. In the majority of cases the foreign body, as soon as it gets into the air-passage, excites more or less alarming symptoms, and leads to a fatal termination, often in a short time, if it is not soon removed. On the other hand, however, undeniable instances have been known in which foreign bodies have remained in the trachea or in one bronchus for weeks, months, and even several years. In spite of all the points mentioned, the differentiation of the diseases we are considering from stenosis occasioned by a foreign body, presents considerable diffi- culty in many cases. This will especially be the case, if, as in an instance recently reported by Hamburger,1 not only every evidence is wanting as to the entrance of a foreign body, but nearly every local symptom likewise, as convulsive cough, pain in the throat, dyspncea, cyanosis, and the like. The diagnosis of bronchial stenosis presents less difficulty than that of tracheal stenosis. The more or less complete inactivity of one lung, wifh at least not infre- quent overaction of the other; the full and clear percussion sound, with absent or enfeebled respiratory murmur; the palpable and audible thrilling of the affected side, its diminished vocal fremitus, and other symptoms of the same nature, readily permit the diagnosis of more or less complete impermeability of one bronchus. On the other hand, the determination whether the case is one of foreign body in a brouchus, or of syphilitic stenosis, or of stenosis from compression, can often be only decided by recalling all the indications above mentioned, especially the recol- lection as to previous history. In by far the greater number of cases, the special diagnosis presents no difficulty on careful consideration of all the attendant cir- cumstances. It is still to be mentioned that tracheal stenosis is frequently associated with bronchial stenosis. In these cases only the accurate appreciation of all the attendant circumstances, and especially with the aid of tracheoscopy, can render the diagnosis possible. 1 Berl. klin. Woch., 1873, Nos. 28 u. 29. VOL. IV.—32 498 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. Finally, the determination of the fundamental disease will also furnish points to help the more special diagnosis. Duration, Terminations^ and Prognosis. Narrowing of the trachea and bronchi is of very variable duration, according to the cause by which it has been occa- sioned. The majority of the above-mentioned processes which can give rise to stenosis are of relatively slow progress; conse- quently the stenotic manifestations developed by these causes will, as a rule, be tolerably protracted. Still, there are also cases in which the complete picture of stenosis is developed in a toler- ably rapid manner. As to the termination, that depends upon the fundamental disease occasioning the stenosis on the one hand, and on the degree of the stenosis on the other. As many of the fundamental diseases mentioned, such as mediastinal tumors, acute aneurisms, and the like, are incur- able and gradually increase more and more, the prognosis in such cases is unfavorable. But independently, also, of these fundamental diseases, a severe grade of stenosis of the trachea or the larger bronchi, even when only one primary bronchus is affected, often leads to a fatal termination. The rapidity with which this ensues is, as a matter of course, very different in dif- ferent instances. Nevertheless, there are cases of stenosis of the large air-passages which offer the possibility of recovery. Such a possibility exists when the narrowing is not yet very great, and when the source of injury occasioning the stenosis is one which can undergo retrogression; such, for example, as swollen glands, goitre, and the like. On the other hand, severe stenoses of the trachea and the bronchi, which have been occa- sioned by syphilis, are usually of unfavorable prognosis. All those cases offer a relatively favorable prognosis in which the stenosis is situated high up in the trachea, and is occa- sioned by benign tumors pressing on the trachea, or by simple cicatrices ; because in such cases tracheotomy is at least com- petent to avert the direct danger to life. Those cases also in which benign growths have become devel- STENOSIS OF TIIE TRACHEA AND BRONCHI. 499 oped in the interior of the trachea frequently present a favorable prognosis ; and the prognosis is the more favorable the higher the location of the morbid growth constricting the windpipe. The final fatal result takes place gradually, with cerebral manifestations in most instances. Pneumonia and oedema of the lungs are frequent complications shortly before death. In rare cases the fatal termination takes place suddenly, while as yet the manifestations of d}Tspncea have not assumed an alarming character. In cases of rather great stenosis of the trachea and bronchi, the possibility of such a sudden fatal termination must not be lost sight of. It may have its origin in sudden occlusion by mucus or secretion, or in the per- foration of abscesses which proceed from contiguous organs, and suddenly rupture into the trachea, or in aortic aneurisms which break through into the trachea or into a bronchus. In some cases the fatal termination has taken place suddenly, and even the autopsy has not disclosed the cause of the sudden death. As a rule, however, it must be borne in mind that death takes place gradually, with manifestations of sopor and coma. Treatment. In general, no especial benefit is to be expected from treat- ment in these affections. The first indication in treatment is to relieve the disease occasioning the stenosis. As, however, the majority of affections occasioning tracheal and bronchial stenosis are incurable, it is not possible to satisfy this indication in most cases. If the stenosis is occasioned by goitre or swollen glands, the indication is to relieve these conditions. As to the special man- ner in which this is to be done we refer the reader to the works on surgery. If the operative removal of swollen glands appears unadvisable from any reason, or is no longer possible, the at- tempt should be made to reduce them by the employment of absorbent remedies, by parenchymatous injection, and the like ; and thus lessen the compression. Where syphilis is the origin of the stenotic manifestations, the attempt should be made to determine whether an improve- 500 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. ment in the symptoms cannot be effected by an antisyphilitic treatment. The iodides are especially indicated in these cases, and, under certain circumstances, subcutaneous injections of corrosive sublimate also. Sometimes an active inunction-cure does great service in these cases. In general, however, no spe- cial benefit is to be expected from the procedures mentioned, in such stenoses as are dependent upon syphilis. There is a series of stenoses, on the other hand, in which, as the causal disease can be in no way relieved or modified, there can be no question of causal treatment. Tliese are the cases due to aneurisms of the aorta, tumors of the mediastinum and the like. In all these cases, and in others also in which the funda- mental disease is beyond relief, either tracheotomy alone can save life, or else treatment of symptoms is all that can be at- tempted. Tracheotomy can be resorted to only in those cases in which the seat of the constriction is high up in the trachea. In bronchial stenosis it is useless as a matter of course, and so even in tracheal stenoses located low down or just above the bifurca- tion. It is therefore necessary to determine the seat of the ste- nosis with accuracy before deciding as to the indication for tra- cheotomy. In those cases, on the other hand, in which no benefit is to be anticipated from the methods previously mentioned, and in which tracheotomy does not appear to be indicated, the treat- ment must be purely symptomatic in character. Thus, if there is an abundant accumulation of mucus, and the breathing is more or less impeded, expectorant remedies are indicated, and even emetics under certain circumstances. If there is great swelling in the neighborhood of the stenosis, and the symptoms occasioned by the narrowing appear to be increased thereby, antiphlogistic treatment is indicated ; especially the local appli- cation of cold, ice compresses, local abstractions of blood, derivatives to the skin, inunctions of stimulating ointments, and the like. In cases of very great dyspnoea, and in cases in which none of the remedies mentioned are called for, sedative remedies are often in place. Finally, stimulants are to be employed in accordance with the general rules for their administration. FOREIGN BODIES IN THE TRACHEA AND BRONCHI. 501 FOREIGN BODIES IN THE TRACHEA AND BRONCHI. Bibliography. Albers, Atlas der path. Anat. und Erlauterung dazu. 1846.—Arnot, Edinb. Med. and Surg. Jour., Vol. XXXV., 1821. (Piece of bone expelled after two months' retention; recovery.)—Bonetus, Med. sept, collect., Lib. II., Sect. 9. De xVffect. asp. art., cap. VIII. (Piece of bone expelled after three months' retention; recovery.)—Donaldson, Edinb. Med. and Surg. Jour., 1834. (Barley ear; expulsion; recovery.)—Hochstetter, Observ. dec. 6. cap. 6. (Coin; retention a year and a half ; expulsion ; recovery.)—Bartholin, Historise anat. IL, hist. 27. (Nut; two months' retention; expulsion ; recovery.)—Lettsom, Memoir of the Life and "Writings of Dr. Lettsom, by J. J. Pettigrew, 1817, Vol. 2, p. 82. (But- ton ; retained seven or eight months; expulsion ; recovery.)— Webster, London Med. and Phys. Jour., Vol. L, p. 269. (Cherry-stone in the left bronchus near the bifurcation; retained sixty-seven days; suffocative sensation ; coughed out with a quantity of fetid pus.)—Broussais, Histoire des phlggmasies, I., p. 212. (Ker- nel ; coughed out; recovery.)—Nooth, Transactions of a Society, V. III. (Leaden ball; expulsion; recovery.)—Borelli, Hist. med. phys. Jour., 1656. (Piece of a nut kernel; expelled with severe cough.)—Tulpius, Obs. I., II., Obs. VII. (Nut- shell, expelled in a severe fit of coughing after seven years' retention.)—How- ship, Practical Observations. London, 1816. (Iron nail; bloody expectora- tion ; expulsion of the nail after four months.)—Halmar, London Med. Jour., Vol. VIII. (Piece of bone; severe spitting of blood after fifteen years' reten- tion, with expulsion of the bone; recovery.) The cases thus far recorded are reported by Albers as having recovered; and he also records the following cases of foreign bodies in the bronchi, with fatal termination: Houston, Dublin Jour. Med. and Chem. Science, V. (Root of a tooth in right bronchus ; death from bronchitis and pneumonia after eleven days.)—Gilroy, Edinb. Med. and Surg. Jour., Vol. 35. (Chicken bone in right bronchus; circumscribed abscess ; death.)—Lenglet, Memoires de l'academie de chirurgie, Vol. V. (Bone in left bronchus ; in spite of its expulsion the patient died; abscess in the left lung.) Anonymous writer, Ephemerid. nat. curios. Dec. II., Ann. X., Obs. 72. (Cherry- tone; death.)—Craigie, Edinb. Med. and Surg. Jour., 1834. (Artificial tooth ; expulsion after two years; death.)—Nasse, Schnickel, Expositio nosograph jiorb. mem. mucos. bronch. Bonnse, 1835, p. 2.—Albers. (Tooth; death; small nail expelled with fetid pus.)—Laurence, Bulletin de la soc. anat., Vol. 13. (Ver- tebra of a fish in right bronchus ; several gangrenous cavities.)—Bordinet, Ibidem. (Nail; several bronchi ulcerated.)—Roger-Collard, Ibidem, Vol. I. 502 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. —Abercrombie, in Craigie's Article, Edinb. Med. and Surg. Jour., 1834. (Arti- ficial tooth.)—Sue, Mem. de l'acad. royale de chir., torn. V., p. 533. (Piece of the vertebra of a pigeon; hectic; expulsion after seventeen years; death one year and a half later.)—Rokitansky, Lehrb. d. path, anat., Bd. 3, p. 42. (Bolt with flag [for shooting at a child's target] in left bronchus.)—Staustky, Gaetan Bull, de la societe anat., ann. X. (Ear of grain in left bronchus; abscess in the right lumbar region.)—Histoire et memoire de l'acad. royale des sciences de Toulouse, torn. I., 1788; also in Hufeland's neuesten Annalen der franzos- ischen Arzneikunde, Bd. I., p. 337. (Ear of grain ; a tumor appeared between the first and last false ribs, which ruptured and discharged the ear.) Bussignol (Gluge's Atlas der pathol. Anat., Lief. 6, p. 19).—Heyfelder, Ein Bei- spiel von spontaner Ausstossung eines in die Luftrohre gedrungenen fremden Korpers nacL einem 12jiihrigen Verweilen. Sanitatsbericht iiber das Fiirsten- thum Hohen_ollern-Sigmaringen, 1833 ; Med. Zeit. v. Ver. f. Heilk. in Pr., 1835, No. 2.—Evanson, Report of a Case in which the Presence of a Foreign Body in the Trachea was Suspected, Dublin Jour., Mch., 1834. (Fishbone.)— Kiihn, De educatione sensuum extern, imprimis medicis necessaria. Lips., 1829, p. 26. Inaug. -Dissert. (Toothpick in right bronchus; expulsion of foreign body; death.)—Ulrich, Luftrohrenschnitt mit todtlichem Ausgange. (Bean at commencement of left bronchus.) Schmidt's Jahrb., Bd. 3, 178.—Bonten, Cas- per's Wochenschr., Mai, 1834, No. 18. (Bone at the point of division of the left bronchus.)—Steinriick, Zvvei Falle von fremden Korpern in der Luftrohre, Casper's Wochenschr., 1835, No. 16.—Serlo, Schneller Tod durch einen in die Luftrohre gefallenen Korper, Med. Zeitschr. v. Ver. f. Heilk. i. Pr., 1835, No. 26.— Wagner, Ein abermaliges Beispiel, dass die Luftrohre dahin herabgefallene fremde Korper zuweilen lange zu erdulden vermoge, Hufeland's Jour., St. H., 1835.—Andriessen, Abermaliges Beispiel von langwierigem Verweilen eines fremden Korpers in der Luftrohre, Casper's Wochenschr., 1836, No. 48.—Behr- endt, Eine Kornahre steckt 3 Jahre in der Luftrohre, Casper's Wochenschr., 1836, No. 51.—Bullock Death occasioned by a Pebble inhaled into the Larynx, London Med. Gaz., Vol. XVTIL, pp. 951-953.—Guastamacchia, Case in which a Foreign Body remained in the Trachea for Two Months and a Half, and was then coughed out. Filiatre sebezio, 1838.—Troschel, Eine Tuchnadel in dem rechten Aste der Luftrohre, Med. Zeit. v. V. f. Heilk. i. Pr., 1838, No. 7.— Bell, Med. Gaz., Vol. V., p. 7L—Pelletan, Clinique chir., Vol. I., p. Q.—Pecheux, Gaz. mgd. de Paris, No. 35, 1840.—Schutz, Miscellen aus der Praxis, Wiirttemb. Corresp.-Bl., Bd. VI., No. 7.—Mertznich, De cognitione morborum tracheae. Diss.-inaug. Colonise, 1839.—Hertel, Mit gliicklichem Erfolge ausgefiihrte Tracheotomie bei einem Kinde, Med. Zeit. v. Ver. f. Heilk. i. Pr., No. 14, 1836. (Bean in the trachea.)—Bonnet, Extraction eines Pflaumenkerns, der 11 Tage in den Luftwegen geblieben war, Schmidt's Jahrb., Bd. 30, p. 69.— Thomson, Suf- focation produced by a Pea in the Trachea ; Tracheotomy, London Med. Gaz., Vol. XXIX., p. 146.—Russ, Eroffnung der Luftrohre zur Entfernung einer Bohne, Oesterr. med. Jahrb., 1842, Nov. (Bean extracted from the left bronchus FOREIGX BODIES IX TIIE TRACHEA AND BRONCHI. 503 through an incision in the trachea.)— Brodie, Report of a Case in which a For- eign Body had fallen into the Right Bronchus, Med. Chir. Trans., XXVI., 2 Ser., VIIL, 1843. (Coin.)—Eindringen eines Kjiochensplitters in die Bronchien und spontane Entfernung desselben, Kurhessische Zeitschr., II., 1, 1845.— Vigla, Ueber Communication des Oesophagus mit den Lungen und den Bronchien, Arch, gen., Oct., 1846. (Large collection of such cases.)—Frazer, Case of Extensive Scrofulous Ulceration, with an Abscess which had opened into the Trachea, Monthly Journal, Jan., 1848. (Scrofulous glands suppurated and perforated into the trachea; recovery.)—Gotschalk und Schneevogt, Eindringen eines Knochenstiicks durch die Stimmritze in den linken Bronchus, Nederl. WeeckbL, Jan'y, 1852. (Bone; death.)— Theile, Deutsche Klinik, 17, 1853.— Fleury, Foreign Body in the Trachea; Hypertrophy of the Thyroid Gland as an Obstacle to Tracheotomy; Death, Gaz. des hop., 19, 1854.—Garelli, Garr. Sarda. 3, 1852. (Bony concretion in the windpipe which was spontane- ously discharged through the mouth.)—Crisp, A Foreign Body in the Bronchus of a Child, coughed out after remaining there for Ten Months. Medical Society in London; Journ. f. Kinderkrankheiten von Behrend und Hildebrand, 12. Jahrg., Hft. 1 u. 2. Erlangen, 1854.—Gross, A Practical Treatise on Foreign Bodies in the Air-passages. Philadelphia, 1854. (Analysis of two hundred cases.)—John Hughes, On the Presence of Foreign Bodies in the Air-tubes, illustrated by a Case in which a Fish-bone passed into the Left Bron- chus, Dublin Quart. Jour. Med. Sci., No. XXXVIIL, May, 1855.—Chassaignac, On the Indications of Tracheotomy derived from the Presence of Foreign Bodies in the Air-tubes, Moniteur des Hop., March 6, 1855.—Porter, Observa- tions on the Surgical Pathology of the Larynx and Trachea, etc. London, 1837.—Hock, Ueber Tracheobronchitis in Folge des Eindringens einer Bohne in die Trachea. Hygiea. Stockholm, Nov., 1854.—Santesson, Foreign Body (Bone) in the Trachea of a Girl Six Years of Age. Tracheotomy, Recovery. Hygiea. Stockholm, Nov., 1854. — Flecken, Eine Kornahre in der Luftrohre, Med. Zeitung, herausgegeben von dem Vereine f. Heilkunde i. Preussen, No. 51, 1855. —Pepper, A Grain of Coffee in the Air-passages, Am. Jour. Med. Sci., April, 1855.—Struthers, Dublin Med. Press, Nov., 1852. (Bone in right bronchus.) —Jobert, Observations on Foreign Bodies in the Air-passages. L'Union, 62, 05, 67, and 68, 1851.—Forbes, Foreign Body in the Orifice of the Third Branch of the Right Bronchus, Med. Chir. Trans., Vol. XXXIII.—Paul Aronssohn, Des corps Strangers dans les voies aeriennes. These. Strassbourg, 1856. (Collection of 170 cases.)—Aubry, Note sur une operation de tracheotomie necessitee par la presence d'un haricot dans les voies respiratoires; guerison. Arch, gener. de med., Oct., 1856.—v. Franque, Fremde Korper in der Luft- rohre; tracheotomie, Med. Jahrb. f. d. Herzogth. Nassau, 14. Hft., 1856.— Rou.v, Balle dans les voies aeriennes. Expulsion spontanue le dix-huitieme jour, Gaz. des hop., No. 81, 1856.— Hamont, Gaz. des hop., No. 108, 1856. (Boy five and a half years of age inhaled a fragment of chestnut shell into the air-passages; formation of pulmonary abscesses; eighteen months afterwards the foreign 504 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. body was expelled in an attack of vomiting; death occurred subsequently.)— TJhcle, Deutsche Klinik, No. 19, 185G.—Opitz, Ueber fremde Korper in den Luft- wegen. Diss, inaug. Lips., 1858; Schmidt's Jahrb., 100, p. 101. (Compilation.) —Lbper, Deutsche Klinik, 47-49, 1857.—J. Spence, Edinb. Med. Jour., Feb. 1858. (Three cases of tracheotomy on account of foreign bodies in the air- passages. In two cases the foreign body had fallen into the left bronchus.)—J. Cooper Forster, Guy's Hosp. Reports, 3d Series, Vol. III., p. 123 et seq.—Schuh, Wien. med. Wochenschr., 1, 1859.—Levin und Hbk, Falle von fremden Korpern in den Luftwegen. Hygiea, Bd. XVI., 1857.—Tracheotomy on Account of the Entrance of a Bean into the Air-passages, Arch, gen de m6d.—Med. Wochen- schr., 1857, Jahrg. VII., No. 45, Beilage.—Zimmermann, Aus der Praxis. Allgem. med. Centralzeitung, No. 51, 1857.—Perret, Corps etranger dans la trachSe, tracheotomie, guerison, Gaz. mgd. de Lyon, No. 4, 1857.—Haughton, Corps Strangers dans les voies aeriennes, tracheotomie ; guerison. Gaz. hebd., No. 3, 1858; The Cincinnati Med. Observer, Vol. IL, Nov., 1857.—Ch. Barrett, Inflammation of the Lungs caused by a Foreign Body in the Bronchus, Brit. Med. Jour., No. 50, Dec, 1858.—Claremont, On a Case of the Simultaneous Intrusion of Solids into the Air-passages of both Lungs, Lancet, May 15, 1858. —Rothmund, Zur Casuistik der fremden Korper, Deutsche Klinik, 15-17,1859. (Spear of grass in the air-passages; spontaneous discharge after the formation of an abscess in the right lung.)—Adler, American Med.-Chir. Review, IV., 6, Nov., 1860. (Extraction of the foreign body with an instrument, after trache- otomy.)—Finkelnburg, Virchow's Archiv. Bd. XIX., 5 u. 6 Hft., p. 550,1860.— Lowy, Wiener Med -Halle, IV., 25, 1863.—Padley, Foreign Bodies in the Air- passages, Brit. Med. Jour., Jan. 5, 1861.—Evans, Abscess of Lung from Presence of Foreign Body ; Evacuation through Bronchial Tubes and Thoracic Walls ; Recovery. Brit. Med. Jour., Jan. 5, 1861.—Tomson, Amer. Med. Times, Jan. 12, 1861. (Piece of a clay pipe stem.)—Howship, Practical Observations in Surgery, 1816. (Nail; coughed out afterwards.)—Duncan, Lancet, 1845. (Bone.)— Fountain, North American Med.-Chir. Rev., III., 5, p. 854, Sept., 1859. (Reports a case in which a foreign body in the right bronchus produced gangrene of the lung, and empyema with perforation into the colon, but was finally coughed out.)—Monckton, Brit. Med. Jour., April 26, 1862. (Half a nutshell; remained twenty-three weeks in the air-passages.)—Armstrong, Ibidem, p. 436. (Bean in right bronchus.)—Beigel, Virchow's Archiv, Bd. XXVI., p. 220, 1862. (Bean in left bronchus; death.)—Lechere, On Perfora- tion of the Lung by Foreign Bodies, Gaz. de Paris, 30, 1863.— Wagner, Archiv der Heilkunde, V. 4, p. 347, 1864.— v. Heider, Memorabilien, IX., 6, 1864.— Fredet, Gaz. des hop., 145, 1865. (Reports a case in which, in consequence of the retention of a foreign body [earring] in a branch of the left bronchus, pneumonia ensued with fatal result.)—Herrmann, Ueber die Indicationen fiir die Tracheotomie und Laryngotomie, Sitzungsberichte des Vereins pract. Aerzte zu Prag., No. 15, 1868.—Rasch, Tracheotomie wegen eines fremden Korpers in der Luftrohre, Norsk. Mag., XIX., p. 751, 1865.— Walters, Removal FOREIGN BODIES IN TIIE TRACHEA AND BRONCHI. 505 of a Foreign Body from the Right Bronchus, Brit. Med. Jour., Feb. 15, 1868. —Bourdillat, On Foreign Bodies in the Air-passages, Gaz. de Paris, 7, 9, 10, 13, 15, 1868. (Has collected 300 cases, the location of the foreign body being accurately given in 166 cases: 80 times in the trachea, 26 in the right bronchus, 15 in the left bronchus, and 35 in the larynx.)—Smyly, Ascaris lumbricoides in the Trachea, Dublin Jour. Med. Sci., May, 284.—Schrotter, Oesterr. med. Jahrb., Hft. 5 u. 6, No. 1, 1868.—Dressier, Einwanderung eines Spulwurms in die Luftrohre eines lebenden Kindes. Bair. arztl. Intell.-Blatt., No. 31, 1869.—Barben-Duboury, Recherches sur les accidents produits par quelques corps Strangers des bronches. These. Paris, 1866.—Reynolds, Case of Laryn- gotomy, Boston Med. and Surg. Jour., Feb. 6, 1868. (Ball in the trachea.)— Werner, Tracheotomie wegen einer in die Luftwege gedrungenen Bohne, Genesung. Wiirtemb. med. Corresp.-Blatt.,No. 14,1868.—Scott, Extraction of a Grain of Corn from the Trachea. Med. and Surg. Rep., Phil., Aug. 22,1868, p. 145.—Bertholle, Des corps Strangers dans les voies aeriennes. Paris, 8, 1867. —Parrot, Sur un cas de mort par l'introduction de chyme dans les voies aSriennes, Union med., 1868, No. 91.—Piegu, Observation d'asphyxie par intro- duction de chyme dans les voies aSriennes, Union med., No. 94,1868.—Senhard, Fremder Korper in der Luftrohre, Tracheotomie unter schwierigen Verhaltnissen mit giinstigem Erfolge. Wien. med. Presse, No. 35, p. 830, 1869. (Piece of bone.)—Giraldes, Des corps etrangers dans les voies aeriennes. Le Mouvement mSd., Nos. 12 and 13, 1869.—Reeve, Tracheotomy for Removal of a Shawl-pin, Am. Jour. Med. Sci., Oct., 1869, pp. 393-94.—i^W?ra», A Grain of Coffee removed from the Windpipe by Tracheotomy. Phila. Med. and Surg. Rep., Oct. 30, 1869, p. 257.—Guyon, Du traitement des corps Strangers des voies aeriennes, Bull. gSnSr. de thSrap., Jan. 15, 1869, pp. 15-25.—Napheys, Foreign Body in the Air-passages. Phil. Med. and Surg. Rep., Vol. XX., April 3, 1869, p. 260.—Foville, Etude clinique et physiologique sur la mort instantanee, causSe par le passage de matieres alimentaires en voie de digestion, de l'estomac dans les voies aSriennes. Arch. gSn. de med., Juillet, 1869, pp. 1-18.—Bour- dillot, Observations pour servir a l'histoire des corps Strangers dans les voies aSriennes. Gaz. mSd. de Paris, Nos. 7, 9, 10, 13, 1868.— Duroziez, Gaz. des hop. 97, Aout, 1870. (Discharge of an echinococcus of the spleen through the bronchi.)—Arentz, Sten in Luftveiene. Norsk. Mag. f. Lagevid., Bd. 23, p. 119, 1870.—Doe, Case of Foreign Body in the Air-passages, Boston Med. and Surg. Jour., Dec. 29, 1870.—Masing, Zur Casuistik der fremden Korper in den Luftwegen. Petersb. med. Zeitschrift, XVTL, p. 30, 1870.— Butler, Foreign Body in the Trachea ; Tracheotomy. Lancet, June 4, 1870.—Gurdon Buck, A Contribution to the Surgical Therapeutics of the Air-passages, illus- trated by Two Cases. Transactions of the N. Y. Academy of Medicine, Vol. IIL, part X., 1870.—Baldwin, Phil. Med. Times, I., Apl. 1, 1871. (Coin in a bronchus.)—Hubbard, Phil. Med. Times, July 15, 1871. (Coin in a bronchus.) —Bitschcy, Phil. Med. and Surg. Rep., XXIV., March 9, 1871. (Rupture of an hepatic abscess into a bronchus.)—Bellamy, Foreign Body in the Air-passages. 506 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. Phil. Med. and Surg. Rep., May 4, 1872. (Two-cent piece in the bronchus of a child a year and a half of age.)—Fallie, Corps Strangers dans les voies aeriennes, Annal. de la soc. de med. d'Anvers, Sept., 1871. (Three casos.)— Herrick, Case of a Foreign Body remaining Four Years in the Lung, Boston Med. and Surg. Jour., Feb. 16, 1871.—Ronsburger, Zur Casuistik der fremden Korper in den Luftwegen. Wien. med. Presse, p. 52, 1871. (Artificial palate; tracheotomy; recovery.)—Leclere, On Perforation of the Lung by Foreign Bodies. Gaz. med. de Paris, No. 30,1863.— Ogle and Zee, Case of Tracheotomy in which the Tube, having become detached from its Shield, escaped into the Trachea, and was removed by a Second Operation, Fourteen Months afterwards. Lancet, Jan. 20, 1872.—Holthouse, Escape of a Tracheotomy Tube into the Trachea, owing to Erosion of the Junction of the Tube and Shield; Removal by enlarging the Original Opening, Lancet, Jan. 27, 1872.—Laudi, Tracheotomia per corpo estraneo. Lo Sperimentale Maggio, pp. 449-457, 1872.— Underwood Hall, Foreign Body in the Trachea. Med. Press and Circular, March 20, 1872. (Lentil.)—Tiirck, Klinik der Krankheiten des Kehlkopfs und der Luftrohre. Wien, 1866.—Hamburger, Diagnose eines fremden Korpers im rechten Bron- chus; klinische Betrachtung dieses Falles. Berlin, klin. Woch., 1873, Nos. 28, 29.—Parrot, Gaz. mSd. de Paris, No. 14, 1873.—Lewis A. Sayre, Inhalation of a bead; Tracheotomy. Medical Record, April 15, 1874.— Weil, Falle von Tracheo- und Bronchostenose. Deutsches Archiv fiir klinische Med., Bd. XIV., p. 82.— Voltolini, Eine Nussschale 10 Monate in der Luftrohre; ein neues Speculum fiir letztere; Operation. Berl. klin. Wochschr., 1875, No. 6. Consult, in addition, Friedreich, Krankheiten des Larynx und der Trachea, in Virchow's Handbuch der speciellen Pathologie u. Therapie, p. 492.—Duchek, Handbuch der speciellen Pathologie u. Therapie, I. Bd., III. Lief., 1873, p. 560; also the works of Gibb, P. Niemeyer, Ruhle, Gerhardt, Stokes, Chelius, Vidal- Bardeleben, Emmert, Pitha-Billroth, etc.; and especially Kiihn (in GLinther's Lehre von den blutigen Operationen, V. Abth., XVIII. Abschn.), who has col- lected very full statistics, comprising no less than 374 cases. Etiology and Pathogenesis. The presence of foreign bodies in the trachea and bronchi produces a condition closely resembling the stenosis occasioned by morbid growths and similar causes, so that it seems very proper to speak of the former in immediate connection with the latter. Both kinds of stenoses exhibit a consonant relation in many important joints. On the other hand, the train of symptoms, and especially the therapeutic management, of the two conditions differ from each other in so many respects that a separate though brief description of the former seems neces- FOREIGN BODIES IN THE TRACHEA AND BRONCHI. 507 sary. Inasmuch as the symptoms due to the presence of a foreign body coincide in their important features with those of tracheal and bronchial stenosis described in the preceding chapter, and also because these affections, with reference to treatment, belong more to the surgeon than to the physician, we shall be very brief in our remarks. We therefore refer the reader to the manuals and treatises on surgery for special details, and especially for details of treatment. Foreign bodies may gain entrance into the trachea and bron- chi in very different manners. The most usual method is that the foreign body gets through the mouth and pharynx into the larynx or the trachea, and thence, according to its size and according also to the existence of certain other determining causes, into a primary bronchus or into smaller bronchi. The foreign bodies which most frequently gain access from without into the trachea and the bronchi are fragments of bone, the kernels of various fruits, spears of grain, beans, peas, fish- bones, nutshells, small stones, coins, needles, and the like. On the other hand, various normal or pathological products exist- ing in the mouth, pharynx, or larynx, may get into the air- passages: such substances as fragments of the uvula, concre- tions from the ventricles of Morgagni, fragments of necrosed laryngeal cartilage, teeth, pharyngeal polyps, fragments of a tonsil, pus, blood, and the like. In similar manner, materials from the stomach may get into the air-passages during vomiting: such as thread-worms, chyme, and the like. In rare instances foreign bodies may gain access into the bronchi and the trachea from a penetrating wound into the lung. Foreign bodies, also, such as pus, bladders of echinococci, and the like, may pass, by perforation, from the pleural cavity, the liver, and other contiguous organs, into the bronchi and the trachea. Usually, in cases of the latter kind, the foreign body is at once entirely or in part discharged again by way of the air-passages. Foreign bodies, again, such as needles and fishbones, may penetrate from the oesophagus into the trachea or into a bron- chus by gradual perforation and the formation of a fistulous track. 508 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. The entrance of foreign bodies into the air-passages from without occurs, in most cases, at a moment in which a deep inspiration is being taken ; during which, as is well known, the epiglottis is somewhat raised, and the glottis dilated. It occurs most frequently during coughing, laughing, sneezing, or speak- ing. If the foreign body is at this moment in the posterior por- tion of the cavity of the mouth, the deep inspiration, which is associated with the acts mentioned, readily favors the entrance of the foreign body into the now widely opened glottis. The simultaneous occurrence of a deep inspiration and the act of swallowing especially favors the penetration of the foreign body into the air-passages. This accident is most frequently observed in children and in imbecile patients ; in the latter, chiefly during a meal, but also during sleep and in conditions of sopor. In not infrequent cases the foreign body becomes impacted in the larynx. This is particularly the case with pointed, sharp- cornered bodies ; and also in cases in which the size of the foreign body is such as to prevent its further passage downward. In other cases—and these are the only ones we shall here take into consideration—the foreign body passes further downwards into the trachea, or into a primitive bronchus, or even into one of the smaller branches. According to its weight, size, form, and other qualities, which may have a determining influence in individual cases, it is retained in one place or the other. Roundish bodies, without sharp corners and with smooth sur- faces, do not remain long in the trachea in the majority of cases, but move further downwards towards the bifurcation or into a bronchus. The foreign body passes into the right bronchus more fre- quently than into the left one. The latter occurrence, never- theless, is by no means as infrequent as we might be disposed to believe from the reports of many anthors. A careful review of the bibliography shows that a considerable number of cases are recorded in which foreign bodies have fallen into the left bronchus. The more frequent entrance of foreign bodies into the right bronchus, is sufficiently explained by the greater diameter of FOREIGN BODIES IN THE TRACHEA AND BRONCHI. 509 this bronchus. In addition to this, as indicated by Friedreich,1 the position of the dividing spur of the two bronchi is directed eccentrically somewhat to the left of the axis of the trachea, so that the larger half of the interior space of the trachea is contin- uous with the commencing portion of the right bronchus. The foreign body by no means remains always in the same place. Even when it has descended into one primitive bronchus, it not infrequently happens that it is repeatedly forced up into the trachea, or even into the larynx, by a vigorous expiration. On this depends the repeatedly observed fact, that the mani- festations of bronchial stenosis, in one and the same patient, are sometimes observed on the right half of the thorax and some- times on the left. The foreign body may be coughed out by a powerful expi- ratory effort, or it may perforate the wall of the air-passage, and thus finally, after a long time, make its way to the exterior. The further course depends principally upon the nature and consistence of the foreign body. In many cases it may remain in the same place for years without producing any further alter- ations ; but in other and more frequent cases its long retention produces secondary alterations in the lungs, especially circum- scribed inflammation, purulent infiltration, and the like. Even abscess and gangrene may be caused. Cases in which the foreign body has remained for years in the air-passages, and which finally recovered perfectly with expul- sion of the offending substance, have been observed in numbers. Thus Halmar2 relates a case in which a bit of bone was not expelled until after fifteen years, and in which complete recov- ery ensued. Heyfelder3 likewise describes an example of spontaneous expulsion of a foreign body from the air-passages after a reten- tion of twelve years. Andriessen4 reports a case in which a 1 Virchow's specielle Pathologie und Therapie. Krankheiten des Larynx und de Trachea. 3 London Medical Journal. Vol. VIIL See, also, Albers, Atlas d. pathol. Anatomie und Erlauterungen, 1846. 3 Sanitiitsbericht iiber das Fiirstenthum Hohenzollern-Sigmaringen, 1833. 4 Casper's Wochenschrift, 1836, No. 48. 510 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. grain of corn remained three years in the trachea. Many similar cases of prolonged retention of foreign bodies within the air- passages are recorded in medical literature. A case recently reported by Voltolini,1 in which a nutshell remained for ten months in the trachea of a ten-year old boy, and was finally removed by operative procedure, is of especial interest. Voltolini justly remarks concerning many similar cases of earlier date, that as they belong to the ante- laryngoscopic period, it was not positively known whether the foreign body was seated in the larynx or in the trachea. It appears, however, that foreign bodies are more frequently re- tained in the larynx for a long time than in the trachea. The case reported by Voltolini is of still greater interest, because the foreign body was seen by aid of the speculum through the tracheal wound, after its long retention in the wind- pipe, and was thus diagnosticated with certainty. Voltolini devised for this purpose a special speculum, similar to Brunton's ear-mirror, which is supplied with a lens. Anatomical Alterations. According to the form, volume, and other qualities of the foreign body in the air-passage, according to its situation, and the duration of its retention, the anatomical alterations occa- sioned thereby are different. It first causes, as a rule, a cir- cumscribed inflammation with great reddening, swelling, and abundant muco-purulent secretion at the place at which it is impacted. After a while, especially if the surface of the offend- ing body is rough, uneven, and jagged, there is necrosis of the underlying mucous membrane, with purulent, serous infiltra- tion of the immediately surrounding parts, and sometimes even deeply penetrating ulceration. After retention for a long time, the foreign body may become enclosed in a mass of connective tissue, or even completely covered with a calcareous envelope. In such a condition, when it does not occasion injurious results ' Eine Nussschale 10 Monate in der Luftrohre ; ein neues Speculum fiir letztere; operation, Berl. klin. Wochenschr., 1875, No. 6, p. 81. FOREIGN BODIES IN THE TRACHEA AND BRONCHI. 511 by its size or its seat, it may remain in the same place for a long time without giving rise to any other manifestations. The alterations caused by a foreign bod}T in a bronchus vary in many respects. Here also a circumscribed inflammation is usually developed at the place at which it remains impacted, and this ma}^ lead to ulceration and necrosis, often with copious fetid secretion. Almost always, however, anatomical alterations in the lungs are produced when foreign bodies remain a long time in the bronchi. Sometimes these consist in pneumonia, some- times in the formation of abscess, and less frequently in intersti- tial inflammation. By suppuration of the surrounding pulmo- nary tissue, which always extends further and further, the foreign body can come even to the outer surface of the lung, and either make its way into the pleural cavity, or penetrate the chest-wall and thus finally reach the exterior. When the foreign body completely occludes the calibre of a bronchus, extended atelectasis of the corresponding portion of the lungs is observed in consequence. In rare cases the foreign body has been seen within the parenchyma of the lungs, imbed- ded in callous cicatricial tissue, or in the cavity of an abscess, enveloped with thickened caseous pus. Symptomatology. In describing the manifestations which occur under the influence of a foreign body within the air-passages, a precise separation of the symptoms occasioned by a foreign body within the laiynx, and those occasioned by one within the trachea, cannot be well made out. It frequently happens that the foreign body is first retained for some time in the larynx, and then travels further downwards into the trachea and the bronchi. The train of symptoms is therefore frequently ushered in by such manifestations as are occasioned by the penetration of a foreign body into the laiynx. When a foreign body gets into the larynx, the patient, in the majority of cases, immediately experiences a more or less intense suffocative sensation ; violent coughing occurs, as a rule, at once, and in favorable cases expels the foreign body. This is 512 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. the case, for example, when small quantities of fluids accident- ally get into the larynx. Usually these are at once expelled externally through mouth and nose with violent coughing and hawking. If, on the other hand, the quantity of fluid which has fallen into the air-passages is considerable, and only weak and feeble attempts to cough take place, or none at all, as occurs in conditions of sopor, or sometimes in small, feeble children, the patient may even succumb asphyxiated. Cases of this charac- ter may be observed, not infrequently, in imbecile patients. If the body which has fallen into the larynx is solid.-, and if it becomes firmly impacted in the rima glottidis, and fills it up completely, so that little or no air can pass by it, the patient may die at once in the very first suffocative paroxysm. In cases of this kind a paroxysm of cough does not set in, but the patient loses consciousness at once and dies asphyxiated. In other cases, at the very moment in which the foreign body gets into the larynx, a severe paroxysm of suffocation occurs, a spasm of the glottis, the countenance becoming markedly cya- notic, the respiration exceedingly laborious and stridulous, inspiration especially prolonged and difficult, cold sweat break- ing out over the brow and the face; the patient grasps invol- untarily towards his throat or his mouth, as if to remove by force the obstruction, the seat of which he correctly recognizes. In favorable cases, the exceedingly violent coughing and gagging succeed after a short time in expelling the foreign body, and then the alarming complication of symptoms ceases at once and entirely, and merely a slight sensation of soreness and irritation in the throat remains for a few days, as the result of the local irritation occasioned by the foreign body. In other and more frequent cases it happens that the first alarming manifestations subside after a short time, the severe spasm of the glottis ceases, the respiration becomes freer again, and the cyanosis disappears or diminishes in a considerable degree, so that the patient and those around him adopt the erroneous idea that the foreign body has been swallowed or coughed out unobserved. This change of symptoms occurs especially in those cases in which the foreign body has been forced from its primary seat by the coughing, and has fallen FOREIGN BODIES IN THE TRACHEA AND BRONCHI. 513 further downwards either into the trachea or into a bronchus. But even in cases in which the foreign body remains in the larynx, the first alarming symptoms may soon subside. Accord- ing, afterwards, as the foreign body is expelled from the laiynx or remains there for a longer time, either all symptoms of dis- ease fade, or an acute laryngitis becomes developed, which may even lead to cedema of the glottis, or pass into the chronic form of the affection. We refrain from further discussion of the train of symptoms produced by the prolonged retention of a foreign body in the larynx, as foreign to our subject, and pass to the cases in which the foreign body has fallen into the trachea. If the foreign body has entered the trachea, it often happens that it changes its location with the current of air. This mobility may be the cause of another severe suffocative paroxysm, if the body again reaches an unfavorable locality, becomes impacted in the rima glottidis, for example, producing stenosis and exciting spasm. This change of locality may take place repeatedly, and thus the scene sketched above, so alarming to the patient and those about him, may be enacted again and again. Often even a sud- den change of position or of posture, or a somewhat more forci- ble inspiration or expiration, will suffice to occasion a further movement of the foreign body in the trachea. According to the locality in which it then becomes impacted, severe suffoca- tive paroxysms may be occasioned anew, or there may be no further alterations in the symptoms. The patient himself, not altogether infrequently, feels this repeated movement of the foreign body up and down within the large air-passages. In very infrequent cases it is possible to feel distinctly the move- ment of the foreign body by means of the finger placed upon the windpipe (Allan Burns). In some cases, the stroke of a hard body, or a valvular murmur could be heard through the stetho- scope placed in the jugular fossa. These last manifestations fail, as a matter of course, in cases in which the foreign body has bored firmly into some portion of the walls of the trachea. This locomotion of the foreign body during forced respiration, is a very important diagnostic sign for the accurate determination of its position. VOL. IV.—33 514 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. As to the remaining symptoms, the cases in which the foreign body has its seat in the trachea are distinguished, in contradis- tinction to those in which it is located in the larynx, by evi- dences of much less irritation, provided that it does not lead to severe stenosis by its volume. Corresponding with the lesser sensibility of the tracheal mucous membrane, compared to that of certain portions of the larynx, and the greater calibre of the tube, the paroxysms of cough and the dyspncea are proportion- ately less. On the other hand, the symptoms of tracheitis usually occur, to which the symptoms of laryngitis may become added, by the spread of the inflammatory process upon the laryngeal mucous membrane. This will readily occasion decep- tion as to the seat of the foreign body. It is of great import- ance, however, to remember that the foreign body may con- stantly get out of the trachea into the larynx again, and thus give rise to extremely severe paroxysms of cough and suffocation. In favorable cases it happens that the foreign body is expelled in one of its journeys towards the glottis. Even when it is certainly known that the foreign body is in the trachea, and when the symptoms apparently are not alarming, the possibility must always be borne in mind that it may become suddenly impacted in the glottis, and thus occasion anew the previously mentioned suffocative train of symptoms. Severe manifestations of dyspnoea are only occasioned when the foreign body in the trachea is of considerable size, concerning the minuter details of which we refer the reader to the chapter on tracheal stenosis. As there stated, the most important symptoms of tracheal stenosis are: slow respiration, often with accelerated pulse; a wheezing noise in respiration, often audible at a distance ; very prolonged inspiration ; diminished, or even abolished movement of the lower borders of the lungs in deep inspiration,—under some circumstances even inspiratory retraction of the thorax at its lowest portion ; enfeebled respiratory murmur with full and clear sound on percussion, and the like. Laryngoscopic examination, though not at once practicable in many cases, is of special importance, because it not only reveals the complete absence of injury to the larynx, but, in FOREIGN BODIES IN THE TRACHEA AND BRONCHI. 515 favorable cases, permits the direct inspection of the foreign body. In many cases the examination with a speculum through the wound in the trachea, after the performance of tracheotomy, is of advantage, as shown in the case recently reported by Voltolini.1 If the foreign body has its seat in one of the two primitive bronchi, either after having first lodged in the larynx or the trachea, and then passed into a primitive bronchus, or after falling directly into one of the bronchi, all the manifestations of bronchial stenosis set in. According as the affected bronchus is wholly or but partially occluded, there will be various modifi- cations of the train of symptoms. The most important symptoms of bronchial stenosis are the following: diminished inspiratory dilatation of the corresponding half of the thorax, which can be demonstrated both by inspec- tion and palpation, and better still by the comparative graphic method (by means of the double stethograph). On the other hand, the extent of the movement of the sound side is often increased. Diminished displacement of the diaphragm, that is to say, of the lower border of the lung on the side of the bron- chial stenosis ; smaller circumference of this side in cases of pro- longed continuance. The respiratory murmur is absent, or is considerably enfeebled, while it is frequently exaggerated or puerile on the sound side. Only where, as in Weil's5 case, the constriction is slight, will considerable enfeeblement of the re- spiratory murmur, as compared with that of the sound side, be absent. The full and clear sound on percussion, which, as all observers admit, differs in nothing from the normal sound, is in marked contrast to the alteration in the respiratory murmur. Sometimes the sound on the healthy side is somewhat more sonorous and deeper, even with a very weak tympanitic sound accompanying it, corresponding to the greater dilatation of this side. In addition, dull pains are sometimes observed on that side of the chest which is the seat of the foreign body. To the symptoms mentioned, three others are to be added, 1 Berl. klin. Wochenschr., 1875, No. 6, p. 71. 5 FiLlle von Tracheo- und Bronchostenose, Deutsches Archiv fiir klinische Medicin XIV. Band. 516 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. upon which Weil has laid special stress in his recently published essay (1. c). The first is a wheezing sound in respiration, which, in the case reported by Weil, was for a long time the only symp- tom of disease. It was present both in inspiration and in expi- ration, and was even audible at a great distance, when the breathing was somewhat forced, while it was weak or audible only in his immediate neighborhood when the patient was at rest. Its occurrence is to be accounted for in the same manner as the stridor, which is usually observed in stenoses of the air- passages dependent on other causes. The second symptom observed by Weil is the diminution of the pectoral fremitus upon the side of the broncho-stenosis, a manifestation which is to be expected a priori from the impac- tion of a foreign body in a bronchus. The third important symptom upon which Weil lays stress is a palpable thrilling of the chest wall of the affected side, on inspiration and expiration, corresponding to an inspiratory and expiratory hum on auscultation. Friedreich, Gerhardt, Biermer, Demme, and others have long laid stress upon the diagnostic sig- nificance of this sound in stenosis of a bronchus due to compres- sion, while it appears not to have been previously observed in cases of foreign body in the air-passages, or but little noticed. Friedreich " has especially remarked the diagnostic value of this sign in broncho-stenosis. In a case observed by him in 1850, and reported in his work on diseases of the heart, a compression of the left bronchus by the dilated auricle, in a young girl affected with marked mitral stenosis and dilatation of the heart, was diagnosticated "by means of a loud humming respiratory murmur, heard over the entire left half of the thorax (and also perceptible to the hand laid upon it) both in inspiration and in expiration, and which, with its greatest intensity on the left side of the cervical vertebrae in the region of the root of the lung, continued to be audible for years, and even up to the time of death." (The autopsy confirmed the diagnosis.) This whirring is to be regarded as a stenotic murmur, pro- duced by the passage of air through the constricted portion of the bronchial tube. Weil compares it to a deep, sonorous rhonchus. 1 Virchow's specielle Pathologie und Therapie, V. Band, II. Abtheilung, p. 236. FOREIGN BODIES IN TIIE TRACHEA AND BRONCHI. 517 With reference to the case observed by him, Weil further says that this murmur was readily distinguishable from a rhonchus, because neither inspiration nor coughing exerted any influence upon it; and that it always preserved the same character, and the same intensity, and occupied the same region. As already stated, it has been frequently observed that a foreign body in a bronchus may suddenly change its position in consequence of a violent fit of coughing, a sudden change of position, or forced expiration, and pass from one primitive bron- chus into the opposite one. Under such circumstances the symptoms of bronchial stenosis leave the side first affected, as a matter of course, and appear upon the opposite side. Atelectasis, or pneumonic infiltration of the affected portion of the lung, often becomes developed subsequently ; so that the manifestations of these affections become superadded to those of bronchial stenosis; or it may eventuate in the formation of a pulmonary abscess, and the like. If the foreign body falls into a narrow bronchus, and oc- cludes it completely, atelectasis, or pneumonic thickening of the corresponding portion of the lung, takes place in most instances. Many of these patients succumb to these secondary affections of the lung. Less frequently the termination is in gangrene or abscess, with perforation externally; or in encapsulation of the foreign body in callous connective tissue within the pulmo- nary tissue. In several instances perforation has taken place into a large blood-vessel, the occurrence being followed by immediate death. Course. As already stated, it not infrequently happens that death occurs at once in persons in whom a foreign body has fallen into the air-passages. On the other hand, however, there are a goodly number of well-authenticated cases, in which foreign bodies have been known to remain in the trachea or in a bron- chus for weeks, months, and even years, without any further untoward results. We have already cited cases of this kind on a previous page, and their number could be readily increased. In seeking the cause why death occurs at once, or very 518 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. shortly after the entrance of the foreign body, in some cases, while in others the foreign body may remain a long time in the air-passages without further injury, it appears, as ad- vanced by Hamburger,1 in his essay on this subject, that the suddenness of the catastrophe is in exact proportion to the completeness with which the entrance of atmospheric air into the lungs, or into a considerable portion thereof, is interfered with. This explains why irregular, sharp-cornered bodies do not kill so quickly as roundish ones, such as beans and peas, which may easily close the calibre of the trachea, or of a bronchus almost entirely; especially as they often swell by imbibition. In cases of the foreign bodies last mentioned, and others like them, which are capable of swelling, it is often observed that the symptoms are not of an alarming character at first, but that only after a time, as the body swells and increases in size, do the symptoms acquire a more and more alarming character. Cerebral symptoms then soon ensue, either in the place of the local symptoms observed in the first stage alone, or in addition to them. The patient begins to complain of headache; he becomes somnolent; delirium is superadded, even with general convul- sions ; and finally the fatal termination takes place after com- plete abolition of consciousness. In many cases this second stage of cerebral manifestations sets in very early. In others a series of paroxysms, of more or less severe local character, precede the cerebral symptoms for a long time. The number and duration of these paroxysms depend in great part on the size and mobility of the foreign body. In cases of foreign bodies firmly impacted in one place, the number of these paroxysms of local symptoms may be quite inconsiderable, or they ma}^ fail entirely (except, of course, the symptoms furnished on physical examination). Thus, in the interesting case reported by Hamburger (1. c), all local symp- toms were absent, so that during its entire course every expres- sion of a local malady was kept completely in the background. It transpired, after recovery, that the patient had choked one 1 Diagnose eines fremden Korpers im rechten Bronchus, Klinische Betrachtung dieses Falles, Berl. klin. Woch., 1873, No. 29, p. 340. FOREIGN BODIES IN THE TRACHEA AND BRONCHI. '519 day while partaking of a dish of gray peas ; but the symptoms produced thereby were so insignificant, and ceased so promptly that, when the patient became affected with cerebral symptoms, light at first, and more severe afterwards, neither he nor his friends suspected any connection with the swallowing of a foreign body. Still in this case, despite the want of history of a foreign body, and the absence of all local symptoms, except those purely physical, a conclusion could be drawn from the latter alone, as to the existence of a foreign body in a bronchus. In other cases the course is longer, and here the symptoms of encapsulization, perforation, purulent infiltration, and the like, as the case may be, are frequently, though not always added to the local symptoms already mentioned. The course is usually accompanied by fever; especially at the commencement. Only when complications become super- added, pulmonary affections especially, or in consequence of local inflammation and the like, are febrile movements often observed in the further course of the affection. The duration of the disease may vary within considerable limits. It is self-evident that the duration of the affection can- not be estimated, even approximately, in most cases. There are cases in which the entire process is over within a few minutes, and others in which it is protracted for months and even years. Diagnosis. The diagnosis presents no special difficulty in the majority of cases, neither as to the determination in general of the existence of a foreign body in the air-passages, nor as to its precise loca- tion. Accurate physical exploration is of especial importance, and furnishes such characteristic results, especially when the foreign body is in one of the primitive bronchi, that the diagnosis may be established with certainty from this examination alone. In many cases, especially in those in which the foreign body is situated higher up in the trachea, examination with the laryn- goscopic mirror is of great value, as it often serves to determine the exact seat of the foreign body. Examination, too, of the pharynx, and of the oesophagus, may assist in the diagnosis of difficult cases. 520 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. The diagnosis is beset with most difficulty in those cases in which the foreign body has fallen into the air-passages unper- ceived, so that the history does not point to its presence in tliese passages. Nevertheless, even here, accurate physical examina- tion, combined under certain circumstances with examination by the mirror, will suffice to determine the diagnosis with certainty. Failure to distinguish it from other forms of stenosis is not likely to occur ; but syphilitic tracheal, or bronchial stenoses are the most likely to lead to mistake. Here, the history, the slow development of the symptoms, and the evidence of other residua of syphilis, such as defects of the palate, cicatrices on the epi- glottis, total absence of the epiglottis, glandular swellings, and the like, indicate the diagnosis. Prognosis. The prognosis is always doubtful. Of course, it is dependent chiefly upon the seat of the foreign body, its size, form, capacity for becoming swollen, and other characters. Even in cases in which the first turbulent manifestations have subsided, the prog- nosis remains doubtful. In cases in which the. foreign body is situated higher up in the trachea the prognosis is more favora- ble, because the momentary danger may be overcome by trache- otomy, and because the removal of the body may thus be readily accomplished, at least in many cases. In general, pointed objects, with uneven surfaces, offer a less favorable prognosis, because their removal involves greater difficulty. The liability of the body to swell is of influence on the prognosis, inasmuch as that adds to the danger of an increase in the symptoms. But even in cases in which the foreign body is apparently well borne by the organism, the prognosis remains doubtful on account of the dangers to which the patient is exposed through the influence of certain secondary diseases of the parenchyma of the lungs. Treatment. The first indication of treatment is, as a matter of course, to remove the foreign body from the air-passages as promptly as possible. Its removal by the finger cannot be accomplished FOREIGN BODIES IN TIIE TRACHEA AND BRONCHI. 521 even in cases in which it is situated high up in the trachea. On the other hand, one may be tempted to consider the administra- tion of emetics as always indicated. It is not to be denied that this procedure has in fact rendered important services in many cases. I need recall here only the case of Hamburger, already cited, in which an emetic certainly saved the life of the patient. Nevertheless, as shown by careful consideration, the employ- ment of emetics entails considerable danger. Emetics can be used without danger only in those cases in which the foreign body is situated above the glottis or in the chink of the glottis itself. But it is just in these cases that its removal with the aid of the laryngoscopic mirror is deserving of preference as a much safer method, and one completely devoid of danger. If the foreign body is located at a lower point, below the chink of the glottis, there is danger that it may become impacted in the glottis during the act of vomiting, and thus occasion a suffocative paroxysm dangerous to life. Pointed, jagged bodies are the more likely to become impacted in the act of vomiting ; while hard round bodies are more likely to be expelled. If the administration of an emetic should be decided upon, apomorphine is to be preferred to all other emetics. The mere fact that it can be administered by the method of subcutaneous injection renders it especially suitable in tliese cases. It is followed by prompt action within a few minutes, but is not attended by any unpleasant effects ; facts which thus entitle it to preference over all other emetics. What has been said of emetics can be said of the method frequently employed in former times of inverting the body of the patient and striking him upon the chest and back in order to facilitate the expulsion of the foreign body. The danger of impaction is not an imaginary one in such procedures. In cases in which other methods cannot be employed, nothing remains but to make a careful attempt with the procedures mentioned, especially with emetics. In general, however, it is advisable not to resort to these procedures, if possible, as they always involve the danger of an impaction of the foreign body in the glottis, and consequently the danger of fatal asphyxia. Where alarming manifestations exist, it is advisable to perform 522 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. tracheotomy as early as possible, particularly as it may be con- sidered as an operation almost devoid of danger when properly performed upon a subject otherwise healthy. Sometimes, when a foreign body is deeply situated, it is expelled externally, after tracheotomy, by the first powerful movement of expiration ; or it becomes practicable to remove it through the wound with instruments. If the foreign body does not come into view at once after tracheotomy, the success of the operation, as mentioned by Hueter,1 should not be doubted on this account; for many cases are known in which the foreign body has been coughed out sev- eral days after the operation. The prognosis is the better, without doubt, the sooner the foreign body is expelled; and thus, from every point of view, the earliest possible performance of tracheotomy is justified in cases of foreign bodies in the air- passages (Hueter). The extraction of a foreign body after tracheotomy often pre- sents special difficulties. In cases of small foreign bodies which are impacted in a larger or smaller bronchus, and which are not coughed out, the attempt should be made to facilitate their extraction by the so-called aspiratory method. Larger foreign bodies, on the other hand, even when located at quite a distance from the wound of tracheotomy, may be reached from the wound and extracted. Concerning the special details of this purely surgical treat- ment, we refer the reader to the manuals and treatises on sur- gery, especially to Hueter (Tracheotomy and Laiyngotomy), in von Pitha and Billroth'1 s Manual of General and Special Sur- gery. The secondary affections of the trachea, bronchi, and lungs are to be treated on ordinary principles. 1 Von Pitha und Billroth's Handb. d. allg. und spec. Chir. BRONCHIAL ASTHMA. 523 BRONCHIAL ASTHMA. Bibliography. Louis, Memoire sur Temphyseme. Paris, 1826. Memoires de la socigte mgdicale d'observation, T. I. Paris, 1837.—Review of the Clinique of Prof. Fouquier in the Hopital de la Charite, in Paris, during Nov. and Dec, 1833, by Dr. A. Damyau.—Chloric Ether, a New Remedy in Spasmodic Asthma. London Med. Gaz., Oct., 1833. — Beobachtungen iiber die medicinischen Wirkungen des Creosots, von Prof. Reich, vorgelesen in Hufeland's med. chir. Gesellschaft, Nov. 22, 1833. —Automarchi, Journ. de chem. med., Mars, 1834—Practical Remarks on the Treatment of Certain Pulmonary Affections, etc., R. Little, Dublin Jour., Vol. V., March 1, 1834.—E. Gedding's Remarks on the Pathology and Treatment of Asthma, Baltimore Jour., No. II., 1834.—A Case in which Alarming Asthmatic Symptoms were excited by Electricity engendered by New Feathers, John Ross, Edinb. Med. Jour., July, 1834.—Jolly, Asthme, in the Dic- tionnaire de med. et de chirg. prat.—Ferrus, Asthme, in the Dictionnaire de med., T. IV., 1833. Paris.—Physiological and Therapeutical Observations on Digitalis Purpurea, Dr. Joret, Archiv. gen., Jan. et Fev., 1834.—Death from Asthma ; Excessive Subpleural Emphysema, Dr. Prus, Revue m6d., Mars, 1834. —Asthma Convulsivum adultorum, with post-mortem appearances, Dr. Wettin. —Sanitatsbericht iiber das Fiirstenthum Hohenzollern-Sigmaringen, wahrend 1833-34, von Dr. Heyfelder.—The same for 1835, Heyfelder.—Heftiges Asthma in Folge hartnackiger Verstopfung durch ein Klystier aus Tart. emet. gehoben, von Dr. Zengerle, in Wangen, Wiirtemb. med. Corresp.-Blatt., Bd. IV.. No. 29, 1835.—Ausgezeiclmete Wirkung des Moschus gegen Asthma arthriticum, von Dr. Voigt. Summarium, Bd. XL, H. 3, 1835.—Asthma periodicum pituitosum, von Dr. Rosch, "Wiirtemb., Corr.-Bl., 1835, Bd. IV., No. 16.—Asthma, its Species and Complications; or, Researches into the Pathology of Disordered Res- piration, by Fr. Hopkins Ramadge. London, 1835.—Spasmodic Asthma, R. Templeton, London Med. Gaz., Vol. XVTL, March 26, 1836.—Recherches mgdicales sur la nature et le traitement de la maladie connue sous le nom d'asthme, par Amedee Lefevre. Paris, 1835.—Asthma rhythmicum, von Dr. von Brunn, Casper's Wochenschrift, 1836, No. 47.—On Smoking the Dried Leaves of Datura Stramonium as a Remedy for Asthma, Miguel, Bull. d. thgiap., T. XL, Livr. I., 1837.—Asthma cyanoticum, Dr. Schlesier, Med. Zeit., v. V., f. H. in Pr., 1837.—Heilsame Wirkung des Argentum nitricum fusum in einem Falle von Brustkrampf, Dr. Olzewski, Casper's Woch- enschr., 1838, No. 45.—Asthma infantile, mit todtlichem Ausgange, nebst 524 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. Sactionsresultat, Dr. Hachmann, Ztsch. f. d. ges. Med., Bd. XIII., Hft. 1, 1840. —Asthma spasticum durch die Lobelia inflata geheilt, Dr. Frdnkel, Med. Zeit v. V. f. H. in Pr. 1842, No. 21.—Medicinaljahresbericht aus dem Oberamts- bezirk Besigheim vom 1. Juli, 1837 bis 30. Juni, 1838, von Dr. Hauff.—Lobelia inflata in asthma convulsivum, Pr. Morelli, Oniodei Annal. univ. Luglio, 1841. —Marshall Hall, On the Nervous System and its Diseases. London. 1836. Translated into German, with some critical remarks, by J. Wallach, Leipzig, 1842.—Lobelia inflata, Dr. Schlesier, Med. Zeit., v. V., f. H. in Pr., 1841, No. 9.—Graves, On Nervous or Spasmodic Asthma, Dublin Med. Jour., 1841, p. 230.—Canstatt, Die Kranheiten des hoheren Alters und ihre Heilung. Erlangen, 1839.—Lobelia inflata in ihren Wirkungen auf den gesunden und kranken thierischen Organismus, nach fremden und eigenen Betrachtungen dargestellt, von Dr. A. Noack, Hygiea, Bd. XV., Heft 1 u. 2, 1841.—Ueber Tonus, Krampf und Lahmung der Bronchien, und iiber Expectoration, von J. Henle, Henle's und Pfeuffer's Zeitschr. f. rat. Med., Bd. I., Hft, 2.—Ueber einige acute and chronische Krankheitsformen, Dr. Eckstein, Oesterr. med. Jahrb., 1841, Juli.— Ammonium liquidum dans 1'asthme, Rayer, Ann. de therap., Nov., 1845.— Nutzen einer Abkochung der Tabaksblatter bei asthmatischen Anfallen, Eis- enmeyer, Wiirttemb. Corr.-Bl., No. 18, 1845.—Krampfasthma der Kinder, Auszug aus den Verhandlungen der med.-chir. Ges. des Cantons Zurich, Eimer, Schweizer. Cant. Zeitschr., N. F., 1, 3, 1845.—Zur Physiologie, Pathologie und Therapie des Asthma, Muhry, Hannov. Ann., N. F., V. 5, 1845.—On the Use of Sulphur Baths in Asthma, with Remarks on the Nature and Signs of this Disease, E. Courtin, Gaz. de Paris, 49 and 50, 1847.—Consult Pinel, Nosogr. phil. IIL, 146.—Laennec, Ausc. m6d., IL, 92.—Grisolle, Elem. path., IL, Art. Asthme.—Andral, Clin, med., III. — Trousseau, Elem. ther., IL, 189.— On Asthma nervosum diaphragmaticum, Dufour, Bull, de ther., Mai, 1848.— Mittheilung kurzer Krankheitsgeschichten in Bezug auf die reine Heilwirkung der in den gegebenen Fallen angewendeten Arzneimittel, Dr. Nagel, Asthma 6pasmodicum adultorum und Asafcetida, C.'s. Wochenschr., 32 u. 34, 1848.— On Nervous Asthma and its Treatment, Sandras, Bull, de ther., Fev., 1848.— Asthma idiosyncraticum, eine bisher noch nicht beschriebene Krankheitsform ; Dr. Itzigsohn, Pr. Ver.-Ztg., 30, 1849.—Das krampfhafte Asthma der Erwach- senen, Dr. J. Bergson, Nordhausen, 1850. (Prize essay.)—Hopkins, Asthma successfully treated by Nitric Acid, Amer. Jour. Med. Sci., Oct., 1850.— Jenni, Praktische Mittheilung, Schweiz. Ztschr., 2, 1850.—Leger, Nouvelle thgorie de I'Asthme, Soc. med. d'Emulation de Paris, seance du 5. Avril, Union med., Q2.—Huss, Traitement de I'Asthme nerveux par le chlorure de Platine, Hygiea, Journ. de med. de Bruxelles, Avril, Journ. des connaissances med.-chir., Oct., 1851.—A. Favrot, Remede centre I'Asthme, Gaz. des hop., No. 138.— Warlomont, Observations sur l'emploi du chloroform en inhalations et en sub- stance dans les maladies internes, Bull, de l'Acad. de med. de Belgique., T. X., No. 4, 1851.—Putegnat, De I'Asthme, Memoire auquel la societe des sci- ences medicales et naturelles de Bruxelles a decerne une mgdaille d'honncur BRONCHIAL ASTHMA. 525 au concours de 1850, Journ. de mSd. de Bruxelles, Jan., Fev., Mars, Avril.— Arnoldi, Nitric Acid in Whooping-Cough and Asthma, Am. Jour. Med. Sci., July, 1852; Gaz. des hop., No. 73, 1853.—Romberg, Lehrbuch der Nerven- krankheiten. Berlin, 1851.—On the Asthma convulsivum of Adults, A. Cramer, Extract from the Tydschrift der Nederl. maatschappy tot bevordering der genees kunst, 1852.— Ebn Watson, On Spasmodic Asthma, Glasgow Med. Jour., No. 1, 1853.—Trousseau, Lecons sur I'Asthme, Gaz. des hop., Nos. 29 and 34, 1853.—Russel Reynolds, On the Use of Chloroform Inhalations in the Treatment of certain Classes of Spasm, Lancet, Oct., 1853.— Winter, Das krampfhafte Asthma der Erwachsenen. Sonderhausen, 1853. (Describes thirty- two species of asthma.)—Valerianate of Atropia, Michia, Gaz. des hop., 115, 1853; Bull, de ther., Nov., 1856.—Ueber das Asthma thyreoideum, Bete, Journ. f. Kinderkr., XXIL, 3 u. 4, 1853.—Ebn Watson, On the Topical Medi- cation of the Larynx in certain Diseases of the Respiratory and Vocal Organs. London, 1854, p. 126.—P. J. Philipp, Bemerkungen iiber das Asthma im Ge- folge des chronischen Bronchialkatarrhs, Deutsche Klinik, No. 4, 1854.— Pellegrino Salvolini, Asthma, Gazz. Sarda, 30, 1854.—Pidoux, Lecons sur I'Asthme, Union med., 90 et 92, 1855.—Mauch, Die asthmatischen Krank- heiten der Kinder. Eine monographic Erster theil: Vom Verhaltnisse der Thymus beim Asthma, 1853.—Forget, De l'element nevrose, et de I'Asthme en particulier, Gaz. hebd., No. 47, 1855.—Examen des theories de la pro- duction de I'Asthme par le spasme et par la retention du mucus bronchique, Gaz. des hop., No. 78, 1855.—Hamon, Gaz. des h_p., Nos, 85, 96, 1855. —De la disparition des acces de I'Asthme sous l'influence d'une affection abdominale, Gaz. des hop., No. 134, 1855.—E. Pipe, Ueber Chloroform- Inhalationen gegen Kriimpfe in den Respirationsorganen, Deutsche Klinik, No. 39, 1855.— Geens, Fowler'sche Solution gegen Asthma, Presse med., 4, 5, 1856.—Monit des hop., Janr., 1856.—Recherches sur TAsthme, Memoria del signor Dottore Guiseppe Bergson, Medico di Berlino, in risposta al quesito : "Determinare con osservazioni cliniche e di anatomia patologica le alterazioni degli organi che diventano causa dell' asma, nell' ordine della maggiore fre- quenza con cui ciascuna di esse produce la malattia," riproposto dell1 J. R. Istituto Lombardo di scienze, lettere ed arti con programma del giorno 1. Lug- lio 1852, Premiata nel concorso biennale dell' anno 1854. Milano, tipografia di Guiseppe Bernardoni di Giovanni, 1855, 4, XX., 173 pp.—Beau, Traite" cli- nique et pratique de 1'auscultation, etc. Paris, 1856.—Anleitung zur Heilung des krampfhaften Asthma. Eine popular-medicinische Skizze, Dr. 0. H. With, 1856.—Habisreutinger, Ein Eigenthiimlicher Fall von Asthma, Schweiz. Zeitschr. f. Mod. Chir. u. Geburtsh., 1. Heft., 1856.—Rostan, De I'Asthme, Gaz. des hop, No. 31, 1856.—Pserhofer, Ueber den Gebrauch des Arseniks gegen nervoses Asthma, Zeitschr. f. Natur- und Heilkunde in Ungarn., 14. Jan., 1856; Allg. Mod. Central Ztg., 23. Jan., 1856.—IT. Valerius, Note sur le Traite- ment de 1'asthme nervcux. etc., Bull, de la soc. de Med. de Gand. Aout et Sept, 1856.—Challery, Emploi du papier nitr6 dans I'asthme essentiel, Gaz. des 526 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. hop., No. 104, 1856. — Letenneur, Emploi du papier nitrg dans l'asthme, Gaz. des hop.; Journ. des Connaiss. m6d., Sept. 20, 1856.—Santlus, Zum Asthma, Deutsche Klinik, No. 2, 1856.—Asthme essentiel, Journ. de m6d. de Bordeaux, Janv., No. 1, 1857.— Wintrich, Virchow's Pathologie, V. Bd. 1. Abth. Er- langen, 1854.— Williams, Report of the Tenth Meeting of the Association for the Advancement of Science, held at Glasgow, 1840. London, 1841; Gaz. med. de Paris, No. 38, 1841.—Longet, Compt. rend, de l'acad. des Sciences, T. XV., 1842.—De l'asthme, Jean-Pierre Thery. Paris, 1859.— Salter, Criti- cism on the Different Theories of Asthma, Edinb. Med. Jour., V. p. 219, Sept., 1859; The Prognosis of Asthma, Brit. Med. Jour., June 18, 1859; On some Points in the Treatment and Clinical History of Asthma, Edinb. Med. Jour., IV., p. 965, 1109, May, June, 1859, and Edinb. Med. Jour., June, 1858; Med.-Chir. Rev., 1859, p. 145; Lancet, 11, 9, 19, Aug., Nov., 1858.— Viaud- Grand-Marais, On Asthma and its Treatment, Gaz. des hop., 69, 1859. These. Paris, 1859.— Courty, Asthma cured by Localized Narcotization of the Vagus Nerve by the Injection of Atropine, Comptes rend, de l'Acad. des sc, T. 49, p. 665; Gaz. des hop., 133, 1859; Annali univers. di med. Milano, I860.— Richelot, On the Treatment of Asthma, with the Warm Springs of Mont-Dore, L'Union, 55-58,1859.—Salter, On Asthma, its Pathology and Treatment. Lon- don, 1860.—Pierre Anatole Bondet, De l'asthme. These. Paris, 1858.—Basile Grediano, De l'asthme. These. 1858.—Trousseau, Quelques-unes des causes occas- sionelles de l'asthme, Gaz. des hop., No. 103, 1858; De l'asthme, Gaz. des hop., Sept. 2, 23, 1858, Oct. 5, 12; ibid. 100, 1858; Rev. de thSr, meYL-chir., 16, 1859.—F. Massima, Sur les rapports de I'Asthme avec la Goutte, Gaz. des hop., Oct. 12, 1858.—Giraud- Teuton, Considerations sur le traitement de I'Asthme essentiel, Gaz. med. de Paris, No. 41, 1858.—Cazenave, Asthme, gu6ri par l'em- ploi des Eaux-bonnes, Union med. de la Girande, Juin; Gaz. hebd., Oct. 1, 1858.—Klinische Fragmente von Prof. Hirsch, 2. Abth., Krankheiten der Ath- mungs- und Kreislaufsorgane, 1858.—Preiss, Meine Entdeckungen und Erfah- rungen im Gebiete der Wasserheilkunst, 1854, 1. Hft., Behandlung intermitti- render Krankheiten und besonders des periodischen Asthma. Berlin; Physiolo- gische Untersuchungen iiber die Wirkungen des kalten Wassers im Bereiche der Nervensystems und iiber die Gesetze der Leitung in der peripherischen sensitiven Nervensphiire. Berlin, 1858.—Hoy de Salter,. Dell' infuso di caffg nell' asma, Gazz. med. ital. Lombardia, 1860, No. 18.—J. P. Thery, De l'asthme. Paris, 1859.—Bridham, T. L., Treatment of Asthma, Brit, Med. Jour., 1860.—Segers, Nouvelle thgorie sur l'asthme, Annal. de la Soc de mSd. d'Anvers, 1861, Dec.—Dollinger et Gerhard, Traitement de I'Asthme, Annal. de la soc. med.-chir. de Liege, Juin, 1861.—H. Green, Iodide of Potassium in Asthma, Bull, de thgr. LXL, p. 27, Juill., 1861.—Dr. Geigel, Ergebnisse aus 84 Sectionen, Wiirzburger med. Zeitschr., 11, 4, p. 245, 1861.— Oppolzer, Ueber das Wesen und die Behandlung des Asthma, Wiener Medicin-Hallc Probenummer fiir 1862.—Kidd, On the Pathology of Asthma, Dublin Med. Journ., May, 1861; Gaz. meU Paris, No. 37, 1862. BRONCHIAL ASTHMA. 527 —Piorry, Asthma induced by Compression of the Superior Vena Cava, Gaz. des hop., 20, 1862.—J. Berger, Guide de I'asthmatique. De I*asthma, sa nature, ses complications et son traitement rationel. Paris, 1863, IV., 196 p.—Sanderson, Med. Times and Gaz., May 16, 1863.—John McVeigh, Some Account of the Datura Tatula, and its Use in Asthma, Dublin Med. Journal, Aug., 1863.—Lebeau, Rapport sur le travail de M. le docteur Poirier, intitule: De l'asthme dans ses rapports avec la diathese dartreuse, BuU de l'acad. de m6d. de Belgique, Serie IL, T. VII., No. 6, 1864.—Trousseau, Du traitement de l'asthme, Bull, de ther., Oct. 15, 1864.—Poggioli, Sur le traitement de l'asthme par l'electricite statique, Compt. rend, de l'Acad. des sc, 1863, Nov. 23.—Hyde Salter, On the Treatment of Asthma by the Iodide of Potassium, Lancet, Jan. 23, 1864; On the Treatment of the Asth- matic Paroxysm by full Doses of Alcohol, Ibid., Nov. 14, 1863.—Sarradin, Formule de Cones antiasthmatiques, Bull, de ther., Oct. 15, 1864.—Barallier, On the Physiological Action and the Therapeutic Employment of Lobelia Inflata, Bull, de ther., LXVL, p. 72, Jan. 30, p. 103, Feb. 15, 1864.— H. von Bamberger, Ueber Asthma nervosum, Wurzburger med. Zeitschr, VI., lift. 1 u. 2.—G. See, 1. Phys. de l'asthme et des dyspnges, Jour, d'anat. et de phys., 1865 ; 2. Diagnostic de l'asthme, etc., Union med., 1865, Nos. 78 and 80.— Poirrier, De l'asthme dans ses rapports avec la diathese dartreuse, Bull, de l'acad. de med. Belg., 1865, p. 158. Discussion sur l'asthme, Ibid., 1865.— Gueneau de Mussy, Quelques exemples de l'hereditg de l'asthme, Gaz. des hop., 1864, 147.— Salter, On Uterine Asthma, Lancet, Dec, 1864.—#. See, Traite- ment de F asthme, Nouv. diss, de mtid. et de chir.; Gaz. des hop., 1864, 78.— Rerolle, De l'emploi de i'huile de Schiste dans le traitement de l'asthme, Journ. de m6d. de Lyon, Sept., 1865.—Fleury, Syphilitic Asthma Cured by Iodide of Potassium, Lancet, March 11, 1865.—G. See, On Remedies Acting on the Heart and Vessels, and their Employment in Asthma, Bull, de ther., LXIX., p. 5, July 15, 1865.— Pidoux, De l'asthme et des dyspnees, Union med., Nos. 36 and 37, 1866.—Levi, Cura dell' asma, specialmente nervosa, colle injezione sotto cutanee di morfina, Gaz. med. ital. Lombard., 1866, No. 53.—Guyot Dannecy, Journ. de Bord., 2. Ser., IX., p. 385, Sept., 1864.— Hellaine, De l'existence d'un asthme essentiel. These. Strassbourg, 1866.—Hyde Salter, An Analysis of One Hundred and Fifty Unpublished Cases of Asthma, Lancet, 1866, 11, L—Lehmann, Om Pathogenesen af Asthma hos Voxne, Biblioth. for Laeger, Bd. XIIL, 66 pp., 1866.—PA. Karell, Arch. gen., 6 Ser., VIIL, pp. 513, 694, Nov., Dec, 1866.—Trousseau, Medical Clinique of Hotel Dieu, 1866.— Eulenburg u. Landois, Die vasomotorischen Neurosen, Wien. med. Woch., XVIL, 64 flg., 1867.—Gibbons, Brit. Med. Jour., June 1, p. 632, 18Q7.—Wolff, Mittheilungen aux der Praxis, Berlin, klin. Woch., 1867, Nov. 22.—E. Levin- stein, Bericht iiber die Krankenanstalt Maison de Sante zu Neu-Schoneberg bei Berlin. Berlin, 1867.— E. Holden, On the Influence of Antecedent Disorders upon Organic Affections of the Heart and Brain, Am. Jour. Med. Sci., July, 1867.—Constantin Paul, On the Therapeutic Employment of Inhalations of 528 RIEGEL.—DISEASES OF TRACHEA AND BBONCIII. Oxygen, Bull, de Ther., LXXV., p. 93, Aout 15, 1868.— Payot, De l'asthme. These. Paris, 1868.—Barnard, Asthma; a New Theory as to its Pathology, Philadelphia Med. and Surg. Rep., No. 614, 1868.—Gueneau de Mussy, Etudes cliniques sur le coryza spasmodique ou asthme pgriodique avec congestion naso-bronchique, Gaz. des hop., Nos. 109, 111, 1868.—Hirtz, Sur les injections sous-cutanees de morphine et de leur efneacite dans le traitement de l'asthme, particulierement de l'asthme nerveux, Gaz. med. de Strasbourg, No. 2, 1868.— Lange, Der pneumatische apparat. Mittheilungen iiber die physiologischen Wirkungcn und die therapeutische Bedeutung der comprimirten Luft, 2. Aufl. Ems, 1868.—Mutter (Wiesbaden), Ueber die vitale Lungencapacitat, Zeitschr. f. rationelle Med., Bd. 33, 1868.—v. Liebig, Bayer, arztl. Intell.-Blatt., No. 26, 1868.—#. Joubert, Journ. de Bord., 4. Ser., I., p. 329, Juillet, 1869. —Bete, Jodkali gegen Asthma, Memorab., No. 11, 1869.—Basset, Atomized Medi- cation for Asthma, Phila. Med. and Surg. Rep., Jan. 8, 1869.—Levi, Nuove osservazioni confermanti l'efficacia delle injezioni sotto cutanee di morfina neglii attacchif d'asma. Giorn. Venet. di sc med., 1868, Luglio.— See, De la tolerance des medicaments, Bull. gen. dcthSrap., 15 Aout, 1869.— Bemiss, Asthma and Emphysema, New Orleans Jour. Med., Oct., 1869.—Fer- ber, Der Niesekrampf und dessen Beziehung zur Migraine, zum Bronchial- asthma und zum Heufieber, Arch. d. Heilk., 1869, No. 6.—Politzer, Ueber Bron- chialasthma im Kindesalter, Jahrb. f. Kinderheilk., N. F., IIL, 4. S. 377, 1870. —Biermer, Ueber Bronchialasthma, Sammlung klinischer Vortrage in Vei bin- dung mit deutschen Klinikern herausgegeben von R. Volkmann. Leipzig, 1870.—Paul Bert, Lecons sur la physiologie comparge de la respiration. Paris, 1870.—Consult, also, Rugenberg, in Heidenhain's Studien des physiol. Instituts zu Breslau, 2. Heft. Leipzig, 1863.—E. P. Hurd, Iodide of Potassium in Bronchial Asthma, Boston Med. and Surg. Jour., Oct. 27, 1870, p. 257.—Roth, Das Aubreesche Geheimmittel gegen Asthma nervosum, Deutsches Archiv f. klin. Med., Bd. VLL, p. 453.—Hyde Salter, On Bronchial Asthma, Lancet, Jan. 29, and Feb. 5, 1870.—Carl Weiser, Ueber Asthma nervosum, Wien. med. Wchschr., No. 59, 1870.—Kiichenmeister, Zur Therapie des Asthma, Oesterr. Ztschr. f. prakt. Heilk., No. 38, 1870.—Gimbert, L'Eucalyptus globulus, son importance en agriculture, en hygiene et en medecine, avec 3 planches. Paris, 1870.—Maclean, Practitioner, VII., p. 268, Nov., 1871.—Lewy, Asthma saturni- num, Oester. Zeitschr. f. prakt. Heilk., XVT., 6, 1870.—Caruba di Giudea gegen Asthma, Blatter f. Heilwissenschaft, 6. p. 48, 8, 1870.—Hofmann, Die Caruba di Giudea gegen Lungendampf und andere Brustkrankheiten. Wien, 1842.— Rinna von Sarenbach, Repertorium der gesammten Heilk., Bd. IL, p. 114.— Maund, Note on the Use of Hydrate of Chloral, Lancet, I., March 12, 1870, p. 409.—Da Costa, Clinical Notes on Chloral, Am. Jour. Med. Sci., Apl., 1870, p. Vm.—Plomley, The Hydrate of Chloral, Lancet, I., Feb. 26, 1870, p. 300.— Mor- ris, Chloral in Asthmatic Bronchitis, Am. Jour. Med. Sci., Apl., 1870, p. 402.— Coghill, Edinb. Med. Jour., XVI, p. 377, Oct., 1870. — Maxwell Adams, Notes on the Ilvdratc of Chloral, Glasgow Med. Jour., IL, 3, p. 364, May, 1870.—Koch, BRONCHIAL ASTHMA. 529 Presse med., XXIL, 5, 1870.—Leyden, Zur Kenntniss des Asthma bronchiale, Vortrag gehalten in der Versammlung deutscher Naturforscher und Aerzte in Rostock, 1871, Tageblatt, p. 24:.—Lessdorf, Asthma nocturnum periodi- cum; Morphiuminjection; Palliativmittel, Comprimirte Luft; Radicalmittel. Deutsche Klinik, No. 2, 1871.— Weber, Das Aubrge'sche Geheimmittel gegen Asthma nervosum, Deutsches Archiv f. klin. Med., Bd. VIIL, p. 217.—Leyden, Zur Kenntniss des Bronchialasthmas, Virchow's Archiv, Bd. 54.— Weber, Asthma nervosum, Tageblatt der 45. Versammlung deutscher Naturforscher und Aerzte zu Leipzig, 1872, p. 159.—Gaskoin, On the Treatment of Asthma, Brit. Med. Jour., March 30, 1872.—Thorowgood, A few Remarks on the Treat- ment of Asthma, Med. Press and Circ, Jan., 1872. Mercury in the Treatment of Bronchitic Asthma, Med. Press and Circ, Dec. 18, 1872.—Holden, Successful Treatment of Asthma, Am. Jour. Med. Sci., Oct., 1872.—v. Liebig, Ueber die Lungen und Hire Beziehungen zum Luftdruck, Deutsches Archiv f. klin. Med., Bd. X.—Guastalla, Ein Fall von nervosem Bronchialasthma, Jahrb. f. Kinder- heilk., N. F., VII. Jahrg., 2. Hft., 1874.—Berkart, On the Nature of the so-called Bronchial Asthma, Brit. Med. Jour., Nov. 8; Lancet, Nov. 15, 1873.— Walden- burg, Berlin, klin. Woch., 1873.— Williams, Clinical Lectures on Spasmodic Asthma, Lancet, Sept. 6, and Oct. 11, 1873 ; Three Cases of Spasmodic Asthma treated by Chloral, Lancet, Oct. 25, 1873; The Pathology and Treatment of Spasmodic Asthma, Brit. Med. Jour., June 13, 1874.—F. Haring, Ueber Bron- chialasthma. Diss. Halle, 1873.— Thorowgood, On Bronchial Asthma; its Nature, Forms, and Treatment, 2d Edit, 1873.—Gigot-Suard, De I'Asthme. Paris, 1873.—Kitchen, Nitrite of Amyl in the Treatment of Spasmodic Asthma and Acute Bronchitis, American Journal of Insanity, Oct., 1873.—Picrantoni, Preparati di ferro nell'asma, II. Raccoglit. med., No. 23, 1873.—Voltolini, Die Anwendung der Galvanokaustik im Innern des Kehlkopfs und Schlundkopfs, etc, 2. Aufl., 1872, p. 246 et seq.—Haenisch, Zur Aetiologie und Therapie des Asthma bronchiale, Berl. klin. Woch., 1874, No. 40.—Paul, On the Use of Arsenic for the relief of Asthma. Amer. Journ. Med. Sciences, Jan. 1874.— Whitehead, Remarks on the Climatic Influence of Colorado in the Cure of Asthma, with a review of a large number of cases reported by a Convention of Asthmatics assembled at Denver in Dec. 1873. American Journ. Med Sa, April, 1874.—Karl Stoerck, Mittheilungen iiber Asthma bronchiale und die mechanische Lungenbehandluflg, nebst einen Anhang iiber den Hustenreiz. Stuttgart, 1875.—R. Pick, Das Amylnitrit und seine therapeutische Anwend- ung. Inaug.-Disert. Bonn, 1874.—Anderson, On the Treatment of Spasmodic Asthma by the Subcutaneous Injection of Morphia. The Practitioner, Nov. 1875. Consult also the treatises of Friedreich (Die Krankheiten des Larynx und'der Trachea in Virchow's spec. Pathologie und Therapie); Biermer (Die Krankheiten der Bronchien und des Lungenparenchyms, ibid); Seitz-Niemeyer, Kunze, Wunder- lich, Lebert (prakt. Medicin); also, Lebert, Klinik der Brustkrankheiten; Eulen- berg, Lehrbuch der functionellen Nervenkrankheiten; Trousseau, Clinique VOL. IV.—34 530 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. mgdicale, T. II. Paris, 1868; Jaccoud, Traite de Pathologie interne. Paris, 1870; Waldenburg, Die locale Behandlung der Krankheiten der Athmungs- organe, etc., etc. Introductory Bernards. While in the older medical literature the word asthma was considered as almost identical with dyspnoea, and thus a series of subdivisions of asthma were recognized in many works of earlier authors, especially in those of Sauvages, Cullen, Winter, and others, the profession seemed disposed, in the period immediately following the discovery of auscultation, to question the very existence of an idiopathic asthma. This dis- position is readily explained by the circumstance that with the advance in physical diagnosis certain pathological conditions had to be withdrawn from the "asthma" group of the older authors, and classed rather among diseases of the heart, of the lungs, and other organs. The existence of an idiopathic asthma was first denied by Rostan, and he was soon sustained by a series of other authors, as Beau, Louis, and others, who endeavored to bring asthma into a condition directly dependent upon catarrh, emphysema, and so forth. These authors, who denied the existence of a purely nervous and independent form of asthma, were soon opposed by a series of capable inquirers, who asserted the exist- ence of idiopathic asthma, though in a much more restricted sense than that formerly entertained. A reliable basis for deter- mining the existence of asthma could exist, however, only on physiological grounds; and thus it was chiefly Romberg and Bergson who first established a sure foundation for the study of idiopathic asthma. Since this time the question of the existence of an independent asthma is to be regarded as decided in the affirmative ; the disputes still pending between different investi- gators now bearing not so much upon the question of the exist- ence of this form of spasm, as upon its seat and nature. The long-received, but subsequently abandoned theory,— which, however, has been lately modernized and recently con- tended for by Biermer' with great acuteness—that the essential 1 Ueber Bronchialasthma, Sammlung klinischer Vortrage, 1875. BRONCHIAL ASTHMA. 531 element of asthma is to be found in a spasm of the smaller and smallest bronchi, has been opposed by a number of other theo- ries. This theory of bronchial spasm has been combated with great ingenuity by Wintrich ' especially, who advances in oppo- sition the theory of a tonic spasm of the diaphragm. While Wintrich maintained the opinion, on the one hand, that a ner- vous asthma, produced by spasmodic contraction of the smooth muscular fibres in the lungs, is not possible, and does not exist at all as such, he believes the view justifiable that it is caused either by a tonic spasm of the diaphragm alone, or by a spasm of the diaphragm and respiratory muscles together, with which even spasms of the glottis may be associated. In most of the cases of nervous asthma which he had the opportunity of observing himself, he believed that the trouble could be referred to a tonic spasm of the diaphragm. Wintrich's theory was soon supported by Bamberger2 and Lehmann,3 both of whom contrib- uted further valuable facts. In opposition to tliese authors, as already stated, the old idea of bronchial spasm has recently received important support in the admirable essay of Biermer (1. c). Asthma has also been regarded as a vaso-motor neurosis; and Weber,4 especially, has recently advanced excellent reasons in support of this view. Storck,5 likewise, has endeavored still more recently to establish the theory that attacks of bronchial asthma are due to acute swelling of the mucous membrane of the bronchioles. Finally, the interesting facts lately reported by Leyden6 de- serve brief mention. Leyden found in the expectoration of per- sons suffering from bronchial asthma a mass of elongated octa- hedral crystals, embedded in a ground substance consisting of 1 Virchow's Handbuch der speciellen Pathologie u. Therapie, V. Bd., 1. Abth. Er- langen, 1854. 2 Wiirzburger med. Zeitschr., VI. Bd., Heft 1 u. 2. 3 Biblioth. for Laeger, Bd. 13, 66 pp., 1866. 4 Tageblatt der 45. Naturforscherversammlung zu Leipzig, 1872, p. 159. 6 Mittheilungen iiber Asthma bronchiale und die mechanische Lungenbehandlung. Xebst einem Anhang iiber den Hustenreiz. Stuttgart, 1875. 11 Virchow's Archiv, Bd. 54. 532 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. cells in the process of granular degeneration. Leyden is dis- posed to consider the entire complexity of symptoms in bronchial asthma as the effect of these delicate sharp crystals, which pro- duce a mechanical irritation of the mucous membrane of the alveoli and smaller bronchi,—that is, of the terminal filaments of the vagus nerve, with reflex spasm of the muscular substance of the smaller bronchi. We will return to a more detailed dis- cussion of this and other theories. Our special description of asthma must be premised by the remark that we are concerned only with pure asthma, in the restricted sense of the word. All forms of paroxysms of dysp- noea, formerly often included under the name of asthma, will be excluded from the following discussion ; that is to say, those in which alterations in the bronchial mucous membrane, the parenchyma of the lungs, the heart, the large vessels, and the like, are amply sufficient to account for the trouble in breathing. These forms have often been designated by the term of symp- tomatic asthma. Genuine bronchial asthma, the existence of which has be- come based upon facts since the discovery by Reisseissen of the presence of muscular fibres in the smallest bronchi, is character- ized by attacks of sudden dyspnoea, coming on after longer or shorter intervals, increasing rapidly in severity,—the attacks being sometimes very severe,—and lasting either for a few hours only or even for several days. It occurs both in the idiopathic form, in which no alteration can be discovered on the minutest examination of the organs during the intervals between the paroxysms, and in the symp- tomatic form, as, for example, in emphysema and chronic bron- chial catarrh. In contradistinction to the forms of dyspncea previously mentioned as erroneously attributed to asthma, and in which the dyspncea is attributable to the alteration of the organs, this symptomatic form of asthma is characterized by the fact that here, also, the physical exploration of the respiratory, circulatory, and other organs, in no wise reveals sufficient altera- tion to account for the severe symptoms which appear so sud- denly. We prefer this division into essential and symptomatic asthma to that which also includes nnder the name of symp- BRONCHIAL ASTHMA. 533 tomatic asthma all those paroxysms of severe dyspncea which can be sufficiently accounted for by anatomical changes. Etiology and Pathogenesis. Bronchial asthma, the cause of which has been located, since the investigations of Bergson (1850) and Salter (1859), in a spasm of the bronchial muscles, which spasm may be occasioned by a periodic excitement of their innervating fibres coming from the vagus nerve, may be produced directly by an irritation applied to the vagus at its origin or along its course, or may be excited in a reflex manner by irritation of various organs. There is no case known in which it has been established with certainty that the bronchial spasm has been directly occasioned by influences proceeding from the nerve centre. Nevertheless, many facts favor the opinion that central irritation may be the occasion of many asthmatic paroxysms. The possibility of hereditary transmission is of much less weight in support of this view, than the alternation, occasionally observed, of asthma with other neuroses. Thus, Salter narrates a case in which asth- matic and epileptic paroxysms alternated with each other ; and Eulenburg' observed in several individuals alternations of asth- matic attacks with hemicrania and with angina pectoris. Cases have also been repeatedly observed in which it was probable that the paroxysms of spasm were occasioned by swol- len tracheo-bronchial glands, which irritated the branches of the vagus directly by occasional increased tumefaction (Biermer).3 Bronchial asthma arises much more frequently in an indi- rect, reflex manner, the origin of the attacks being not in the respiratory organs alone, but in the circulatory organs, in the abdominal organs, and the like. Thus the excitement of the bronchial branches of the vagus may sometimes originate in the sexual organs (uterine asthma), sometimes in the sensitive nerves of the intestinal tract, as in disorders of digestion, irrita- tion from worms (dyspeptic asthma, verminous asthma), some- 1 Lehrbuch der functionellen Nervenkrankheiten. Berlin, 1871. 2 Ueber Bronchial Asthma. Sammlung klinischer Vortrage, herausgegeben von R. Volkmann, 1870, No. 12, p. 55. 534 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. times from the sensitive nerves in the skin and mucous mem- brane, as in taking cold, and the like. It has been recently remarked by Voltolini,' that nasal and naso-pharyngeal polyps not infrequently give rise to bronchial asthma ; and Haenisch2 has very lately reported a confirmative observation. This case is of especial interest because the asthma not only disappeared with the removal of the polyp, but became re-established as the polyp grew again; the same cycle of phe- nomena being repeated several times. The frequent occurrence of asthmatic paroxysms in children has been repeatedly observed after measles and whooping- cough. Both Biermer and Williams believe that the etiological cause of the attacks is to be found in the enlargement of the bronchial glands, and the pressure made by them upon the vagus nerve. Psychical and sensual impressions may occasion attacks in a reflex manner. The nerves of smell frequently take up this reflex action, and under the influence of certain irritations transfer the excitement to the pulmonary fibres of the vagus, the effect being manifested in a bronchial spasm. This form has been specially designated as " idiosyncratic asthma." Thus Itzigson3 relates a case in which a merchant got the asthma every time fresh coffee was piled up. A dyer got the asthma whenever he used yellow-oak. In a florist it was always produced by lamp-black. The asthma occasioned by ipecacuanha has been repeatedly observed. Cullen narrated a case in which the wife of an apothecary got an attack of asthma whenever ipecacuanha was powdered in the shop. Similar cases have been reported by Trousseau, Lebert, and others. Trousseau relates of himself that he got the asthma whenever he remained in a room in which there was a bouquet of violets. The so-called hay asthma, observed with especial frequency 1 Die Anwendung der Galvanokaustik im Innern des Kehlkopfs und Schlundkopfs, etc., 2. Aufl., 1872. 2 Zur Aetiologie und Therapie des Asthma bronchiale, Berlin, klin. Wochenschr., 1874, No. 40. 3Pr. Ver.-Ztg., 30,1849. BRONCHIAL ASTHMA. 535 in England, and which, as shown by the recent interesting investigations of Blackley,1 is occasioned by the pollen of cer- tain grasses, although it must be included among infective dis- eases in its restricted sense, must still, on the other hand, be placed in the same series with the forms of idiosyncratic asthma already mentioned. As to the connection between these sources of injury and asthma, it may be attributed simply to a special irritability, so that the irritation is at once transmitted to the motor roots of the vagus; or else the fluxionary element may be regarded as the immediate cause. In those cases of catarrhal asthma which are occasioned by the odor of dried hay, fodder, rye pollen, and the like, Biermer sees a proof that fluxionary manifestations of the respiratory tract precede and accompany the asthmatic symptoms under certain circumstances. The odoriferous sub- stances mentioned here excite a sympathetic disorder of the circulation, in the form of a fluxion, in addition to the perception of smell. Biermer is still more disposed to attribute a certain role to the fluxionary element in bronchial asthma, because other forms of asthma also frequently begin with bronchial catarrh. The nature of the connection between them, however, he leaves undetermined. This may be explained in three ways. Either the bronchial spasm and the catarrhal fluxion may be the common effect of a reflex excitement, or the catarrh may be the cause of the spasm, or the spasm may give rise to the fluxion secondarily. Clinical observation offers numerous proofs in support of the last view. There is not infrequent opportunity of observing cases of bronchial asthma in which all catarrhal irritation is wanting at the commencement, and in which it is first observed only at the end of the attack. In other cases, on the contrary, the train of symptoms is not to be explained by spasm of the bronchial muscles alone, especially in those cases in which moist rales, secretion of a more or less tenacious mucus, and its frequent expectoration are observed. In these cases an acute catarrh may give rise to the bronchial spasm secondarily. 1 Experimental Researches on the Causes and Nature of Catarrhus aestivus (Hay- fever). London, 8., 202 pp. 536 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. We are therefore constrained to admit with Weber,1 for many forms of asthma, the existence of an acute tumefaction of the bronchial mucous membrane in consequence of dilatation of its blood-vessels through vaso-motor nervous influence. Biermer justly remarks that as a congestion of the bronchial mucous membrane cannot be well recognized as long as the mucous membrane remains dry, it is possible that a fluxionary tumes- cence of the bronchial mucous membrane may have been the first to occur, even in cases in which the asthmatic attack apparently begins without catarrh. As to the further etiological causes of asthma, inheritance plays a great and important role, according to many authors. Lebert is disposed to consider hereditary influence as very slight; and he states that, according to his own experience, inheritance has been the exception, and by no means the rule. According to other authors, asthma is often transmitted from the father to the son, or only to the grandchild, even when the father was no longer asthmatic at the period of his marriage or afterwards. Often asthma appears for the first time at the same period of life in which the father suffered most from it. In other cases only a certain disposition to neuroses in general is inherited. Concerning the role played by the nervous element in the etiology of asthma, the fact may be of significance that men in general suffer with asthma much more frequently than women. Thus in a statement presented by Salter,2 of 153 asthmatics 51 were females and 102 were males. The difference between the two classes at different ages is very remarkable. Thus, of twenty- three patients between 20 and 30 years of age, nine were males and fourteen were females ; of nineteen patients between 50 and 60 years of age, sixteen were males and three were females. Thus during the period of life in which organic alterations of the lung are less frequent, and in which the nervous system is more sen- sitive, the females preponderate over the males as 3: 2 ; while at that period which presents organic diseases in increased propor- 1 Tageblatt der 45. Versammlung deutscher Naturforscher und Aerzte zu Leipzig, 1872, p. 159. 2 An Analysis of a Hundred and Fifty unpublished Cases of Asthma, Lancet, II., 4, 1866. BRONCHIAL ASTHMA. 537 tion, the males affected preponderate over the females as 5:1. The greater number of cases, according to Salter, commence in the first ten years of life, after this there is a gradual increase up to the fortieth year, and then there is a gradual decrease. Salter rejects the belief that asthma is a disease of age. In one-fourth of his cases the patients were under ten years of age, and the age was below forty years in four-fifths of the cases. According to the experience of others, asthma is infrequent in childhood, and by far the greatest number of cases are observed in middle life. The connection of asthma with other diseases is to be men- tioned among the other etiological conditions. Thus the attempt has been made by some observers to bring asthma into a closer relation with gout, and to distinguish a special form as arthri- tic asthma. They also perceive a relation with rheumatism, haemorrhoids, and the like. A close association with chronic skin diseases has also been believed to have been repeatedly recognized. Thus Dollinger1 believes that asthma, which is observed more frequently in warm climates than in cold ones, is often occasioned by the retrocession of eruptions, and is very fre- quently observed after the disappearance of herpetic affections. Waldenburg,2 especially, has lately expressed himself in favor of the view of an antagonistic relation between asthma and affections of the skin. He proposes to designate this form as herpetic asthma. It is furthermore worthy of remark that the congenital enlargement of the thyroid gland has been repeatedly blamed as the cause of asthmatic paroxysms. It is claimed that the obstacle to the respiration in tliese cases is in the entrance into the larynx, which is narrowed by the projection of the thyroid gland into the cavity of the mouth (Betz). Although the above-mentioned enlargement of the thyroid gland may produce an impediment to breathing, and give rise to greater or less difficulty of respiration, such cases can by no means be included in the category of essential asthma as long as 1 Annal. de la soc. med.-chir. de Liege, Juin, 1862. 1 Die locale Behandlung der Krankheiten der Athmungsorgane, 2. Auflage. Berlin, 1872, p. 484. 538 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. the term asthma is not again, as formerly, more or less identified with dyspnoea. We have already referred, on a previous occa- sion, to the distinctions between the differently localized impedi- ments to respiration, and Biermer, especially, deserves the credit of having brought out sharply the distinctions which exist between the clinical pictures, and which are dependent upon the different locations of the impediments to respiration. We shall consider more closely the distinctions between these individual varieties, in speaking of the differential diagnosis. At present the remark suffices that the form mentioned above does not belong to essential asthma. Of many other varieties described as asthma, it is also questionable whether they are to be included under the head of essential asthma. Attempts have also been made to establish a relation between lead and asthma. Lewy * has described a saturnine asthma as an infrequent manifestation of lead poisoning, sometimes appear- ing in the acute form, and sometimes in the chronic form. It is occasioned by the inhalation of the dust of white lead. This form is in general rarely observed, having occurred but twenty- six times in 1186 cases of lead poisoning. As to climatic influence, many are of the opinion that cli- mates with brusque changes of temperature excite asthma. A fact remarked by Trousseau2 deserves some attention, that is, that a few individuals become attacked with asthma in certain localities, and not in others. Lebert, also, as stated in his "Klinik der Brustkrankheiten," has had frequent opportunity of witnessing the favorable influence of change of locality on asthma. According to Thery,3 summer is less unfavorable than winter to asthmatics, an assertion, however, with which Trous- seau is not in accord. Taking cold is not infrequently mentioned as the exciting cause of asthma. It is frequently observed that persons who suffer with asthma get an asthmatic attack at once whenever there is any sudden change of weather. Winds which increase the humidity of the atmosphere are supposed to cause the ! Oesterr. Ztschr. f. prakt. Heilk. XVL, 6, 1870. 2 Clinique medicale, T. II. Paris, 1868. 3 De I'Asthme. Paris, 1859. BRONCHIAL ASTHMA. 539 affection, but dry winds also are not infrequently prejudicial. Rosenstein1 has said of Groningen that the north-east wind especially is to blame in that locality, and that it is so apt to produce the affection that patients anticipate their complaint as soon as it begins to blow. Weber (1. c), on the contrary, asserts that, according to his experience, light winds, on the whole, are not always unfavorable; on the contrary, many patients are better under their influence, even when they are specially ex- posed to the inclemency of the weather, for example, when they ride against the wind. The night-time is to be mentioned as one of the best known disposing causes. Many patients are attacked by asthma only in the dark, and avoid the attack by burning a night-lamp. The understanding of the influence of light upon asthma is still rather difficult, despite Salter's attempts at explanation. As regards the influence of different professions upon asthma, it is to be remarked that at all events it appears to occur with more frequency among certain of them, among preachers, law- yers, and teachers for example. No very great and constant preponderating frequency however is to be recognized in one station of life or another. Asthma occurs in general among the well-to-do classes more frequently than among the poorer ones, and especially in middle-aged males who lead a luxurious life. A plethoric constitution predisposes to asthma in a measure. Nevertheless, it is by no means infrequently observed among the poorer classes, especially among those who are advanced in years. In similar manner the influence of damp, low dwellings, of residence in newly built and not yet thoroughly dried houses, has been cited as an exciting cause. Although these influences may be regarded as co-operative factors in the production of the complaint, they are not at all competent to excite asthma directly, as long as there is not a certain predisposition to it, a certain unknown something which enables such influences, not otherwise attended by like results, to call forth attacks of bronchial asthma. From all this, it appears that the ultimate cause for the production of the asthmatic paroxysm is unknown. Turning, now, to the question of the manner in which asthma 1 Tagbl. d. 45 Versammlung Deutsch-Naturforscher u Aerzte. Leipzig, 1872. 540 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. occurs, in what its nature consists, we are again reluctantly com- pelled to admit that with reference to this cardinal question, no ultimate uniformity in the different opinions has yet been arrived at. Of course we must avoid the mistake, so frequently made in practice, of confounding bronchial spasm with spasm of the glottis, with paralysis of the dilators of the glottis, and so on. We will recur later to the differences in the clinical pictures of these forms of disease, which are likewise associated with dyspncea, as compared with the characteristic paroxysms of asthma. Concerning the nature of essential bronchial asthma, however, the opinions of different authors are still divided. We refrain from a more detailed description of the older and now abandoned theories concerning the nature of bronchial asthma, and turn to the description of those which have more or less value at the present day. The view presented by Bree, for example, belongs in the first class. According to it, all the muscular exertion in asthmatic attacks is but an effort to remove irritating material present in the bronchi. This irritating material is finally expelled as mucus ; and then the paroxysm subsides. Walshe believes that the difficulty of respiration depends on a want of oxygen in the blood,—the lungs being entirely sound,—which the patient must compensate for by deep breathing, like the panting breathing of healthy persons engaged in violent exercise, ascending moun- tains, and the like. Others, again, regard asthma only as a bronchitic dyspncea, which is sometimes occasioned by occlusion of the bronchi with mucus, and sometimes by thickening of the bronchial mucous membrane. According to others, asthma is altogether depen- dent upon paralysis of the bronchi. Kidd considered a tonic spasm of the inspiratory muscles as the cause of asthma. Sanderson advanced the view that there is a paralysis of the dilating muscles of the glottis and the contrac- tile fibres of the lung tissue, with consecutive impediment to expiration. These and other theories, the enumeration of which is of no interest, have long been abandoned; and the dispute, at the present day, is narrowed down to closer limits. BRONCHIAL ASTHMA. 541 Even in the present narrow limits of dispute, there is as yet scarcely any prospect of agreement; and the different theories about to be mentioned are still maintained by their supporters with equal tenacity. Of these theories the oldest, and at the same time the one which still counts the greatest number of adherents, is that which places the nature of asthma and its ultimate cause in a spasm of the bronchial muscles. This theory, which is of the most ancient origin, and which was defended by numerous authors, as Trousseau, Salter, Ramadge, Romberg, Lefevre, Bergson, Thery, and others, has recently received important sup- port in the experiments of Bert,1 who has again substantiated the frequently contested results of Williams 2 and Longet, and likewise by the works of Biermer4 and Leyden.5 Passing by the objections made by the older authors, almost entirely supported by theoretical discussions only, it was princi- pally Wintrich 8 who, with weighty reasons, as it seemed, and supported by numerous personal experiments, denied the influ- ence of bronchial spasm in the production of nervous asthma. The importance of the question before us justifies the presenta- tion of a short account of the reasons urged by Wintrich against this theory. Wintrich, both from the results of his experimental inves- tigations, and especially from the physical signs during the asthmatic paroxysms, believed himself justified in the assertion that a nervous asthma, produced by spasmodic contraction of the smooth muscular fibres in the lung, is not possible, and that such a condition does not exist. While earlier experiment- ers, as Prochaska, Reisseissen, Haller, Williams, Longet, Volk- mann, and others, were able to demonstrate, experimentally, 1 Leqons sur la physiologie comparee de la respiration. Paris, 1870. 2 Report of the Tenth Meeting of the Association for the Advancement of Science, held at Glasgow, 1840. London, 1841; Gaz. med. Paris, 1841, No. 38. s Compt. rend, de l'Acad. des sciences, T. XV., 1842. 4 Sammlung klinischer Vortrage, herausgegeben von R. Volkmann, No. 12, Ueber Bronchialasthma, 1870. 6 Zur Kenntniss des Bronchialasthmas, Virchow's Archiv, Bd. 54 6 Virchow's Handbuch der speciellen Pathologie u. Therapie, V. Bd., 1. Abth. Erlangen, 1854. 542 RIEGEL.— DISEASES OF TRACHEA AND BRONCHI. the contractibility of the lungs through muscular force, Wintrich came to the conclusion, through his investigations, that the vital muscular forces of the lungs may indeed be active, but that they have a much smaller share in the contractile force of the respi- ratory organs, than the prolonged post-mortem elasticity of the elastic fibres and the like, which is entirely independent of nerve influence. It was, however, the physical signs found during the asthmatic paroxysm, rather than the results of his experimental inquiries, which led Wintrich to the opinion that a nervous asthma is utterly impossible as a result of spasmodic contraction of the smooth muscular fibres. Wintrich considers it impossible to explain the enlargement of the lungs with increased air-con- tents, observed by all authors during the attack, by a spasmodic contraction of the bronchial muscles. The limits of the lungs should be rather rendered smaller by the asserted muscular spasm, as it is not to be supposed that it would always obstruct the exit of the air during expiration, and, on the contrary, would admit it into the vesicles during inspiration. In the second place, according to Wintrich, if nervous asthma is actu- ally able to produce, by means of the muscular spasm, that enormous hindrance to the respiratory function which is ob- served during the paroxysms, the muscular fibres must over- power both inspiratory and expiratory pressure in their action. The inspiratory air-pressure, however, is, in fact, not overpow- ered, for the lungs could not otherwise be made larger by increased quantity of air in the vesicles, and that the expiratory pressure can be overpowered by them, is held by Wintrich to be a physical impossibility. On the contrary, Wintrich believes that everything is easily understood in nervous asthma, if it is viewed as a momentary impediment to respiration, produced either by a tonic spasm of the diaphragm alone, or a similar spasm of the diaphragm and the respiratory muscles together; in connection with which, spasm of the glottis may or may not be associated. This theory, first advanced by Wintrich, soon received a pow- erful support from Bamberger,l who, by means of a carefully ob- served case of asthma, furnished important contributions to the 1 Wiirzburger med. Ztschr., Bd. VI., Hft. 1 u. 2. BRONCHIAL ASTHMA. 543 pathology of the disease. The great retraction of the lower borders of the lungs in this case during the attack is especially to be mentioned, and likewise the fact that neither inspiration nor expiration exerted the slightest influence upon the limits of the lower borders of the lungs. During the deepest inspira- tion the upper limit of hepatic dulness did not vary the breadth of a line from its position during the deepest expiration. The same condition was found to exist with reference to the limits of cardiac dulness. The board-like hardness of the abdominal muscles collectively, mentioned in Bamberger's case, is of prom- inent interest. As to the question of the mechanism of nervous asthma, Bamberger believes, as does also Wintrich, that with the de- pressed position of the diaphragm there can be no spasm of the bronchi, but, on the contrary, that all the manifestations are fully explained by tonic spasm of the diaphragm, and by the secondary antagonistic spasm of the muscles of expiration occa- sioned thereby. Bamberger considers it undoubted that there are asthmatic paroxysms, the cause of which lies in a tonic spasm of the diaphragm. He considers this the most frequent and most important cause of asthma, but not the only one, as he has observed very important differences in the constituent elements and in the entire form of the paroxysm in different patients. Sometimes the spasm was more inspiratory in character, and sometimes more expiratory. In the complicated nature of the respiratory acts Bamberger believes that different possibilities may be imagined. Thus in many cases the paroxysm may be produced by a more clonic spasm of most of the inspiratory muscles, as in hysteric asthma for example. A second pos- sibility lies in paralytic conditions of the diaphragm ; another possibility, not yet observed, exists in isolated spasm of the expiratory muscles, especially the abdominal muscles. Finally, there remains the spasm of the bronchial muscles, which is in the highest degree improbable, if not unimaginable; and here, according to Bamberger, inspiration and expiration, espe- cially the former, must be laborious and prolonged. Biermer has recently expressed himself1 strongly in opposition to these 1 Sammlung klinischer Vortrage, herausgegeben von R. Volkmann, Xo. 12. 544 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. views of Wintrich and Bamberger as to the nature of asthma, based as they are upon good grounds. He seeks again to vin- dicate for the bronchial muscles the rank accorded them by the older authors. On the other hand, he denies the tonic spasm of the diaphragm as a co-acting factor in the production of asthma. He justly asserts, in the first place, that the principle of asthma lies in disorder of the expiration, and that the remarkably pro- longed and forced expiration, and the sibilant rales, indicate an obstruction in the medium-sized and minuter bronchi, which almost necessarily enforces the view of a spastic bronchial con- striction. To the negative results obtained by Wintrich (1. c.) and Riigenberg,1 on the influence of the vagus on the contraction of the bronchial muscles, he opposes the more recent positive investigations of Bert,2 who succeeded, as Williams (1. c.) had done previously, in producing distinct contractions of the bron- chi by galvanization of the lungs as well as of the vagus. It is therefore no longer doubtful that the bronchial muscles can be excited to tonic contraction under the domain of the vagus nerve. Wintrich, however, has laid greater stress upon the physical signs than upon the negative results of irritation of the vagus, especially on the depressed position of the diaphragm, which he cannot associate with a spasmodic contraction of the bronchi; for which reason both he and Bamberger believe that a tonic spasm of the diaphragm must be regarded as the cause of the asthmatic symptoms. Biermer also recognizes this position of the diaphragm as a constant occurrence in bronchial asthma; but he does not regard it as the result of a tonic spasm of the diaphragm, but as due to an increased quantity of air contained in the lungs, a dilatation of the lungs, which is dependent upon spastic contraction of the bronchi. Apart from the improba- bility of a diaphragmatic tetanus continuing for hours, Biermer maintains that he has always been able to satisfy himself that the diaphragm contracts rhythmically during the asthmatic attack. The indistinctness of its movements is explained by the obstacle to its elevation during its relaxation furnished by the 1 Heidenhain's Studien des physiol. Instituts zu Breslau, 2. Heft. Leipzig, 1863. 2 Lecons sur la physiologie comparee de la Respiration. Paris, 1870. BRONCHIAL ASTHMA. 545 dilatation of the lungs. Even, also, where no movement of the diaphragm can be observed, it cannot be taken as an evi- dence of tonic diaphragmatic spasm, because the diaphragm may appear to be immovable from other causes. Biermer asserts in particular that the bronchial muscles are the antagonists of the inspiratory muscles, and serve for expira- tory purposes simultaneously with the elasticity of the lungs. Their functions have not yet been studied experimentally, and our knowledge of them rests more upon theoretic deductions than on positive foundations (Biermer). According to Biermer's opinion, in which most authors coin- cide, tonic spasm of the medium-sized and minuter bronchial twigs must render inspiration and expiration more difficult; the disturbance of expiration, however, being more important than the disorder of inspiration. Biermer thinks that the bronchial muscles in the spasmodic condition, may form a sphincter-like occlusion which is more readily overcome in inspiration than in expiration, and that the escape of the air from the alveoli is impeded. The excep- tion taken by Wintrich, that the spasm of the bronchial muscles must be overcome by the greater antagonistic forces of expira- tion, such as elasticity of the lungs and thorax, the expiratory muscles and the like, is rejected by Biermer, who denies that the role of the expiratory forces is antagonistic to the bronchial muscles. The expiratory pressure, moreover, acts by no means only upon the contents of the alveoli—the bronchial spasm would be readily overcome thereby, as a matter of course—but acts upon the broncheoli also. The bronchi, during expiration, are subjected to the general expiratory pressure and to the pressure of the morbid contraction of the bronchial muscles; and it is thus understood how the compressibility of the bron- chioli favors their further closure, under the influence of forced expiration rather than their further dilatation. Another, and by far the most important objection urged by Wintrich, Bamberger, and Lehmann against the view of spasm of the bronchial muscles, is, as stated, the descent of the diaphragm. The low position of the diaphragm, according to these authors, is incompatible with spasm of the bronchi; while VOL. IV.—35 546 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. all the symptoms may be explained with remarkable lucidity on the theory of a tonic spasm of the diaphragm and the con- sequent secondary antagonistic spasm of the muscles of respira- tion. Bronchial spasm, on the contrary, according to these authors, being in fact an obstacle to both acts of respiration, both inspiration and expiration must take place laboriously, slowly, and at great expenditure of muscular force, and this would be the case to a greater degree in inspiration, inasmuch as a somewhat greater amount of pressure is at disposal in the act of expiration. Furthermore, in spasm of the bronchi we should expect an elevated position of the diaphragm, diminution of the thorax on all sides, and probably also, greater retraction of the intercostal spaces (Bamberger). The picture presented by these authors, as developed by bronchial asthma, is directly opposed to what is actually observed and designated by them as spasm of the diaphragm. Biermer justly asserts that the symptomatic picture referred to, which these authors attribute to bronchial asthma, might correspond rather to a pulmonary spasm, harmoniously involving the bron- chi and the alveoli together, but not to a bronchial spasm. In real bronchial spasm, on the contrary, says Biermer, the inspira- tory force becomes the antagonist of the bronchial muscles, and drives the air with force through the constricted bronchi into the alveoli. This air, however, escapes but slowly and incompletely, despite the assistance of all the expiratory forces in expiration. This insufficient ventilation and distention of the lung is fol- lowed, secondarily, by sensations of want of air and reflex straining of the respiratory forces. Lebert, in his most recent article on bronchial asthma,1 adopts a middle position between the theory which seeks the essence of asthma exclusively in a tonic spasm of the bronchial muscles, and that which believes it to exist chiefly in a tonic spasm of the diaphragm. Lebert is of the opinion that the tonic spasm of the diaphragm is not the first act in the asthmatic paroxysm, but that the tonic muscular spasm, on the contrary, is reflex, and begins in the bronchial muscles, in which it has its 1 Klinik der Brustkrankheiten, I. Bd., 2. Halfte, 1873, p. 438. BRONCHIAL ASTHMA. 547 main factor, and that thence the inspiratory muscles of the throat and chest are first excited to great forced activity, approaching clonic spasm, and the diaphragm to more tonic, though not continuous contraction; something similar being liable to take place in the abdominal muscles also. He con- siders a valvular sort of closure, such as Biermer supposes it, as hardly possible. Lebert sees a further objection to the sole action of bronchial spasm in asthma, in the rapid occurrence of enormous pulmonary dilatation. He believes that the dilatation would occur gradually, and not so rapidly, if spasm alone were its cause. Lebert believes that with the great inspiratory efforts which laboriously drive the air through abnormally con- tracted tubes, and by the greatly increased respiratory stimu- lation of the corresponding portion of the medulla oblongata and its respiratory centre, transferring a reflex spasm over the phrenic nerves, the diaphragm is excited to tonic contraction. The two taken together, the bronchial spasm as primitive, and the tonic diaphragmatic spasm as consecutive, perhaps associ- ated with consecutive spasm of individual muscles of expira- tion, explain most completely the physical manifestations of the asthmatic paroxysm. With reference to the question of the possibility of such rapidly occurring extensive pulmonary dila- tation from spasm of the bronchial muscles, Lebert calls atten- tion to its absence in fibrinous acute bronchitis. "Here," says Lebert, "the obstruction is enormous; many bronchioles and alveoli are obstructed in greater part, the former less completely, because in them the fibrinous exudation is generally tubular. The dyspnoea usually reaches a very high grade rapidly ; yet we have but slight pulmonary dilatation, even at points bordering on the occluding masses or in their vicinity, no exaggerated resonance, no marked immobility of the lower portion of the lungs ; in short, this severe cylindrical constriction of many bronchioles does not lead to that pulmonary dilatation which is tolerably constant, very rapid, and very extensive in asthma. It remains, finally, to briefly mention two more observations and theories of asthma, of very recent date. Leyden,1 in 1871, first drew attention to the coincidence of a 1 Virchow's Archiv, 54. Bd. 548 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. characteristic sputum in the lung affection, designated as bron- chial asthma. According to this observer, the expectoration is scanty during the paroxysm, more copious after it; in general viscid, grayish- white, very frothy, and containing in a transparent, almost vitre- ous mass, a mixture of fine threads, flakes, and plugs, some of which are distinguished by their dense dry consistence and generally clear gray color. These present, under the micro- scope, a compactly matted bundle of brownish cells undergoing granular degeneration, between which are more or less abundant layers of crystals. These crystals are colorless, have a dull lus- tre, and always the form of very pointed octahedra. They differ greatly in size, some of them being so large that they attract attention at once, while others are recognizable only by the aid of strong immersion lenses. According to the investigations of Salkowski, they are readily soluble in water, especially in warm water, and likewise in acids and alkalies; insoluble in ether; and swell in glycerine until they become invisible. The nature of these crystals has not been determined with certainty; but it is probable that they are composed of a crystallized substance analogous to mucine. As to the connection with the symptoms, Leyden advances the probability that these fine-pointed crystals irritate the peripheral terminations of the vagus nerve in the bronchial mucous membrane, with reflex spasm of the musculature of the smaller bronchi, and thus occasion all the symptoms of asthma. Leyden's attempt to prove this connection experimentally has not yet succeeded. It is further worthy of mention, that similar crystals had been previously observed by Friedreich, Forster, and others, in dry catarrh and in croupous bronchitis. These are apparently identical with those found by E. Neumann in the bone-marrow and blood of leuksemic patients. The latest theory, and one well worthy of attention, is that of Weber.1 Weber believes that in addition to spasm of the bronchial muscles various other causes, such as acute catarrh, diaphragmatic spasm and paralysis, insufficiency of the heart, Tageblatt der 45. Versammlung deutscher Naturforscher und Aerzte zu Leipzig, 1872, p. 159. BRONCHIAL ASTHMA. 549 aneurism of the aorta, poisonings, etc., may occasion asthmatic manifestations, and that a difference in the symptoms may be observed according to the difference in the cause; so that it is frequently possible to distinguish between the individual forms. The most usual train of symptoms, according to Weber, is as follows: dyspnoea caused by difficulty of inspiration and expiration, orthopncea, whistling, sonorous and sibilant rales, cyanosis, sweating frequently, great anxiety and restlessness; then moist rales, secretion of a more or less viscid mucus, fre- quent expectoration of this secretion, and with it abatement and disappearance of the dyspnoea. Such a paroxysm may continue half an hour, or it may last for days. This group of symptoms, and especially the secretion of the mucous membrane, according to Weber, are not to be explained by diaphragmatic spasm or spasm of the bronchial muscles alone. Acute catarrh also is shown not to be the cause of the paroxysm in many cases, according to Weber. On the other hand, another hypothesis explains the collective manifestations the most naturally, namely, the supposition of a tumefaction of the bronchial mucous membrane in consequence of dilatation of its blood-vessels through vaso-motor nervous influence. Such vascular dilatation, with tumefaction of the mucous membrane producing a stenotic narrowing of the air-passages, frequently takes place in the nose ; and many people suffer very frequently from this often only momentary stopping of the nose, sometimes affecting only the one or the other nostril. By careful examin- ation, the much congested and swollen mucous membrane can readily be recognized as the cause of the impeded passage of the air. It might be conjectured, d priori, that, as the mucous mem- brane of the nose is anatomically very like the bronchial mucous membrane, and as the nose likewise belongs to the respiratory organs, processes may occur in the bronchi similar to those which take place in the nose. This opinion finds an important support in the fact that in many asthmatics the asthma is pre- ceded by such stopping of the nose, which ushers in the parox- ysm, or, as is less frequently the case, continues during the whole of it. 550 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. This theory, presented by Weber, finds a further important support in the fact that there are not only asthmatics in whom almost every acute bronchial catarrh, every "taking cold," at once occasions an attack of bronchial asthma, but it also hap- pens that asthmatic attacks which apparently begin without the slightest catarrhal symptoms, nevertheless terminate with them. In these cases it appears as if the asthma occasioned a hyper- emia of the bronchial mucous membrane. As Biermer, how- ever, justly advances, in tliese cases the possibility is by no means excluded that, even when the attack begins without catarrhal symptoms, a fluxionary hypersemia of the bronchial mucous membrane may, nevertheless, be its primary manifesta- tion. The last-mentioned theory deserves our consideration the more that it is in full accordance with known physiological laws concerning vaso-motor nervous influence. I recall here only the well-known experiment of Loven,x by which it was shown that, upon irritating sensitive nerves, a reflex vascular turgescence ensued in the domain of the irritated section. In an analogous manner we can suppose that whenever an irritation affects the bronchial or nasal mucous membrane, this irritation may excite a reflex vascular turgescence in this region. Storck2 has just entered the field as a decided defender of this theory of Weber, and, at the same time, an opponent of the theory of bronchial spasm. On the other hand, Storck admits that tonic spasm of the diaphragm plays a role in bronchial asthma, in addition to the acute tumefaction of the mucous membrane of the bronchioles. Storck recognizes a special support for the supposition of an acute tumefaction of the bronchial mucous membrane in the fact discovered by him, that tracheoscopic inspection in asthmatic attacks showed great congestion both of the entire trachea as far up as the larynx, and partially, also, of the right bronchus. Passing from the description of the most important theories 1 Ueber die Erweiterung von Arterien in Folge einer Nervenerregung. Arbeiten aus der physiol. Anstalt zu Leipsig, herausgegeben von Ludwig, 1867. 2 Mittheilungen iiber Asthma bronchiale und die mechanische Lungenbehandlung, Nebst einem Anhang iiber den Hustenreiz. Stuttgart, 1875. BRONCHIAL ASTHMA. 551 of asthma to the question, which of them corresponds best with the clinical symptoms, we must first remark that a complete uniform train of symptoms is by no means to be comprehended under the term "asthma." As long as a complete agreement as to the train of symptoms to be accredited to asthma has not yet been reached, a definite answer to the question, which of the current theories above mentioned is the only correct one, cannot be expected. In this connection Biermer has rendered a real service ; not only because he has so sharply delineated the clinical picture of essential bronchial asthma, but also because he has signalized with emphasis the preponderant expiratory dyspnoea of asth- matics, and has brought out sharply the differences between inspiratory dyspnoea and the predominant expiratory dyspncea. This difference between inspiratory and expiratory dyspnoea is by no means sufficiently borne in mind ; and consequently we still find the remark repeated in current writings on asthma, that a spasm of the glottis is often at the same time the occa- sion of the asthma. How essentially, however, the symptomatic pictures of asthma and spasm of the glottis differ, has been shown by Biermer in the clearest manner. In referring to the chapter on symptomatology for the special train of symptoms occurring in bronchial asthma, I must men- tion, in reference to the different theories above presented, that the objections offered to the explanation of asthma as a spasm of the smaller bronchi, should be regarded as refuted by Biermer's recent detailed expositions, which we have reproduced above in extenso. That a depressed position of the diaphragm, and acute pulmonary dilatation are the necessary consequence of bronchial spasm, as of every sudden constriction of numerous bronchioles, has been proved by Biermer with such excellent reasons that any further discussion of the question may be abstained from in this place. Just as here an acute pulmonary dilatation ensues, under the influence of sudden, though not absolute obstruction, so we see, in an analogous manner, chronic pulmonary dilata- tion, actual emphysema, become developed in chronic catarrhs in consequence of the slowly developed but continuous obstruc- tion. While, therefore, on the one hand, there can be no doubt 552 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. that the symptomatic picture of asthma may be produced under the influence of intense obstruction in numerous small and minute bronchi, as occurs in bronchial spasm, yet the question is by no means decided, on the other hand, whether the bronchial spasm is always primary, or whether it is not rather a secondary manifestation. That the fluxionary element also plays a role in bronchial asthma is beyond a doubt. This is proven by the catarrhal symptoms attending every attack, and sometimes appearing with special intensity at the close. Towards the close of the attack, there is more or less discharge of bronchial secretion, correspond- ing, as a rule, with the appearance of numerous moist rales. On the other hand, the question is less easily answered, in what connection the congestion of the bronchial mucous membrane stands to bronchial spasm. Biermer has already considered this question, and has suggested, among other possibilities, that as a congestion of the bronchial mucous membrane, so long as it remains dry, cannot be well recognized, and at least cannot be distinguished by physical signs from an asthma commencing simultaneously, so also in these cases in which the asthmatic attack apparently commences without catarrh, a fluxionary turgescence of the mucous membrane of the bronchi may have preceded, and increased secretion during the height of the attack may or may not follow. A further possibility, suggested by Biermer, is that the bronchial hypersemia is a consequence of the asthma ; a relation that has been especially maintained by Trousseau. Finally, both the hyperaemia and the spasm of the bronchi may be regarded as co-effects of an irritation of the nerves of sensation. Weber and Storck treat the subject in another manner, inas- much as they also attribute an important role to the fluxionary element, but, in contrast to Biermer, endeavor to explain the entire train of symptoms by this alone. Storck, in particular, sees an important support to this theory in the fact that he has repeatedly observed great congestion of the trachea and a por- tion of the bronchi, on tracheoscopic examination during the attack. At the same time he is compelled, at least in certain cases, to adopt the theory of a tonic spasm of the diaphragm. BRONCHIAL ASTHMA. 553 The view that there is sudden tumefaction of the mucous membrane of the bronchioles, in bronchial asthmatic attacks, has much probability in its favor; and the view that this tumefaction is the primary movement of the entire attack, is rendered the more probable, when we consider that, as a rule, there is a sero-mucous bronchial secretion after a short duration of the paroxysm, and, furthermore, that this increased secretion must always be preceded by a hypersemia, which has been proven to be actually present by Storck's investigations ; and finally, that analogous sudden tumefactions at other portions of the respiratory apparatus, the nasal mucous membrane for instance, are likewise observed by no means infrequently. Although, therefore, the opinion that bronchial asthma is always ushered in by an intense hypersemia, is becoming more and more plausible, the question still remains for discussion, whether the entire symptomatic manifestations of the asthmatic attack can be explained by this hypersemia alone, or whether we must accept an accessory spastic element. It is in this last point that the difference culminates between the views of Weber and Storck on the one hand, and those of Biermer on the other. Biermer himself first suggested the pos- sibility that fluxionary turgescence of the mucous membrane of the minuter bronchi might be the first phenomenon of asthma. Even Storck,1 in combating the theory of bronchial spasm on the one hand, finds himself inclined to the opinion, on the other, that the diaphragm may be excited to tonic spasm. While I am willing, upon the grounds above mentioned, to concede a more important role, than has been hitherto assigned to it by most observers, to the fluxionary element in the pro- duction of bronchial asthma, and to admit that the acute tume- faction of the mucous membrane of the bronchioles is the pri- mary element of asthma, I consider it going too far to endeavor to explain the entire symptomatic picture by these conditions alone. This explanation may suffice, perhaps, for very mild grades of the affection. But that the severer grades, in which the patient forcibly struggles for air, in which, despite the assist- 'L.c, p. 15. 554 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. ance of all the auxiliary muscles of respiration, he is still tor- tured with the most painful hunger for air, so that the dread of death evinces itself; in which phenomena of the intensest pul- monary dilatation become developed within a short period, can be explained by the mere tumefaction of the mucous membrane, appears to me improbable. Here a second factor must be associ- ated, and that this can be only the spastic element is evident. How otherwise shall we explain the frequently observed rapid amelioration after the administration of chloral hydrate, and similar remedies ? In this sudden disappearance of the alarm- ing asthmatic manifestations, after the employment of chloral hydrate, Biermer justly recognizes an evidence that spastic processes play a role in the manifestations. To explain, with Storck, the restoration of free respiration after the employment of chloral hydrate, or morphia, by a sudden subsidence of the tumefaction of the mucous membrane, resulting from the use of these remedies, may, at any rate, be somewhat disputed; and cannot be supported by any other analogous manifestation. According to the view given above, in which we have attributed a prominent role to acute tumefaction of the mucous membrane, it is also comprehensible how chloral hydrate fails in its effects in many cases; how the use of this or similar remedies is not infrequently followed only by moderate amelioration, and by no means by a complete cessation of the asthmatic symptoms. It is easy to understand, however, that the pulmonary dilata- tion and the deep descent of the diaphragm will be more marked when a spasm of the bronchial muscles is superadded to the con- striction of the minuter bronchi occasioned by swelling of the mucous membrane. The simple swelling of the mucous mem- brane can hardly suffice to occasion such intense pulmonary distention as is constantly observed in the severer grades of asthma. Both together, however, if the inspiratory force is not too much enfeebled, must lead to acute pulmonary distention as a necessary consequence. At the same time, it can by no means be denied that cases occur in which a spasm of the diaphragm may be superadded secondarily. That here, however, the symptoms must vary in many points from those which occur in pure bronchial asthma, BRONCHIAL ASTHMA. 555 hardly needs any special affirmation. But in no instance can the nature of asthma be found in a diaphragmatic spasm alone, and this be considered as the primary phenomenon. An entirely different picture must be presented if there is spasm of the glottis, whether it be primary or secondary. In our description of the symptoms, and of the differential diag- nosis, we will have occasion to speak more in detail of the differ- ences between these individual forms of dyspncea. It appears, therefore, of essential importance to separate sharply the symp- tomatic pictures of the individual forms of dyspncea, according to the different locations from which they originate. Here, how- ever, we are especially concerned with that form only which has been designated as bronchial asthma in the restricted sense of the word. In the following pages, therefore, only that form will come under description which is distinguishable as pure bron- chial asthma. With reference to the theory presented by Leyden, which plausibly attributes the occurrence of bronchial asthma to the presence of the crystals previously mentioned, a greater number of observations must first be made before we can arrive at a definite conclusion. At any rate, this theory gains in proba- bility if we accept hypersemia as the principal factor in the affection. The fact that the same crystals have been found in other cases than those of asthma, by no means militates against regarding them, in individual cases, as the exciting cause of the hypersemia and the bronchial spasm. Anatomical Alterations. In bronchial asthma there can be no essential anatomical alterations. It belongs to the functional neuroses, and is char- acterized, at least in accordance with the general opinion, by the very absence of anatomical alterations. In so far as a series of diseases of the respiratory and circula- tory organs dispose to asthmatic attacks, a series of anatomical changes will not infrequently be found in the dead body. Tliese, however, cannot be brought into direct relation to asthma, but only into remote relationship, as is also evident 556 RIEGEL.—DISEASES OF TRACHEA AND BRONCHL from the fact that these diseases are at least just as frequently observed without being followed by asthma. In so far as long- continued and oft-returning asthmatic attacks frequently occa- sion a series of alterations in the respiratory and circulatory organs secondarily, and inasmuch as the asthmatic attack, as such, is not fatal, but may become so eventually by reason of consecutive manifestations and complications, it is comprehen- sible how the existence of an idiopathic asthma was so long doubted, and how asthma was brought into direct relation with a series of anatomical alterations. Catarrh and emphysema occupy the most important role among the sequelse of asthma; and, on the other hand, it has long been established that chronic bronchial catarrh and emphy- sema belong to the most frequent, though at the same time remote, occasioning causes of asthma. Inasmuch as all observers, as already stated, agree in the ex- perience that the asthmatic paroxysm hardly ever brings life into direct jeopardy, no matter with what severity its manifestations may be ushered in, there is no opportunity to make any direct examinations in this direction. The fact that, in pure bronchial asthma, every subjective disorder, every objective alteration, is wanting outside of the period of the attack, speaks against the existence of any special anatomical lesion as the substratum of the affection. If we have thus far spoken only of negative anatomical results, this applies only to the actual examination of the dead body. As we have already mentioned, in speaking of the mode of origin of the disease, not only do the clinical facts lead to the assumption that a severe congestion of the bronchial mucous membrane takes place during the attack, but Storckx has even adduced direct evidence of the correctness of this view, he him- self having demonstrated by tracheoscopic examination that the mucous membrane of the trachea and main bronchi is intensely reddened during the attack. But if this is true of the larger bronchi, we are certainly justified in accepting the same view with regard to the mucous membrane of the smaller ones ; 1 Mittheilungen iiber Asthma bronchiale. Stuttgart, 1875. BRONCHIAL ASTHMA. 557 and even to a greater degree. It is self-evident, however, that this hypersemia can hardly be subjected to anatomical demonstration. On the other hand, it cannot be wondered at that long con- tinued and frequently recurring attacks may lead, in the course of time, to permanent anatomical alterations. In this category belongs chronic catarrh, which, on the one hand not infrequently attends the asthma, and on the other is one of its not infrequent consecutive manifestations. This is the more readily understood if we incline to the view just mentioned, namely, that congestion is the introductory element of the attack of bronchial asthma. It is still easier to understand how, after the frequent recur- rence of such asthmatic attacks, which are always attended with excessive pulmonary distention, a permanent loss of elas- ticity of the pulmonary alveoli, and even an actual emphysema, may result. Symptomatology and Course. Like many other neuroses bronchial asthma has a more or less typical course. It consists of attacks of dyspncea and oppression, which come on usually at irregular intervals, some- times occurring more frequently and sometimes less frequently, and interrupted by shorter or longer periods of complete com- fort. In the intervals between the attacks, the functions of the respiratory organs appear altogether undisturbed, at least in the idiopathic forms of the affection. In the majority of cases the attack begins unexpectedly, and usually during the earlier hours of the night. The patient, hav- ing gone to bed perfectly well, is suddenly awakened in the night, while sleeping quietly, by an intense sense of oppression and anxiety. Breathing is very laborious, and the respiration is attended with audible whistling and rattling; and the dyspncea rapidly increases to an excessive degree. The cyanosis increases from minute to minute, the face becomes bluish red and turgid, the eyeballs protrude, the patient supports himself on both arms to struggle powerfully for air, and the face becomes bathed in perspiration. The patient can no longer get his breath in the recumbent position, and often assumes the most varied 558 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. attitudes in order to appease in a measure his craving for air. Sometimes he sits up in bed and supports his shoulders with both arms, in order to diminish the size of the thorax by the assistance of the firmly contracted abdominal muscles. The expiration is thus rendered especially loud, groaning, whistling, and audible at a distance ; and it is proportionately longer than the inspiration. Soon the patient hurries to the window to struggle for a mouthful of fresh air. In spite of all this he does not succeed in appeasing his craving for air, even by the forcible action of all his auxiliary muscles. The paroxysm continues at this height for a long time,—one, two, or more hours,—and then it gradually subsides. The respiration becomes easier again, the cyanosis disappears, the patient feels gradually freer and freer, and then drops off into a quiet, deep, uninterrupted sleep. In many cases the patient feels completely well, until a fresh par- oxysm, frequently coming on at the same hour, reproduces the same severe train of symptoms, upon the subsidence of which, the patient again feels completely well, until overtaken by another paroxysm. In this manner the paroxysms recur again and again, for weeks or months, in a more or less irregular man- ner, to disappear altogether eventually, or for a long period. There are many deviations, however, from this course, which we have just described, and which characterizes true asthma, Thus it happens, by no means infrequently, that the attack is preceded for a shorter or longer time by prodromal manifesta- tions, a sort of aura in fact, which announces to the patient the approach of a paroxysm. Sometimes there is a sensation of constriction in the throat, sometimes abnormal sensations at the epigastrium ; sometimes the attack is preceded by gaping, or severe sneezing, and the like. In many cases the asthmatic paroxysm is ushered in by severe acute coryza. The patient, who has hitherto felt perfectly well, is suddenly attacked by an exceedingly severe, obstinate fit of sneezing, which leads at once to greatly increased secretion from the nasal mucous membrane ; the eyes become injected and the secretion of tears augmented. These symptoms then give place, with or without a pause, to the essential asthmatic paroxysm. In other cases, again, the asthmatic attacks continue for days BRONCHIAL ASTHMA. 559 or even weeks, with but slight remissions, so that the patient is no longer able to attend to his employments during the time. The slightest exertion, or any emotional irritation, at once increases the dyspncea, and the paroxysms increase during the night to an almost unbearable degree, so that the patient is hardly able to secure a position in which he can be more com- fortable. Sometimes the patient is no longer able to remain in bed ; soon, again, he must have his bed so arranged that he sits in it rather than lies upon it; soon, again, he finds that he has no rest in any position, so that he is constantly changing it. There are not infrequent exceptions to the rule that the asth- matic paroxysm usually begins before midnight. Trousseau, who suffered from asthma himself, relates that he formerly had his paroxysm always at about three o'clock in the morning, and that he was regularly awakened from sleep at this hour by a sense of oppression. His mother, on the contrary, from whom he had without doubt inherited his asthma, had her attacks between eight and nine o'clock in the forenoon. Trousseau further relates the case of a tailor, who was so regularly at- tacked with asthma at three o'clock in the afternoon, that Trous- seau suspected malarial disease, a sort of masked intermittent, on account of this very regularity. As a matter of course, quinine was without any influence on the paroxysms. Cases of diurnal asthma, however, are exceptional, and the rule must be accepted that the attacks occur chiefly at night. In other cases, again, as remarked by Trousseau, the asthma takes on the catarrhal form,1 in which the bronchitis, which so often, and in fact ordinarily, terminates the paroxysm, appears to represent the only expression of the attack. This form of asthma is observed with especial frequency in children, though it is not altogether infrequently observed in adults also. It is of significance, however, in these cases, that the intensity of the dyspnoea stands in no relation to the auscultatory manifesta- tions. Trousseau not only deserves the credit of pointing out the ! Trousseau, like Biermer, accepts two forms of asthma, idiopathic and catarrhal. According to the opinion advanced by ourselves, that every asthma is associated with congestion of the mucous membrane, in addition to the spasm of the bronchioles, this subdivision is superfluous. 560 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. frequency of asthma in children in general, but he was also the first to pay attention to the characteristic forms under which it occurs in children. As Trousseau remarks, it must be con- sidered exceptional when asthma occurs in children in the same form as in adults, and he states that for his own part he has seen but a single such case. According to Trousseau, asthma occurs in children much more frequently in the catarrhal form, so that it may readily be confounded with genuine catarrh. Although the catarrh is marked in these cases by more severe manifestations than in cases of simple genuine bronchial catarrh, it is much more easy to subdue the disease at once than genuine bronchial catarrh, as soon as the spastic element is directly attacked. This form offers some difficulties for the diagnosis; still, it can always be recognized on careful consideration. Sen- sations of great oppression, feelings of anxiety and the like occur from time to time, especially at night, and continue even when the catarrh is already on the decline, or is in course of extinction. An important characteristic element of this form of asthma lies in the lack of harmony between the catarrhal and the nervous symptoms. The general disturbances are also absent in these cases, fever especially, almost com- pletely, while the manifestations on the part of the respiratory organs come on with excessive turbulence. Finally, a very characteristic feature of this form of asthma lies in the sudden, almost causeless subsidence of the paroxysm, as well as in its rapidly recurring and equally causeless return. The catarrhal element, therefore, plays only the role of an immediate cause. It coincides in a certain measure with the spasmodic parox- ysm, but not in such a way that it can ever be considered as a rule that the severity of the catarrhal symptoms is propor- tional to the degree of nervous disorder. On the contrary, it appears that the same individual who to-day, with a slight bron- chitis, is attacked by a very severe asthmatic paroxysm alto- gether out of proportion to the slight degree of change in the bronchial mucous membrane, on another will not suffer the slightest nervous or spastic attack with a much severer bronchi- tis (Trousseau). Let us now turn from this short general delineation of the BRONCHIAL ASTHMA. 561 most important forms under which asthma appears to an analy- sis of the individual symptoms. As already mentioned, the paroxysm begins before midnight as a rule; less frequently after midnight. If no prodromes have preceded, the patient is awakened suddenly out of sleep by a sensation of severe oppression and dyspncea. This dysp- noea rapidly increases to a very intense degree, to complete orthopncea. The patient now seeks in every manner to satisfy his need of fresh air; sometimes he runs to the window and opens it, hoping thus to secure some amelioration; sometimes, as he is no longer able to lie in bed, he leans hard upon his arms so as to facilitate breathing. Respiration goes on laboriously, noisily, with many rales ; a loud whistling sound is heard on inspiration, often audible at a distance; the same is heard, but with greater intensity, in expiration, which is considerably pro- longed, and is performed with the assistance of all the expira- tory forces. The intense anxiety and desire for breath is most distinctly imprinted on the countenance. More or less intense cyanosis of the face is often rapidly developed; the alse of the nose are powerfully agitated; and even a short time after the commencement of the attack the entire terrifying train of symp- toms is completely developed, and continues for a long time; hours usually, but even days sometimes, with slight remissions. Often a profuse cold sweat covers the entire body. The peri- pheric portions of the body, the face and extremities particu- larly, usually feel cold. With regard to the position of the body during the parox- ysm, the patient, as already mentioned, is almost without ex- ception unable to retain the horizontal position. Sometimes he sits upright in bed, leaning firmly on his arms ; sometimes he is no longer able to remain in bed even in this position, and he rushes to an arm-chair or to the open window. It must be regarded as an exception that in the case so clearly and dis- tinctly described by Bamberger,1 the patient constantly retained the horizontal position on his back during the paroxysm, that he did not make the attempt to sit up, to support himself on his 1 Wurzburger med. Zeitscher, VI., Heft 1 u. 2. VOL. IV.—36 562 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. arms, or even to raise his head higher, and that no movement took place except a restless tossing to and fro of the trunk from side to side when the spasm reached a great degree of severity. The latter point—the avoidance of forcible movements—applies certainly to the majority of asthmatic attacks up to a certain degree of severity. The patient anxiously avoids every move- ment in order not to increase the already excessive dyspncea by the muscular effort. The number of respirations is usually diminished during the asthmatic paroxysm, as mentioned by Bamberger, on account of the considerable prolongation of the expiration. The inspira- tion is proportionately short, but deep and powerful; the upper portion of the thorax is strongly raised, often much more than in the normal condition, as I have demonstrated by comparative graphic measurements during the paroxysm and at other times. The lower portion of the thorax not only often bulges but very little forwards, but sometimes even sinks a little backwards, in the severest cases, towards the vertebrae. This disproportion is especially pronounced in male patients, in whom, as is well known, during normal respiration, the extent of movement increases, as a rule, the lower the portion of the thorax. The upward movement of the thorax is considerably increased there- by. At the same time the sterno-cleido-mastoid, the scaleni, and other muscles contract powerfully, and the shoulders are strongly raised. Expiration, however, exhibits more important deviations from the normal act than does inspiration. While inspiration, as Bamberger pertinently remarks, shows nothing that varies from an ordinary powerful and somewhat forced effort, expiration presents the picture of a most laborious and tormenting, and at the same time fruitless struggle. It lasts from two to three times as long as inspiration, and in very severe cases even longer. All the expiratory auxiliary muscles are spasmodically tense, and the abdominal muscles collectively are contracted so that in severe cases the slightest impression cannot be made upon them with all the force that can be exerted. In individual cases, as for example in the one reported by Bamberger, this tension of the abdominal muscles was so great that the urine BRONCHIAL ASTHMA. 563 always escaped involuntarily during the attack; and sometimes the fseces also. Despite all this severe, powerful, muscular effort, a sufficient contraction of the thorax cannot be effected. While, as above stated, the number of respirations is not increased during the paroxysm, despite the severity of the dysp- ncea, but, on the contrary, is usually diminished, a temporary acceleration is sometimes observed if the patient endeavors to change his position, or any other special factor acts momentarily. Otherwise a diminution, or at least a want of acceleration of the number of respirations is observed as a nearly constant symptom. In seeking an explanation of this diminution in the number of respirations, despite severe dyspncea, I must recall the analo- gous and long known reduction of the number of respirations in croup, laryngeal stenosis, and the like; only that instead of expiration as here, it is inspiration which appears greatly pro- longed and laborious. This manifestation may be explained in a manner analogous to that by which I have previously explained this reduction when accompanying constriction of the larger air- passages.1 It is just in this prolongation of the breathing, as I have there shown, that an important means of compensation is given to the severe dyspncea in the lengthening of one phase of respiration, while, conversely, accelerated respiration would only increase the dyspncea under these circumstances. The result of tracheoscopic examination, exhibiting consider- able congestion of the mucous membrane of the trachea, and partially of the bronchi (Storck), has already received mention on a previous page. The results furnished by percussion are of especial interest. While at all other times the lungs remain within normal limits in pure uncomplicated cases, —the limit of clear pulmonary reso- nance, for example, corresponding, on the right side and in front, to a point somewhere about the lower edge of the sixth rib anteriorly in the mammary line,—during the paroxysm they extend considerably lower, say two inches and even further downwards, to the depth which is observed in cases of the utmost emphysematous distention of the lungs. In an analo- 1 Riegel, Die Athembewegungen, Wiirzburg, 1872, with 12 tables; A. Struber. 564 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. gous manner, as a matter of course, the lower border of the liver is lower, and extends more or less beyond the ribs. The extent of cardiac dulness is sometimes diminished, in consequence of the distention of the edges of the lungs. The pulse is often remarkably small, and sometimes even very weak. A further very significant result of percussion is the slight change of the limits of the lower edges of the lung during inspi- ration and expiration. In individual cases, as for example, in that reported by Bamberger, which deviates in many condi- ditions from the ordinary symptomatic picture of bronchial asthma, inspiration and expiration have not the slightest influ- ence upon the limits of the lower border of the lungs. Even with the deepest inspiration the upper limit of hepatic dulness did not deviate the breadth of a line from its position during the deepest expiration. In the majority of cases there is a move- ment of the border of the lungs, though slighter than in the normal condition. A third deviation revealed on percussion of the lungs is an alteration in the volume of the percussion resonance. During the asthmatic paroxysm, the percussion resonance shows a remarkable increase of volume, and with it a distinct tympani- tic quality, usually in the lower portions of the thorax, espe- cially behind and on the sides. Biermer terms this resonance "band-box tone," on account of its resemblance to the per- cussion sound of a pasteboard bandbox. The physical cause of this modification of resonance is due, as is easily understood, to the greater distention of the alveolar tissue. The same sound will be observed wherever dilated and more distended portions of the lungs of some size are found lying against the thoracic walls. Concerning the retrocession of these changes (as ascertained by percussion) to the normal standard, after the termination of the paroxysm, it may be remarked, that it does not usually take place immediately after the termination of the paroxysm, but only gradually. As a rule, however, the organs mentioned have again resumed their normal limits within a few hours. On auscultation the first thing remarked is the absence, masking, or enfeeblement of the vesicular respiratory murmur. BRONCHIAL ASTHMA. 565 Usually no vesicular respiration at all is audible at the lower portions of the thorax; and in the upper portions it is some- times also almost entirely absent, or is very much enfeebled. Nevertheless the breathing during the paroxysm is so loud and rattling, especially the expiration, that it can be distinguished at a considerable distance. The respiration has withal a pecu- liar whistling, sibilant tone, audible both in inspiration and in expiration, but unusually intense in the markedly prolonged expiration. The dry, sonorous rhonchi, audible especially dur- ing expiration, and which not infrequently merge into moist rales towards the end of the attack, are peculiarly characteristic. These rhonchi are usually considerably shorter and weaker dur- ing inspiration than in expiration, and so loud, as a rule, as to completely mask the remaining respiratory sounds. Concerning the assistance of other accessory forces, it has already been mentioned that a great number of auxiliary muscles are brought into action according to the degree of the respiratory obstruction. Corresponding to the nature of the obstructions, which concern expiration mainly, it is especially the expiratory auxiliary muscles which are called into action. As pertinently remarked by Bamberger, the expiration is at- tended with a true tetanus of the expiratory muscles ; and the tightly stretched recti often project as board-like ridges. That speech and cough should be considerably impeded under such circumstances, hardly needs special mention. The sputum is usually scanty, and is almost always com- pletely absent in the beginning. As a rule, it is first discharged towards the end of the attack. It is frequently very frotlry, grayish-white, and sometimes colored reddish-gray from bloody admixture. On close examination with a lens, small yellowish- green clumps are often found in it, which are dense and elastic, and which with some difficulty can be crushed under the cover- ing glass to a dull, glistening, crumbly, dry mass. In these clots the crystals already described (Leyden) are often found imbedded in great quantity. Furthermore, granular mucus cells are found, in which, often, these crystals are imbedded ; and pus cells also, and ordinary mucus cells, and cylindrical and ciliary epithelium. Many cells show, sometimes, the so-called 566 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. myeline metamorphosis, an alteration into pale, roundish masses, similar in appearance to myeline (Leyden). In rare exceptional cases the train of symptoms characteriz- ing bronchial asthma extends chiefly over only one-half of the thorax; and it is evident that the physical signs mentioned must be developed chiefly on this side also. The temperature of the body shows no important deviation from the normal standard. I have repeatedly observed a re- markably low temperature during the paroxysm, lower than that found between the paroxysms. The peripheric portions of the body—the face especially—are usually cool, and more or less cyanotic. As to the subjective symptoms, and the disorders on the part of the nervous system, the patient complains, during the attack, of the greatest oppression and dyspnoea. Conscious- ness is always maintained in the pure uncomplicated forms of asthma. In severe cases the patient sometimes appears as if stu- pefied. Cases are only very rarely observed in which conscious- ness is lost during the paroxysm. Thus in the case reported by Bamberger, the consciousness, retained during moderate attacks, regularly disappeared in severe attacks, after the spasm had lasted some time. In such cases, associated with disorder of consciousness, sometimes opisthotonous and tetanic spasms of the trunk and the extremities are observed, and even twitchings of the muscles of the face. The further course of this affection is subject to extremely numerous variations. Sometimes only a few paroxysms occur, sometimes very many. Sometimes the paroxysms are relatively mild at the commencement of the disease, and recur only at great intervals, to increase, later, in number, and also in inten- sity. Sometimes, again, the paroxysms occur with extreme severity from the very beginning. The disease sometimes sud- denly ceases spontaneously, after having resisted all remedies for months, and even years, and never returns. The asthma of children is relatively favorable in this respect, inasmuch as it often ceases spontaneously after a short time, or else at the period of puberty. On the other hand, when com- mencing in middle life, asthma continues not infrequently for BRONCHIAL ASTHMA. 567 the entire remainder of the patient's existence, although with manifold fluctuations and interruptions. It has already been mentioned on a previous page that two chief forms of asthma have been distinguished : a so-called essen- tial or idiopathic asthma, and a symptomatic asthma. The for- mer form is distinguished by the circumstance that the patient is entirely well between the intervals of the attacks, and that the most accurate examination reveals no alteration of the organs. In the second form, on the contrary, there are different affec- tions, especially of the lungs, the large vessels, and the heart, which must be brought into close or remote causal connection with the asthma. Chronic bronchitis and emphysema especially belong to this category. In those cases in which the catarrhal element prevails, we may, perhaps, be disposed to attribute the dyspncea directly to a sudden increase in the bronchitis. Such a conception, as has repeatedly been advanced, must evidently be regarded as erroneous. The nature of asthma must be regarded as a pure neurosis, because even in those cases which are simultaneously coincident with catarrhal or other symptoms, the severe dyspnoea occurring periodically can never be ex- plained by the catarrhal or other disorder without the assist- ance of other special factors. On the other hand, both catar- rhal inflammatory processes of the bronchial mucous membrane and emphysema represent not infrequent sequelse of frequently recurring and long-continuing severe asthmatic paroxysms. If, as we have already explained, an acute pulmonary distention always exists in the asthmatic attack, if the limits of the lungs reach further down, and the expiration always appears impeded to a great degree, so that, despite the assistance of all the expira- tory forces, the thorax cannot be diminished, or the lungs re- duced to their normal volume, then it is easy to comprehend how, in the frequent recurrence of such attacks, the lungs event- ually remain distended beyond their normal dimensions, and how actual emphysema or chronic dilatation may result from the acute pulmonary distention. Something analogous applies to catarrh. We have already mentioned that even in those cases in which the asthmatic seizure is not ushered in by any appa- rent manifestations of congestion, such conditions are very prob- 568 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. ably always present in the beginning. It is then very easily comprehensible how, from the frequent recurrence of such asth- matic attacks, permanent disorders of the circulation and nutri- tion of the bronchial mucous membrane may result from this temporary congestion. Diagnosis. It might be supposed that the separation of bronchial asthma from other forms of dyspncea presented no difficulty at all. This is not the case in fact. Bronchial asthma has, as a matter of course, its own peculiar type, so that on careful consideration of all the points no difficulty will be experienced, usually, in distinguishing it from all related forms of dyspncea. The com- plete integrity of the circulatory and respiratory organs, and the perfect good health between the seizures are of special im- portance ; but this applies only to the true uncomplicated form of pure nervous bronchial asthma. As already mentioned, attacks of asthma are not infrequently superadded to various other affections, especially those of the heart and the lungs; and in these cases, as a matter of course, the point mentioned loses its differential diagnostic significance. In such cases it may readily be confounded with the symptomatic difficulties of res- piration, which are occasioned by* the fundamental disease, especially by catarrh and accumulations of mucus. Neverthe- less it is easy even here to distinguish this form [of dyspncea from that occasioned by spasm of the bronchi. The latter never keeps step with the physical changes, and is especially occa- sioned by a series of mere accidental causes. Hence an impor- tant differential indication is afforded in the sudden and appa- rently causeless onset of the paroxysm of dyspnosa, and in the disproportion between the physical changes and the severity of the dyspnoea. Notwithstanding, then, the fact that the asthma is attended by evidences of hypersemia and swelling of the bronchial mucous membrane, so that one feels repeatedly dis- posed to attribute to this local disorder alone the dyspnoea as it occurs in the paroxysms, we must not forget, on the other hand, that an important differential indication lies in the fact that this sudden seizure of severe dyspncea, as it occurs in genuine BRONCHIAL ASTHMA. 569 asthma, can in no wise be sufficiently explained by a simple hypersemia and swelling of the mucous membrane. Even in- tense acute catarrh hardly ever leads to such severe dyspncea and such intense pulmonary distention as are constantly ob- served in attacks of asthma. The forms mentioned, however, are not so likely to be mis- taken for genuine bronchial asthma as certain other forms of dyspnoea, which also occur more or less suddenly. To this category belongs especially the dyspncea, often extremely severe, occasioned by spasm of the glottis. Such confusion still occurs daily in practice ; but it can hardly continue if we distinguish more closely than has been done hitherto, between inspiratory and expiratory dyspncea. To Biermer and Gerhardt belongs chiefly the credit of hav- ing first accurately established the difference between inspira- tory and expiratory dyspncea. This difference between the inspiratory and expiratory forms of dyspncea has had further demonstration and verification through my own graphic obser- vations, and through the method of manometry introduced by Waldenburg l into clinical practice. As Biermer suggests in his admirable work upon bronchial asthma, it is convenient to distinguish two principal forms of dyspncea: the one, chiefly inspiratory, the other chiefly expira- tory in character. The breathing in croup, in oedema of the glottis (larynx), in stenosis of the trachea, in spasm of the glot- tis, in paralysis of the dilators of the glottis, and so on,—in short, the breathing in any form of constriction of the larger air- passages will serve as an example of inspiratory dyspnoea. Em- physema, chronic bronchial catarrh, and bronchial asthma repre- sent examples of expiratory dyspncea. The difference between these two forms of dyspnoea is evident upon mere contemplation, but it becomes more distinct on graphic exploration. Here, as I have previously shown, very great differences become manifest, so that a mere inspection of the curves is sufficient to distinguish the two forms from one another, even to afford a judgment as to the severity of the inspiratory or expiratory dyspncea. 1 Berlin, klin. Wochenschr., 1871, No. 45. 570 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. Of the affections just mentioned which are associated with dyspncea, it is chiefly spasm of the glottis which may lead— and indeed often has led—to confusion with asthmatic seizures. The distinction between these two forms is principally based on the following points : In spasm of the glottis, inasmuch as inspiration is chiefly impeded, all the inspiratory auxiliary forces are called into assist- ance, often with stretching of the vertebrae and bending of the head backwards, in order to raise the thorax and dilate it as much as possible. The respiration is retarded, inspiration being considerably prolonged, while expiration follows relatively easily and promptly. This one circumstance, that the breathing appears retarded in the same manner as in asthma, though, as a matter of course, in the reverse sense, suffices to show that the very common explanation, which refers the prolongation of the breathing in croup and analogous diseases to reflex action of the superior laryngeal nerve, does not answer in every case. As Breuer' has shown, it is by means of the principle of self-regulation of the respiration through the vagus nerve that the different respiratory obstructions are overcome by appropriate changes in the mode of breathing. Expiration, therefore, is strengthened and prolonged in a reflex manner in impeded escape of air from the lungs ; and conversely, a stronger inspiratory activity is called into play in case of insufficient access of air to the lungs. To repeat this in other language, it is simply upon grounds of utility that the respiration is thus retarded. It has been shown for example, that the retardation never affects both phases of breathing in the same manner; but that, in diseases of the larger air-passages associated with stenosis, and therefore, in spasm of the glottis also, inspiration appears considerably lengthened, while but little time is expended in expiration. This great prolongation of the expiratory act is an important characteristic of stenosis of the larger air-passages, just as we have shown it to be of the bron- chial asthmatic seizure. In the one case, therefore, inspiration is considerably prolonged at the expense of expiration, while in 1 Die Selbststeuerung der Athmung durch den N. Vagus. Sitzungsber. der k. k. Akademie der Wissensch. zu Wien, Bd. LVIIL, Abth. II., Nov., 1868. BRONCHIAL ASTHMA. 571 the other the expiration is prolonged at the expense of inspira- tion. It is therefore evident that despite the great slowness of breathing, an admirable compensating medium is furnished by this very disproportion between inspiration and expiration. From what has been stated there could hardly be any special difficulty in distinguishing the great prolongation of inspiration attending the breathing in spasm of the glottis from the analo- gous prolongation of expiration attending the breathing during the paroxysm of bronchial asthma. That this distinction has not always been fully comprehended, is best evinced in the fact that the nature of asthma has been repeatedly believed to reside in a spasm of the glottis; and also in the fact that the opinion has often been expressed that bronchial asthma is always, or very frequently, attended with a spasm of the glottis. Pure bronchial asthma, on the contrary—and with this we are chiefly concerned —is always to be distinguished by the points last mentioned from spasm of the glottis and other analogous affections. Is in all diseases associated with considerable narrowing; of the larger air-passages, so, in spasm of the glottis, the patient cannot introduce the necessary quantity of air into the lungs, or can do so only by means of extremely severe and slow efforts. The air in the lungs therefore becomes more rarefied than under normal conditions, at least in the severer grades of stenosis; and a necessary consequence of this is the inspiratory retraction of a larger or smaller portion of the yielding portions of the thorax. The epigastrium, the lowermost portion of the sternum, and the contiguous cartilaginous ribs are drawn in the most; so that a horizontal furrow is formed there, which disappears again in expiration. At the same time the intercostal spaces become deeper, and the clavicular fossse sink inwards. A further characteristic symptom of spasm of the glottis is tne great increase in the up-and-down movements of the larynx. With this there is a loud, almost hissing, stenotic sound during inspiration, often audible at a great distance ; while expiration follows relatively easily and promptly. It is unnecessary to go any farther into the symptomatic evi- dences of spasm of the glottis. The points mentioned, especially the greatly prolonged inspiration, in direct contradistinction to 572 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. what is observed in bronchial asthma, the relatively easy expi- ration, the participation of all the auxiliary, inspiratory muscles, the inspiratory retraction, and the like, will suffice to prevent the physician from confounding this form of dyspncea with that occasioned by bronchial asthma. In bronchial asthma the fol- lowing points are especially characteristic: the great extent of the full and clear pulmonic resonance on percussion, which at individual localities takes on the character of the so-called band- box tone of Biermer; the great prolongation and strengthening of the expiratory act; the sibilant rhonchi, audible at a great distance, especially during expiration ; the very slight movement of the diaphragm, and the slight, or absent bulging forwards of the epigastrium during inspiration, with increased expansion of the uppermost portion of the thorax, and the like. A further mistake may be made between bronchial asthma and that extremely rare affection, spasm of the diaphragm. The manifestations of the latter affection deviate in numerous direc- tions from those observed in bronchial asthma, as is shown in a passing comparison of the latter with those produced by Du- chenne in artificially excited diaphragmatic spasm, following fara- dization of the phrenic nerve in animals. Diaphragmatic spasm is observed with the greatest relative frequency in hysterical subjects. The symptoms manifested are chiefly as follows: Inspiration is relatively short, and takes place with the assist- ance of all the auxiliary muscles of inspiration; the thorax then remains in this inspiratory position for a few seconds, the inspi- ratory muscles remaining in continuous tension ; and then expi- ration follows rapidly and powerfully. Then begins again a new, forced inspiration, and a retention of the thorax in this inspiratory position for a short time ; then a short, forced expi- ration again, and so on. It is not necessary to go any more closely into the consideration of the further symptoms of clonic spasm of the diaphragm. The symptoms presented will suffice for the recognition of the marked difference between the two sets of manifestations. In like manner it seems hardly possible to confound the dyspnoea occurring in consequence of paralysis of the posterior crico-arytenoid muscles with that observed in attacks of bron- BRONCHIAL ASTHMA. 573 chial asthma. This affection, as I first accurately pointed Out in an article on this subject,1 is characterized by the above-men- tioned signs of inspiratory dyspncea; but the voice of the patient is entirely unchanged, and laryngoscopic examination shows considerable approximation of the vocal cords during respiration, so that only a very small slit remains for the pas- sage of the air. In contradistinction to spasm of the glottis, however, this form of disease is distinguished by the gradual manner in which the manifestations of dyspncea reach their maximum, and by the continuance of the dyspnoea, instead of its being paroxysmal, as in spasm of the glottis. Sufficient data are given in the points mentioned to avoid confounding this form of disease with bronchial asthma. Prognosis.—Terminations. The asthmatic paroxysm itself, no matter how alarming a character the symptoms may assume, is ordinarily without danger. Life is hardly placed in direct danger from the par- oxysm itself. At the same time bronchial asthma encloses a series of dangers, in so far as, by long continuance, it not infre- quently leaves consecutive diseases behind it, which in their severer grades may eventually even endanger life. Emphysema, especially, is one of those affections which must be regarded as a not infrequent consecutive disease of asthma; while, on the other hand, the asthmatic paroxysm not infrequently becomes superadded to emphysema already existing. In such cases, then, a continuous dilatation of the pulmonary vesicles becomes developed out of the acute pulmonary disten- tion, and a loss of elasticity becomes associated with it,—in short, true emphysema, with all its consecutive manifestations, such as secondary hypertrophy and dilatation of the right heart, secondary changes in the kidneys, dropsy, and the like. Why in one case emphysema becomes developed in conse- quence of the frequent recurrence and prolonged duration of the attacks, while in another, notwithstanding the longer duration of the affection and the greater severity of the paroxysms, the 1 Berlin, klin. Wochenschr., 1872, Nos. 20 u. 21, 1873, No. 7. 574 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. patient remains completely well, so that outside of the asthmatic periods his general health exhibits no deviation from the normal standard, is a question hardly to be answered. In other cases chronic bronchial catarrh remains as a conse- quence and residuum of frequent asthmatic attacks. Pure nervous asthma only exceptionally exhausts itself in a few attacks. This is observed with the greatest relative frequency in children, and in the so-called hysterical asthma. In the major- ity of cases asthma is a very obdurate disease, which lasts for years and decades, and frequently defies the effects of all reme- dies. Favorable points are: youth, complete integrity of all the organs and completely free intervals, infrequent recurrence and short duration of the paroxysms. Unfavorable points, on the other hand, are: advanced age, frequent recurrence and great intensity of the paroxysms. These circumstances give occasion, not infrequently, to secondary chronic catarrh, and to pulmon- ary emphysema. It is not infrequently observed that the paroxysms follow each other in a group, after which the patient is free from them for some time, when they are again repeated in a group of seiz- ures. Such forms as these frequently lead to the consecutive manifestations mentioned. The younger the patient, the more readily may complete recovery ensue, and the less readily do consecutive disorders become developed, inasmuch as the organism is better able to equalize the effects of the attacks during the intervals between them; while in older subjects, in whom the forces are already more diminished, the disease is inclined to increase, and to become complicated with organic alterations of structure. Ac- cording to Salter, recovery is rare after the forty-fifth year, as the disease is then continuously disposed to become worse. On the other hand, according to the same author, the disease is always curable in subjects below twenty years of age, in the absence of organic disorders. In general it may be said, as a rule, that the hope of recovery is in inverse proportion to the duration of the disease. If the respiratory and circulatory organs are fully intact, the cure of asthma is possible, and, on the contrary, when it is BRONCHIAL ASTHMA. 5/o linked to a lesion which leads to bronchial spasm as a symptom, the latter is usually only in so far curable as is the former. The prognosis also depends upon the fact whether the excit- ing cause can be discovered and can be removed. Should this be possible, the cure, as a matter of course, presents no diffi- culty. Cases, therefore, which are occasioned by certain odors, by certain dusts, by certain localities, offer a favorable progno- sis in so far as the subject is able to withdraw himself from tliese influences. If, however, the cause is undiscernible, or if, when discovered, it is irremovable, the prognosis is always more or less doubtful. Treatment. In the treatment of asthma two main indications are to be fulfilled: firstly, to shorten the paroxysm, to ameliorate and remove it; and secondly, to prevent its recurrence. We will first describe those remedies which, according to present experi- ence, have proved of most value during the existence of the par- oxysm. During the paroxysm itself, fresh, pure air is necessary above everything else, and this may be most simply secured by opening a window. Articles of clothing, which compress too tightly the abdomen and chest, must be removed at once. It is hardly necessary to give any regulations concerning the position and attitude of the patient during the attack. Patients find out instinctively the position which best facilitates their breathing ; they usually lie by preference with their heads elevated or assume the sitting posture. Of special remedial agents, narcotics especially deserve to be preferred far above all other remedies. In accordance with the previous delineation of asthma as a spasm of the bronchial mus- cles with simultaneous congestion of the bronchial mucous mem- brane, benefit might be anticipated from the administration of narcotics; and practical experience has fully confirmed this view. Only it is necessary to give large doses of narcotic remedies, if we wish the benefit to be prompt and certain. Above all other remedies the preparations of morphia and opium deserve to be employed, and the hypodermic use of morphia is more to be recommended than its internal administration; but, as a matter 576 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. of course, the dose has to be gradually increased the more fre- quently it is employed. Chloral hydrate deserves to be placed in the same rank with preparations of morphia. It may be given in doses of from thirty to forty-five grains or more. In many cases it is of excel- lent service. Thus Biermer1 reports an observation in which the alarming symptoms of the paroxysm were fully banished within a few minutes after the administration of the chloral hydrate. Liebreich also states that chloral hydrate was tried by different observers, on his recommendation, and that all their reports coincide in stating that the asthmatic symptoms disappeared within a few minutes after its administration. Lebert speaks rather more cautiously on this point. I have almost always seen the paroxysm diminish considerably in severity after the use of chloral hydrate, though, for the most part, I have not seen it fully subside at once. This sort of incomplete effect is readily understood, in accordance with the theory advanced that the congestion of the mucous membrane plays an important part outside of the spasm of the bronchial muscles. I must mention nitrite of amyl as a remedy newly intro- duced into practice. Experience with this remedy is still too scanty to permit recognition of the exact indications for its employment. Very favorable results from its use in asthma have been reported by individual observers. Thus Pick 2 reports an observation of his own in which great, though very tempo- rary, amelioration followed the administration of this remedy on every occasion. The case was that of a physician who had suffered from asthmatic troubles since his earliest youth, the disease having gradually increased in the course of time, and having resisted the collective series of remedies recommended in asthma. Expectorants and narcotics only were competent to afford some relief. Great relief ensued from inhalation of nitrite of amyl, as long as the inhalation lasted, and for some little time after. The breathing was then very deep, and accom- plished exceedingly well. The benefit was only temporary, but 1 L. c, p. 39. 2 Das Amylnitrit und seine therapeutische Anwendung. Inaug.-Dissert. 1874, Bonn. BRONCHIAL ASTHMA. 577 at the same time so certain that the patient always resorted to it every time he was attacked. Pick relates, in addition, two other cases of asthma, not observed by himself, in which the attack was always subdued at once by the nitrite of amyl, and in which the intervals became lengthened; but complete recovery was not attained, so that the nitrite of amyl had but a palliative influence. I have had frequent opportunity to test this remedy in asthma. In all the cases there was a slight decrease of the dyspncea, slower and deeper breahting, and some subjective relief after the inhalation of a few drops of the nitrite of amyl; but in no instance was there a complete disappearance of the paroxysm. The preparations of belladonna and cannabis Indica have long played an important role in the treatment of the asthmatic paroxysm. In like manner, subcutaneous injections of atropia have been found of assistance in asthmatic attacks (Courty and Hirtz). So also inhalations of chloroform and of sulphuric ether have been repeatedly employed with good results. Bromide of potassium, too, in large doses, is sometimes competent to relieve the paroxysm to a great extent. It is less to be recommended for the purpose of cutting a paroxysm short, than to diminish the frequency and intensity of the attacks by its prolonged administration. The old method of ordering draughts of strong Mocha, and the administration of ice pellets or small portions of frozen fruit, as especially recommended by Romberg, belong to> dietetic rather than to actual medicinal treatment. Inhalations of oil of turpentine, with or without admixture of narcotics, have been recommended by Waldenburg in mild asthmatic attacks, especially in emphysematous subjects. It may be remarked, in this connection, that inhalations can be employed only in mild asthmatic attacks; for a long-continued inhalation is impossible with very severe dyspnoea. Besides the remedies already mentioned, there are a great num- ber of others which have been repeatedly recommended by this or that observer, and have proved serviceable in individual cases. We confine ourselves, her to recording the most important VOL. IV.—37 578 RIEGEL.—DISEASES OF TRACHEA AND BRONCni. of them, but must, with Trousseau, premise the remark that, like all neuroses, asthma will often be relieved by remedies of extremely different nature, according to the individuality of tl;_ case. Experiment only will reveal the proper one. An enumeration of all the remedies with which patients often help themselves is hardly possible. Thus, just to quote an example, Trousseau relates a case in which an asthmatic sub- ject, as often as he was attacked with asthma, lighted five or six Carcel lamps in his room, and was immediately relieved thereby. A second patient, whose attacks occurred in the day- time, jumped upon his horse and could not obtain relief until he rode incontinently at a sharp trot against the wind. The inhalations of certain fumes and the smoking of narcotic or indifferent substances, have had very extensive employment; of these remedies stramonium has become most widely resorted to. In the East Indies, as related by Trousseau, smoking the leaves of the indigenous datura metel was a popular remedy. Sims, who first experimented with this remedy in Germany, endeavored to replace it with stramonium. The attempt suc- ceeded, and thus stramonium gradually became introduced as a general remedy in .asthma. Trousseau says of it, that of all remedies employed in the asthmatic paroxysm, it is ordinarily of the most service. The dried leaves are either smoked or burned in the apartment of the patient. It also frequently happens that the paroxysm may be cut short by tobacco- smoking, provided the patient is not too much accustomed to tobacco. Espic's cigarettes have long stood in special favor in the treatment of asthma ; and in their composition nearly all the poisonous solanacese—datura, tobacco, hyoscyamus, belladonna, and the like—are used. The formula for tliese cigarettes is, according to Trousseau, as follows : Belladonna leaves...................... 5^ grains. Hyoscyamus leaves..................... 2f " Stramonium leaves..................... 2f " Leaves of Phellandrium aquaticum..... 1 " Extract of opium....................... ■£• " Cherry-laurel water..................... q. s. BRONCHIAL ASTHMA. 579 The well-dried leaves, stripped of their stems, are cut small and intimately mixed. The opium is dissolved in the cherry- laurel water, and the mass is moistened with the solution. In addition to this, the paper used for making the cigarettes is previously washed in a maceration of the plants mentioned in cherry-laurel water, and then carefully dried. The patient smokes one or two of tliese cigarettes during the paroxysm. When the patient cannot smoke, the stramonium leaves may be burned in his apartment. Much depends, however, upon the individual. While the stramonium helps some at once, there are others who do not obtain the slightest benefit from it. It is especially inefficacious in tobacco-smokers ; yet, on the other hand, there are some patients who, because they do not use it habitually, are able to suspend their paroxysms by smoking tobacco (Trousseau). Thus Trousseau, who suffered from asthma himself, mentions that it often sufficed for him to take a few whiffs from a cigar, to free himself from his asthmatic trouble. The fumes of arsenic or of saltpetre paper have been recom- mended by many. To use the arsenic, a solution is made of fifteen grains of arsenite of potassa in half an ounce of distilled water. A sheet of unsized paper is saturated in this solution, and then thoroughly dried and divided into twenty equal parts. Each piece is then rolled into the form of a cigarette. The patient, after lighting one, lets the smoke penetrate into the bronchi by means of a slow inspiration. Not more than eight or ten inspirations should be taken, and tliese but once a day. The saltpetre paper is prepared in a similar manner. A piece of unsized paper is soaked in a half-saturated solution of saltpetre ; it is then divided into a certain number of small pieces, which are rolled into cigarettes. If the patient cannot smoke, the paper is rolled into a ball, which is then lighted, and covered with a funnel, or simply with a cone of pap^r, through the narrow end of which the smoke passes into the mouth of the patient, and is then inhaled. Besides the remedies last mentioned, the application of am- monia to the posterior portion of the pharynx, first recom- mended by Ducros, has played a great part in the treatment of the asthmatic paroxysm, especially in France. Rayer and 580 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. Trousseau have seen good results from the use of this remedy in individual cases. In others, on the other hand, Trousseau saw fearful paroxysms set in at the moment of the application, on which account he took the precaution of commencing by letting the patient inhale ammonia from a phial containing it held under the nose, and then touched the pharynx with a weak solution, the strength of which was then gradually increased. The asthmatic patient may also be surrounded by an ammonia atmosphere, by letting liquid ammonia evaporate from dishes in the apartment. The advice of Trousseau is good, to close the patient's nostrils with a little cotton-wool, so as to render the odor of the ammonia more bearable. In accord with these therapeutic results is the fact that many asthmatics find themselves much better in places where ammonia is developed. Thus Trousseau relates the example of a sea-captain who had no trace of his malady as long as he was aboard his guano-laden vessel, or as long as he remained on the island where this material is obtained. Finally, emetics have been extolled by some authors as effi- cacious in aborting the asthmatic attack. Lebert recommends the use of an emetic of ipecacuanha, especially in severe, ob- stinate, and protracted cases. Seitz also praises emetics in such cases, but especially recommends the administration of nauseating doses of tartar emetic or ipecacuanha instead of doses sufficient to produce vomiting. The otherwise so effica- cious muriate of apomorphia is not so well adapted to these cases, as it is a nauseant influence that is required rather than emesis. At all events, however, the use of emetics does not seem to be indicated, except in cases in which the majority of the remedies enumerated, especially the most valuable ones, have proven to be useless. Inhalations of oxygen have been repeatedly recommended in asthma. Whether strychnia, from which Storck observed temporary benefit in a few cases, is of important service, further trials must decide. With reference to the coexisting congestion of the bronchial mucous membrane, ergotine deserves trial, espe- cially by hypodermic injection. Rarefaction of the air during expiration also deserves to be BRONCHIAL ASTHMA. 581 tried; but this method is not practicable in severe cases of dyspncea. I have not seen any striking results from this treat- ment, as far as regards cutting the paroxysm short. We must refrain from enumerating further remedies which have been occasionally found serviceable in this or that case. As already mentioned in our introduction, the remark applies here that no general rule can be presented applicable to every case. In the second place, the treatment to be carried out between the paroxysms comes under consideration. In other words, there is an indication to prevent the recurrence of the paroxysm. To this end, it is of especial importance to avoid or remove, when possible, those sources of injury which the patient knows to have produced previous attacks, or which have favored their occurrence. Thus, to give an example, the attack, in some patients, has a certain relation to darkness. Such patients, therefore, must burn a light during the night. As a rule, the patient is himself mindful of these particulars. In many cases the asthma is occasioned by pregnancy, and then disappears spontaneously after the subsequent confinement. In other cases, as observed especially by Voltolini,1 and more recently by Haenisch,8 the asthma is associated with nasal and naso-pharyngeal polyps. Here, as a matter of course, the first indication is to remove them. Voltolini and Haenisch report observations of this kind, in which the asthmatic attacks disap- peared with the removal of the polyps, and recurred with their fresh reappearance ; so that a direct relation between the polyps and the occurrence of the asthmatic attacks was established beyond a doubt. Among the medicaments which are calculated to prevent the recurrence of the paroxysms, and thus to cure the asthma com- pletely, arsenic deserves the most prominent mention. It is most frequently employed in the form of Fowler's solution (three or four drops three times a day). Lebert recommends, in obstinate cases, a combination of quinine with arsenic and atropia, as in 1 Die Anwendung der Galvanokaustik im Innern des Kehlkopfs und Schlundkopfs, u. s. w., 2 Aufl., 1872, p. 246 et seq. 8 Berliner klin. Wochenschrift, 1874, No. 40. 582 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. the following formula : muriate of quinia, sixty grains ; arseni- ous acid, one grain ; atropine, half a grain ; extract of gentian, sixty grains ; mix, and make into sixty pills. At first one pill is given daily; after a few days, two daily; and the quantity is gradually increased to four pills in the twenty-four hours, or even to two pills three times a day. In that form of asthma, especially, described as occurring in a certain, though not well explained interchange with cutaneous eruptions—the form designated as herpetic asthma by Walden- burg—arsenic has been repeatedly found serviceable. Fowler's solution has also been repeatedly employed by inhalation, with very good results (Eck, Wistinghausen, Waldenburg). In like manner, its employment by subcutaneous injection is to be rec- ommended. lincture of lobelia must be mentioned as a remedy formerly much praised, though less employed at the present day. It is given in doses of from ten to thirty drops, and as often as three times a day. Lebert has seen good results from its use in sev- eral cases ; but he reports, in addition, that not only is its effect temporary, but that it loses its efficacy with time; so that it eventually becomes wholly useless, even with variation in the dose and mode of administration. Trousseau recommends the following complex method of treatment, continued for a long time : 1st. For ten successive days in the month, the patient is to take at bedtime, at first one, after three days two, and the last four days four pills, each containing one-sixth of a grain of extract of belladonna and the same quantity of powdered bella- donna root; or else one, two, and finally four granules of atro- pine, each containing one sixty-fourth of a grain. 2d. The ten following days the belladonna preparation is to be superseded by syrup of turpentine (a tablespoonful three times a day), or better, by three capsules of oil of turpentine. 3d. During the last ten days of the month the patient is to smoke arsenical cigarettes. Finally, in addition, every tenth day the patient is to take in the morning, on an empty stomach, sixty grains of powdered calisaya bark in black coffee. BRONCHIAL ASTHMA. 583 Trousseau claims to have seen great benefit from this method of treatment in a certain number of cases. Waldenburg recommends, in the asthma of emphysematous subjects, the smoking of saltpetre and inhalations of oil of tur- pentine every evening; and he has observed freedom from par- oxysm for many months follow the treatment; although com- plete recovery has ensued only in the rarest instances. Quinine has been found to be serviceable in man}7 cases (from one and a half to three grains twice a day). The shorter, and especially the more uniform the intervals which elapse between the paroxysms, the more can something be expected from qui nine (Seitz). Besides the remedies cited, some metallic nervines deserve mention, especially oxide of zinc, nitrate of silver, and pills of carbonate of iron. Bromide of potassium, too, is worth trial in many cases. On the other hand, hardly any special benefit is to be anticipated from castor, camphor, assafoetida, tincture of valerian, and similar remedies likewise recommended by indivi- dual authors. Sublimed sulphur has been recommended by Duclos as a "therapeutic agent of infinite efficacy" against the recurrence of asthmatic paroxysms. Sulphur baths have been praised by Courtin, Lebert, and others. Finally, we have to mention the secret remedy of Aubree as one of the most noted remedies. The formula for this remedy is, according to Trousseau, as follows : Seneka root............................ 30 grains. Make a decoction with 4 fluid ounces of water ; then add— Iodide of potassium..............231 grains. Syrup of opium *................. 4 fluid ounces. Brandy......................... 2 fluid ounces. Tincture of cochineal............. enough to color. Filter. 1 Extract of opium, 1 part: dissolve in a small quantity of genuine white wine, and mix with simple syrup, 1,000 parts.—German Ph. 584 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. The patient is to take three tablespoonfuls of this elixir daily until the asthma has entirely disappeared. According to Roth,1 who likewise reports good results from the use of Aubree's mixture, its actual composition is as follows: Lactucarium..................... 9 grains. Iodide of potassium............... 77 grains. Spirit of chloric ether2............ 18 minims. Water........................... 5 fluid ounces. Syrup........................... 1 fluid ounce. One-sixth part at a dose. Similar good results have been reported by several other authors who have experimented with Aubree's secret remedy. Others again have found no benefit follow even a prolonged use of it. The good effects of this remedy seem to reside solely in the iodide of potassium which has long been recommended in asthma. Even at the present day iodide of potassium is recom- mended by many physicians, and frequently resorted to. My own experience is not much in favor of its great efficacy. Finally, the treatment suggested by Le}7den is worthy of men- tion, though further experience has not yet been reported. As previously stated, we are indebted to Leyden for evidence of the existence of peculiar crystals in the sputa of asthmatic sub- jects, which he believes to have a certain relation with the occurrence of the paroxysms. The idea of dissolving these crystals by substances administered by inhalation naturally sug- gested itself. Leyden, on account of their ready solubility in alkalies, tried inhalations of table salt and carbonate of soda, of each one part in the hundred, twice daily. These inhalations appeared to be of service. That the constitution of the patient must be taken into care- ful consideration in the treatment of asthma, is self-evident. Thus, for example, the preparations of iron, residence in the country, and the like, are to be ordered for chlorotic girls and 1 Deutsches Archiv f. klin. Med., Bd. VII., p. 453. 2 An officinal of the German Pharmacopoeia, obtained by distilling a mixture of 6 parts of crude hydrochloric acid and 24 parts of alcohol from black oxide of manganese. The distillate is neutralized by slaked lime and redistilled. BRONCHIAL ASTHMA. 585 ansemic patients. If there be chronic bronchial catarrh, the remedies employed for this affection, especially the expecto- rants, the alkaline mineral waters, and the like, are to be resorted to. The employment of rarefied air in expiration, and condensed air in inspiration, has proved an especially effective remedy, par- ticularly in cases associated with chronic bronchial catarrh or emphysema. Not long ago it was usually necessary to send patients to some remote locality, inasmuch as the so-called pneu- matic cabinets were to be found in but few places. Recently the employment of compressed and rarefied air has been greatly facilitated by the construction of portable pneumatic apparatus, as first devised by Hauke.' The favorable action of this remedy in catarrhs and emphysema complicated with asthma is easily comprehended. In contrast to the pneumatic cabinets in which the entire body of the patient is placed, so that he not only inspires com- pressed air, but must perform the expiratory act in it also, and in which, furthermore, the compressed air not only acts upon the interior surface of the lungs, but at the same time upon the exterior of the chest also, as well as upon the entire exterior surface of the body, we are enabled by means of portable pneu- matic apparatus, to allow the increased pressure to act upon the interior surface of the lung only. It is to be especially recommended, on principles readily com- prehended, to permit such patients—emphysematous subjects particularly—to breathe into rarefied air, and this is quite feasi- ble with the apparatus last mentioned, especially that devised by Waldenburg, which has become widely known, inasmuch as inspiration of condensed air and expiration into rarefied air may be performed alternately. Where, therefore, the bronchial asthma is in intimate associa- tion with emphysema and chronic catarrh, but also without this association, in pure idiopathic asthma, the method of employing compressed and rarefied air is much to be recommended, as at least a portion of the difficulty can be removed, and the asthma 1 Ein Apparat zur kiinstlichen Respiration und dessen Anwendung zu Heilzwecken. Wien, 1870. 586 RIEGEL.—DISEASES OF TRACHEA AND BRONCHI. be thus far relieved. In several cases of idiopathic asthma I have seen the paroxysm markedly diminished in severity and frequency under the long-continued exclusive use of rarefied air in expiration. In cases in which the procedures mentioned are incapable of curing or relieving the malady, nothing else remains but to try a change of residence. In making a choice the adviser must be guided by the personal experience of the patient. There is no absolute rule in this respect. The same locality which pre- vents the paroxysm in one patient, may not have the slightest influence in the case of another. DISEASES OF THE PLEURA. PRAENTZEL. DISEASES OF THE PLEUKA. PLEURITIS. BIBLIOGRAPHY. Hippocrates, Editio Ermerins, II., De morbis, Lib. IL, p. 215, etc.—Galenus, De loc. affect., Lib. V., cap. 3 and 8.—Celsus, De medicina, Lib. IV., cap. Q.—Caelius Aurelianus, Acut. morb. I., Lib. n., cap. 16, p. 130, etc.—Sydenham, Opera omnia medica. Genevse, 1749, II., p. 163.— Herm. Boerhave, Institutiones medic, et Aphorismi. Norimb., 1756.—van Swieten, Commentaria in H. Boer- have Aphor. Lugduni Batavorum, 1745, IL, p. 710, etc.—Holler, Biblioth. medic. Bernae, 1777, IL, p. 46, etc.—Avenbrugger, Inventum novum ex per- cussione thoracis hum. ut signo abstrusos interni pectoris morbos detegendi. Vind., 1764.—Morgagni, De sedibus et causis morb. II., De morb. thorac. epist. XX. and XXI.—De Haen, Ratio medendi, p. IX., cap. 4.—Pinel, Nosographie philosophique, II., p. 404. Paris, 1818.—Laennec, Traite" de 1'auscultation mediate, 3. 6dit. Paris, 1831, n., p. 282, etc.—Raynaud, Journ. hebdom., A. V., p. 563.— Andral, Clinique medic, 2. edit. Paris, 1829, T. I. and IL— Gendrin, Histoire anatomique des inflammations. Paris et Montpellier, 1826. — W. Collin, De diverses mfithodes d'exploration de la poitrine. Paris, 1824. —Piorry, De la percussion mediate et des signes obtenus a" l'aide de ce nouveau moyen d'exploration dans les maladies des organs thoraciques et abdominaux. Paris, 1828.—Chomel, Dictionnaire de medecine, T. XVH—Cruveilhier, Diet. de medec. et de chirur., T. IH. Paris, 1835.—Townsend, A Tabular View of the Principal Signs furnished by Auscultation and Percussion. Dublin, 1832. — W. Stokes, A Treatise on the Diagnosis and Treatment of Diseases of the Chest. Dublin, 1839.— C. J. B. Williams, The Pathology and Diseases of the Chest, 4th edition. London, 1840.— Woilliez, Recherches pratiques sur Inspec- tion et la mensuration de la poitrine. Paris, 1838.—Skoda, Abhandlungen iiber Auskultation und Perkussion, 1839, 6. Aufl., 1864.—B. Mohr, Beitrage zu einer kiinftigen Monographic des Empyems. Kissingen, 1839.—C. H. W. Posselt, De pleurae ossificatione. Heidelberg, 1839.—Hasse, Pathologische Anatomie. Leipzig, 1841.—Damoiscau, Le Diagnostic de la Pleurgsie, Arch. g€ner., Octo- bre, 1843.—A. Krause, Das Empyem und seine Heilung. Danzig, 1843.— Rokitansky, Handb. d. pathol. Anatomie, II. Wien, 1844. — Schuh-Skoda, 590 FKAEXTZEL.—DISEASES OF THE PLEURA. Ueber die Entleerung pleuritischer Exsudate, Oesterr. Jahrbb., 1841-1843.— Trousseau, Punction dans les epanchements pleuritiques, Journ. de med., Nov. 1843, and Bull, de l'Acad. de med., 15. Avril, 1846. Ditto, Clinique mgdicale, 4. edit. Paris, 1872.—MacDonnell, On the Diagnosis of Empyema Necessitatis, Dubl. Journ. of Med. Science, March, 1844.—Riecke, Beitrage zur Heilung des Empyems, Journ. f. Chirurgie und Augenheilkunde, 1846.—Bowditch, The Treatment of Pleuritic Effusions, American Journal of Medical Sciences, April, 1852.—Meyer, Neubildung von Blutgefassen in plastischen Exsudaten seroser Haute, Annal. d. Berl. Charite, L, 1853.—von Gutzeit, Die Pleuritis. Hamburg, 1853.— Virchow, Thrombose und Embolie, Gesammelte Abhand- lungen. Berlin, 1862, p. 219, etc. — M. A. Wintrich, Krankheiten der Respirationsorgane. Erlangen, 1854.—Marrotte, On the Operative Treatment of Pleuritic Effusions, Arch, gengr., 1854, February and April.—Sedillot, Thoracentesis by Perforation of a Rib, Gaz. des h6pit., 1855, No. 66.— Traube, Ueber den Zusammenhang von Herz- und Nierenkrankheiten. Berlin, 1856.—Ditto, Gesammelte Beitrage zur Pathologie und Therapie, 1871, II., 1 and 2. (The papers on pleuritis collected here have been partly published in other journals during the last fifty years.)—F. Hoppe, Ueber serose Transsudate, Virch. Archiv, IX., p. 245 etc.—Laudouzy, Sur le Diagnostic de la Pleuresie, Arch, gengr., 1856, Nov. and Dec.— Woillez, Method of Measuring the Thorax, Arch, ggner., May, 1857.—H. Althaus, De thoracis sono percussorio nonnulla. Inaug.-Dissert. Berlin, 1857.—H. Ziemssen, Pleuritis und Pneumonie im Kin- desalter. Berlin, 1862.— Weber, Ueber die Entleerung pleuritischer Exsudate, Verhandl. der Naturforscherversammlung in Giessen, 1864.—Roser, Zur Opera- tion des Empyems, Arch. f. Heilkunde, 1865.—Bowditch, Thoracentesis in Pleuritic Effusions, American Journal of Medical Sciences, Jan., 1863.—Traube, Ueber einige Verhaltnisse in Betreff der Punctio thoracis, Verhandl. d. Berl. med. Gesellschaft, 1866.—Ditto, Symptome der Krankheiten des Respirations- und Circulationsapparates. Berlin, 1867.—Biermer, Krankheiten der Bron- chien und des Lungenparenchyms, Virchow's Handb. d. spec. Pathologie u. Therapie, Vol. V. Erlangen, 1867.—Moutard-Martin, Lecons sur la thoracen- tese, 1867, Gaz. des hopit., 46 and 48.—A. Kussmaul, Sechszehn Beobachtun- gen von Thoracocentese bei Pleuritis, Empyem und Pyopneumothorax, Arch. f. klin. Med., IV., pp. 1-33 and 173-203.—Bartels, Ueber die operative Behand- lung der entziindlichen Exsudate in Pleurasack, Arch. f. klin. Med., IV., pp. 263-303.—H. Nothnagel, Zur Lehre vom Husten, Virchow's Archiv, XLIV., p. 95, etc.—Gintrac, Des indications de la thoracentese, Journ. de med. de Bordeaux, Mars, 1868.—Blachez, Du traitement des epanchements pleuraux par la thoracentese capillaire, Union medic, 1868, pp. 130-132.—M. Peter, De la pleure'sie; Valeur diagnostique, pronostic et thfirapeutique des courbes de Damoiseau, Gaz. des hop., 1869, No. 4.— Vogel, Aus der medicin. Klinik des Prof. Kussmaul; Ueber eine neue Mithode zur Entleerung des Eiters nach der Thoracentese, Berl. klin. Wochenschr., 1869, 46 and 47.—Fr. Hoffmann, Ueber Empyem und iiber fremde Korper in den Luftwegcn, Berl. klin. Wochenschr., BIBLIOGRAPHY. 591 1869, p. 526.— M. Huss, Ueber den anderseitigen pleuritischen Schmerz, Deutsch. Arch. f. klin. Medic, IX., p. 242.— Dupre, De la ponction dans les epanche- ments pleuraux, Bull, de l'Academie de mgd., XXXIV., 1869.—Toft, Entlee- rung des serosen entzundlichen Exsudates der Pleura, Hospitals Tidende, 1869, pp. 65, 69, 73, 77.—Dieulafoy, Le diagnostic et le traitement des epanchements de la plevre, Lyon, med., 1870, 12. (Read Nov. 2, 1869, in the Paris Acad, de medec.;—Feltz, D'un mode de mort subite dans les maladies de poitrine, 1870, Gaz. des hopit., Juin.—Glauert, Aus der klinik des Prof. Niemeyer, Schnelle Heilung eines pleuritischen Exsudats durch Beschrankung der Zufuhr von Wasser und flussiger Nahrung, Berl. klin. Wochenschrift, 1870, Q.—Boinet, Le traitement de l'empyineme, Gaz. des hopit., 1870, 95.—Rasmussen, Den seroese Plevritis operative Behandlung, Hosp. Tid., 13. and 14. Aarg.—Bowditch, Tho- racentesis and its General Results, during Twenty Years of Professional Life. New York, 1S70.—Traube, Ueber eigenthumliche systolische Elevationen an der kranken Brusthiilfte; Ueber einen natiirlichen Heiluugsvorgang beim eitrigen pleuritischen Exsudat, Verhandl. der Berlin, med. Gesellsch., 1871.— Quincke, Zur Behandlung der Pleuritis, Eodem loco u. Berl. klin. Wochenschr., 1871.— Traube, Ein Fall von chronischem Bronchialkatarrh und Volumensver- grosserung der Lungen mit Bemerkungen iiber Cyanose, Bronchialkatarrh, Bronchiektasie, etc., Berl. klin. Wochenschr., 1871.—Bardeleben, Lehrbuch der Chirurgie, 1872, Vol. III.— Walshe, A Practical Treatise on Diseases of the Lungs, 4th edit London, 1871.—Pimser, Ueber die Durstkur bei pleuritischen Exsudaten, Allg. milit. Zeitung, 1871, 37-48.—John Mayne, The Pneumatic Aspirator, Dubl. Quart. Journ., May, 1871.— Toft, Bidrag til kundskab oin Empyem., Nord. med. Arkiv, Vol. III.—Dieulafoy, Du diagnostic et du traite- ment des epanchements aigus et chroniques de la plevre par aspiration, Bull. gener. de ther., 30. Juin, 1872.—Moutard-Martin, La pleuresie purulente et son traitement. Paris, 1872.—Castiaux, Appareil pour l'operation de la thoracen- tese, Bull, de l'Acad. de med., 1872, 12.-r-Lereboullet, Pleuresie et thoracentese, Montpellier medic, Fevr., Mars, Avril, 1872.—Chassaignac, Sur l'empyeme purulent trait, par le drainage chirurgicale. Bull, de l'Acad., 1872, 12.— Loomis, Lessons in Physical Diagnosis. New York, 1872.—Andrews, Anti- septic Injections and Drainage Tubes in Empyema, Chicago Medical Examiner, Dec. 15, 187-2.—Potain, De l'utilite des trocarts capillaircs dans la thoracentese, Gaz. des hopit, 1872, 91 and 92.—Lichtheim, Ueber die operative Behandlung pleuritischer Exsudate, Volkmann's Sammlung klinischer Vortriige, No. 43 — Dieulafoy, Traite de Inspiration des liquides morbides. Paris, 1873.—Michd Peter, Lecons de clinique medicale, I. Paris, 1873.—Tirillon, De l'expectora- tion albumineuse apres la thoracentese. Paris, 1873.—Marotte, On Perforation of the Lung as a Complication of Thoracentesis, Bull, de l'Acad., 1873,1., 15.— Castiaux, Documents pour servir a" l'etude de la methode aspiratrice. These de Paris. 1873.—Lebert, Ueber die operative Behandlung der Brustfellentzundung, Berl. klin. Wochenschr., 1873, 46, etc.—Leak, Thoracentesis, Medical Record, May 1, ls::l—The same, Plastic Exudation within the Pleura; Dry Pleurisy, 592 FRAENTZEL.—DISEASES OF THE PLEURA. Archives of Scientific and Practical Medicine, March, 1873.—Kohts, Experi- mentelle Untersuchungen xib. d. Husten, Virchow's Arch., LX., p. 191, etc.— Tutschek, Die Thoracentese mittelst Hohlnadelstichs. Miinchen, 1874.—Fraent- zel, Ein neuer Troicart zur Entleerung pleuritischer Exsudate, Berl. klin. Wochenschr., 1874, 12.—Ditto, Ueber die Behandlung pleurit. Exsudate, Deutsch. milit. Zeitschr., 1874, Nos. 5 and 6.—Niemeyer-Seitz, Lehrbuch der speciellen Pathol, u. Therapie, IX. Auflage, 1874, I., 1.— Corson, General Treat- ment of Pleurisy, Medical Record, Dec 1, 1874.—Janeway, Vocal Fremitus in Pleurisy and Pneumonia, and the Use of the Hypodermic Syringe in their Diagnosis, Medical Record, June 5, 1875.—Isham, Penetrating Incised Wound of Thorax and Liver; Large Abscess of Liver Opening into Right Pleura; Evacuation by Operation through Intercostal Spaces; Recovery, American Journal of Med. Sciences, July, 1875.—Da Costa, Respiratory Percussion, American Journal of Med. Sciences, July, 1875. Occasional communications in Canstatt's or Schmidt's Jahresberichten are to be referred to, as well as the short treatises which have been so numerous in recent years, especially those of French authors, which propose slight modifications in the method of performing operations now in use. History. Inflammations of the pleura, whether of the plenra costalis or of the pleura pulmonalis, we are in the habit of calling pleurisy, or generally nowadays pleuritis. The term pleuritis dates from a period anterior to that of Hippocrates. By it was meant a feverish affection of the respiratory organs, accompanied with "a stitch in the side," without its being quite clear what was the precise seat of the disease, or to which organ it was limited. Diodes, Erasistratus, Asclepiades, and others localized the disease in the pleura alone; whereas Euriphon, Evenor, Praxagoras, Philotimus, Herophilus, and their disciples * looked upon the lungs as the part affected, while they regarded the plenra costalis and the intercostal muscles as the seat of the pain. Already in the Hippocratic writings, pleuritis is distinguished from peripneumonia, and is divided, according to its seat, its causes, and its symptoms, into pleuritis ascendens, descendens, posterior, anterior, sanguinea, biliosa, pituitosa, melancholica, and finally into pleuritis sicca and humida. Galen also speaks 1 Vide Cselius Aurelianus, L c. PLEURITIS.—ETIOLOGY. 593 of pleuritis in contradistinction to pneumonia and peripneumo- nia. Yet writers of later date have always taken a more or less wavering position as to the seat of pleuritis, and accordingly Sydenham, Boerhaave, van Swieten, Haller, Morgagni, de Haen, and others have always in their writings returned to this ques- tion, and of tliese Haller and Morgagni still defended the view that in pleuritis the lungs are always affected as well as the pleura. Pinel was the first to place pleuritis definitely amongst the inflammations of serous membranes, and since then it has been regarded nosographically as an independent disease. Its anatomical and pathological relations, as well as its diag- nostic signs, were first made known to us more accurately by Laennec, and it is on the foundation of his systematic observa- tions that the pathology of pleurisy has attained greater and greater development. Many of his views have since been proved to be erroneous, many have been greatly extended, many new facts have been recently investigated ; but we must still acknowl- edge, as well to-day as fifty years ago, that the foundation of our present pathology and treatment of pleuritis was laid by Laennec. It has, however, been reserved for the last ten years to mark an epoch in the treatment of pleurisy by chronic- ling advances which can scarcely be claimed for any other malady. In this particular direction we may look with justifiable pride on the results which our improved methods of treatment have enabled us to place on record, and may point to recoveries from severe illnesses which, according to former notions, were to a great extent incurable. Etiology. Pleuritis may either occur as an independent primary disease in persons previously healthy, or it may arise in the course of other maladies, and then, most frequently, as secondary to other affections of the respiratory organs. We are often unable to point to the cause of an attack of primary pleurisy, though we frequently find that it has arisen from direct exposure to cold. VOL. IV.—38 594 FRAENTZEL.—DISEASES OF TIIE PLEURA. In contradiction to the view widely spread in hand-books, and held by many private practitioners, that it is only theoret- ically, and not from practical observation, that cold can be asserted to be a cause of primary pleurisy, I can positively main- tain that a very careful examination of my own experience would enable me to bring forward many proofs in favor of this view. For example, even imperfectly educated hospital patients have frequently assured me, in the most decided manner, that they had, when heated, undressed and exposed themselves to draughts on that side which subsequently became affected; or that, having been wetted through by a cold shower of rain, the side attacked was that which had been exposed to the wind ; and I could mention many other cases like these. It is constantly stated that sitting at an open window, or near a badly closing door, especially when the room has been warm and the outer air very cold, caused the illness; that in this way pain immedi- ately arose in the affected side, and increased gradually until the attack became fully developed. Persons recovering from severe illnesses, and individuals who are under the influence of active medicinal agents, are most prone to succumb to such causes of disease. Men, for example, who are going through a course of mercury or iodine, readily become the subjects of pleuritis from very slight exposure to cold. Frequently, how- ever, we fail to find any tangible causal condition to which we can refer the origin of the illness. When pleurisy arises in consequence of an injury to the chest, as from severe contusions and such like, without any exter- nal wound or evidence of fracture of the ribs, it is usual to call this a primary traumatic pleuritis; if, however, there should be, at the same time, great laceration of the soft parts, or a frac- ture of one or more ribs, or when, in consequence of the injury, blood or pus or any foreign body has found its way into the pleural cavity, the inflammation thus excited is termed second- ary traumatic pleuritis. Cases of the latter kind are usually complicated by the entrance of air into the pleural cavity. Thus traumatic pleurisies form, in a manner, the transition between the primary and secondary affections. The last are PLEURITIS.—ETIOLOGY. 595 incomparably more frequent than the first, since the greater number of affections of the lung-tissue lead secondarily to changes in the pleura ; either the inflammator}^ process extend- ing directly from the lung to the pleura pulmonalis, or, from their close adjacency, the lung and the pleura becoming attacked simultaneously. Thus we always find fibroid pneumonia associated with pleu- risy as pleuro-pneumonia, even when the inflammation of the lung-tissue itself does not reach the pleura pulmonalis. Indeed in such cases the pneumonia is frequently the subordinate affec- tion, while the pleuritis assumes a dangerous character. These are the cases of pneumo-pleuritis, or peri-pneumonia, concerning which a number of important and valuable observations have already been recorded in the Hippocratic writings; and the pathological relations of which it has been the merit of modern times, and especially that of Traube, to estimate accurately. Caseous pneumonia goes really hand in hand with inflammation of the pleura. This is sometimes quite circumscribed, and leads to adhesion of the pleural layers at the affected spot; some- times it is diffused over a great part of the pleura, and it is then not infrequently associated with a considerable outpouring of different kinds of effusions. Catarrhal pneumonia rarely occurs without secondary pleuritis. Even feverish bronchial catarrhs, especially when they are accompanied by violent and protracted fits of coughing, lead frequently to a similar complication. The same may be said of hemorrhagic infarctions, as these generally reach as far as the pleura pulmonalis, and of gangrene of the lung, especially when it appears as the consequence of numer- ous infective emboli, collected in different small groups. For these also are spread in wedge-like masses, regularly, as far as the surface of the lung, and there they excite a pleuritis which commonly leads to extensive purulent exudation; or the gan- grenous mass may perforate the pleural cavity and give rise to a pyopneumothorax. These inflammations of the pleura, which are of especially frequent occurrence in cases of so-called pyae- mia, are regarded by many physicians of the present day as linked together as a general blood disease. It would lead us too far if we were to attempt to examine in 596 FRAENTZEL.—DISEASES OF TIIE PLEURA. detail all the possible conditions under which a secondary pleu- ritis may arise as a consequence of inflammatory affections of the respiratory organs. One remark must, however, be made, viz., that a circumscribed inflammation of the pleura may itself lead to secondary pleuritis, as, for instance, when from the part originally affected the disease spreads wider and wider around it; or when a limited inflammation of the upper part of the pleura is attended with liquid exudation, and this collecting in the lower part of the pleural sac, acts there as an exciter of inflammation. Small purulent or sanious effusions are especially prone to spread the inflammation in this way. The same result follows when, from any cause whatever, the pleura becomes per- forated at one spot, and air is thus admitted into the pleural cavity; when, in short, a pneumothorax has been produced, then either the contents of the bronchial tubes, or a necrosed portion of pleura, or a particle of gangrenous lung-tissue, or, finally, the air itself, if it contains infective germs,—either of these, by entering the pleural cavity, may excite inflammation there. We must also clearly understand that pleuritis may be produced by an extension of disease from any of the organs adjacent to the pleura costalis ; and, conversely, pleuritis itself may induce inflammation of neighboring tissues and organs, so that in many cases it may be difficult to decide which form of disease is secondary and which primary. Thus pleuritis some- times accompanies pericarditis, and sometimes abscesses under the pleura costalis, whether these be produced by purulent peri- pleuritis or by caries of a rib or a vertebra. Diffuse peritonitis is often complicated with pleurisy, the inflammatory process extending from the peritoneum to the pleura, through the dia- phragm, by means of the serous canaliculi described by von Recklinghausen. This complication is frequently seen to occur in puerperal peritonitis, and then almost invariably leads rapidly to a fatal issue. So also from abscess of the liver, by means of the same canals, pleuritis may be set up, without the diaphragm itself being widely implicated. Much more rarely it arises from other disorders of the digestive organs, as, to take the most com- mon instance, when cancer of the oesophagus directly invades the pleura. We have learned during the repeated epidemics of PLEURITIS.—ETIOLOGY. 597 relapsing fever,1 which have of late years prevailed in Berlin, from post-mortem examinations,2 that abscess of the spleen is a comparatively frequent complication of this disease, and that by the passage of purulent masses through the lymph channels of the diaphragm into the pleural cavity a purulent inflammation may be set up therein. Finally, secondary pleurisy may occur as a complication of other diseases which cannot be proved to have an}^ direct connec- tion with the pleura. Many authors refuse to recognize these cases as secondary affections, but they are wrong, for the pleu- ritic complication follows so frequently, and without any other evident cause, that we are forced to regard it as a complication peculiar to the disease to which we find it so generally conse- quent. This is especially the case with rheumatic polyarthritis, when, besides the affection of the different joints, the pleura, the endocardium, and the pericardium often become the seat of inflammation. Although Richardson's theory, that lactic acid is discharged from the blood into the joints, the pleura, the pericar- dium, and elsewhere, and, acting as an irritating material, excites inflammation therein, falls to the ground for want of sufficiently convincing experiments, yet we are compelled to admit, on vari- ous other grounds, among which I will only mention the pecu- liarly favorable results which have followed Davies's method of treatment as reported to us by Traube,3 that in fact an irritat- ing material does exist in the blood in these cases, and that when this is discharged into the pleura it excites secondary pleuritis. The same may be said with regard to gout, in the course of which attacks of pleurisy are common. And I would include scarlet fever in the same category, since joint affections and inflammation of the pleura are commonly secondary to it. The pleurisies which very commonly appear in the course of chronic renal disease are often reckoned amongst these, but in a great number of cases this view is erroneous. For it must be remembered that patients who suffer from chronic renal disease are hydraemic, and like persons who are taking mercury or 1 See page 258 of Vol I. of this Cyclopaedia s Ponfick, Virchow's Archiv, LX., p. 128 et seq. 3 Verhandl. d. Berl. med. Gesellsch., 1865. 598 FRAENTZEL.—DISEASES OF the pleura. iodine, or who from any other cause have become cachectic, are especially prone to become the victims of inflammatory affec- tions, which are then erroneously regarded as peculiar to the renal disease. On the other hand, a serous effusion into the pleural cavity may occur as a part of that general dropsy to which patients with renal disease are subject, and, like hydro- thorax from other causes, it may, without any discoverable reason, assume an inflammatory character. Nevertheless the view is not to be wholly rejected that in individual cases renal disease, as such, may produce secondary pleuritis; and it does so, apparently, by the retention in the body of those solid con- stituents which should be eliminated in the urine, and which are in this case discharged into the pleural sac. As a further con- firmation of this view we might cite the fact, which every tolera- bly experienced hospital physician must have often observed, that in these patients diffused peritonitis (the rheumatic origin of which we have long considered to be set aside) occurs inde- pendently of ordinary exciting causes, and rapidly leads to a fatal termination. In this case we are at all events forced to admit that, in consequence of the renal disease, irritating matters have been retained in the blood, and having been discharged into the peritoneal sac have there acted as exciters of inflam- mation. This irritating matter we believe to be urea, and we speak of uremic peritonitis, though no actual proof has hith- erto been furnished that a secretion of urea is the cause of it. An analogous instance to this is, however, afforded by the secretion of urea through the skin. We cannot, therefore, reject the hypothesis that, when a patient with renal disease becomes, without any other evident cause, and coincidently with a diminution of the renal secretion, suddenly attacked with one- sided pleurisy, it should be regarded as a secondary affection to the renal disease. The fact deserves to be prominently mentioned, as opposed to the experience that different diseases are frequently compli- cated with secondary pleuritis, that in typhoid fever, in the first weeks, whilst the fever has still the type of a continued-remit- tent, and in which the morning remissions do not fall below a temperature of 102° F., the occurrence of pleuritis as a complica- PLEURITIS.—ETIOLOGY. 599 tion is extremely rare, so that the development of a secondary pleurisy in this stage of typhoid fever is almost excluded. I wish to lay especial stress on this statement, because by firmly holding to this view—previously taught by the older physicians —I was, even in the time when I first began to practice in con- nection with medical charities, repeatedly, in many well-remem- bered cases, preserved from gross blundering. But, strange to say, it has, on the other hand, been unhesitatingly maintained by some authors that pleurisy is a frequent secondary affection in typhoid fever. If the fever of typhoid assumes a hectic form, that is to say, if the morning temperature is normal or sub-nor- mal, while the evening temperature is still high, and especially if there has been exposure to cold, an attack of pleurisy may supervene. It may happen very frequently to convalescents from typhoid fever, as indeed to all convalescents, to be attacked by pleurisy, but this naturally would not be regarded as a secondary affection of the original illness. Age and sex may be disregarded in connection with the greater number of cases of pleurisy. The old opinion, that very young children are not attacked by pleurisy, still finds support in the assertion of Barrier, that this disease is never observed in children under six years of age. It is true that diagnosis in children of tender years is difficult, but improvements in our diagnostic methods have had the effect of dissipating the idea that young children enjoy an immunity from pleuritis. Guinier, of Montpellier, punctured an empyema in a child twelve months old, and Ziemssen tabulated fifty-four of his young patients who suffered from pleurisy, and of these 3 were one year old, 1 two, 7 three, 4 four, 2 five, 4 six, 4 seven, 5 eight, 9 nine, 7 ten, 2 eleven, 1 twelve, 1 thirteen, 2 fourteen, 1 fifteen, and 1 sixteen years old. The male sex suffer most from primary pleurisy in youth and early manhood, because they are most exposed to injurious atmospheric influences, and to accidental wounds. To the same causes may be referred the prevalence, in Berlin at least, of primary pleurisies during the winter months. I should mention here, as a result of my experience, that I have seen pleurisies, especially with extensive exudations, much more frequently on the left side than on the right. 600 FRAENTZEL.—DISEASES OF THE PLEURA Pathology. Various Forms, and General Course of Pleuritis. Pleuritis presents itself in very different forms. It may be limited to a small portion of the pleura, or it may be spread over the greater part of it. It may be attended with a large or a small amount of effusion into the pleural sac, or with none at all. It may differ also in the nature of the fluid effused, and finally, it varies according to the rapidity of its course. We are therefore in the habit of speaking of circumscribed pleurisy, or pleuritis circumscripta, as contradistinguished from the more common form of pleurisy, which is, as a rule, spread over a wider tract of pleura. A circumscribed pleuritis, as its name implies, runs its course without any noteworthy effusion of fluid ; we therefore call it dry or fibrous pleurisy—pleuritis sicca, or fibrinosa. We cannot, usually, in the first days of the illness, draw an distinction from the nature of the exudation which has been poured out. It is only later in its course, when special symp- toms become prominent or strikingly developed, that we can draw any further conclusions as to the nature of the fluid effused, and then, grounded on these symptoms, we may be able to distinguish the different forms of the disease from one an- other. Any effort to make this distinction at the beginning is met by great difficulties. Even the separation of pleuritis, according to its course, into an acute and a chronic form, bears, as Wintrich very justly remarks, more the character of conventional usage than the mark of a true distinction, indicated by nature itself. In fact, speaking anatomically, chronic pleuritis often presents many more intense signs of inflammation than the acute form ; and, clinically, we very often see an acute pleurisy become chronic, and quite as often a chronic pleurisy return to the acute stage, whether it had, in the first instance, an acute form or not. If the local symptoms of inflammation, as well as the fever ish manifestations, last only a short time, and if the exudative deposit is absorbed in a few weeks, the pleuritis is termed acute. PLEURITIS.—GENERAL COURSE. 601 Slight attacks of pleurisy, which we know from experience frequently lead to adhesions, may apparently run their course without any subjective symptoms, or these are so slight that they pass unobserved by many persons who are not accustomed to pay particular attention to their bodily sensations. At least, we often find more or less extensive pleuritic adhesions in the case of people who, apparently, have never been ill. On the other hand, quite slight attacks of circumscribed pleuritis, in which merely fibrinous exudation occurs between the pleural layers over a very limited portion, may produce, among persons who carefully regard their sensations, a feeling of oppression or even of pain in the part affected. Such persons often complain, in addition to a dull feeling of oppression, of a certain dragging feeling on deep inspiration, or when they sneeze, yawn, etc. ; on questioning them more closely, they will admit that they expe- rience a certain amount of dyspnoea on going upstairs and in other fatiguing exercises. On looking at the affected side it always appears a little retracted; percussion rarely affords us any information ; but on auscultation we may almost always hear a friction sound, though it may be confined to a very cir- cumscribed area. According to my experience, therefore, I must decidedly object to the view maintained in many hand- books, that these cases of circumscribed pleuritis run their course without objective symptoms. Should the disease be somewhat more widely spread, then it is accompanied with all the signs of fever; there is some shortness of breath as well as cough ; and on the affected side, where the friction sound is not heard, the vesicular breathing is weaker than on the sound side. A more severe attack of pleurisy, with a greater amount of fibrino-serous exudation—a frequent consequence of exposure to great cold—is sometimes ushered in by an intense rigor, which may recur, with less severity, during the course of the ill- ness. The rigor is succeeded by a feeling of heat, by thirst, and by more or less prostration. Commonly, before, during, or immediately after the shivering fit, pains are felt in the affected side, and tliese, contrasting with the milder forms, assume a stabbing and sometimes a tearing or dragging character. Dur- ing the first eight days this pain forms the chief complaint of 602 FRAENTZEL.—DISEASES OF THE PLEURA. the patient, the fever continuing at a considerable height. Most cases of acute pleuritis do not begin with an initial rigor, but the temperature rises gradually. If the course of the illness is very acute, it is accompanied with high fever. The morning and evening temperatures rise to above 104° F., and the pulse to 120 or higher ; the skin is dry and burning hot to the touch; there is entire loss of appetite and increasing thirst; frequently in the case of children, and sometimes with adults, there is slight disturbance of the sen- sorium ; the urine is scanty and very high colored. In a few very rare cases, which are accurately designated as pleuritis acutissima, the attack comes on, in previously healthy people, with a severe rigor, the beginning of an evident typhoid state; the skin is burning hot and dry, the temperature keeps over 104° F.; there is great disturbance of the sensorium, often violent delirium ; the tongue becomes dry and fissured, the thirst is excessive, the appetite wholly fails ; the anterior extremity of the spleen, even in the early days, can be distinctly felt, and diarrhoea may set in at this time. When we first see such patients, we are all the more inclined to believe that we have to do with a case of typhoid, since the patient is unable to give us any account of himself. If, however, we learn from the attend- ants that the illness began with a severe shivering fit, that it has only existed for a few days, while, at the same time, we notice the absence of any rose-rash, the constant abnormal elevation of the pulse to 120 and over, the deeply cyanosed complexion, and if by physical examination we discover signs of pleuritic effu- sion, we must set aside the idea of typhoid and regard the case as one of pleuritis acutissima. The progress of such a case is altogether "foudroyant." There is continued high temperature, as well as great frequency of pulse and respiration. A temperature of above 106° F., a pulse of 140, and respirations 60 in the minute may be observed; the exudation increases during the first eight days to such an extent, and is attended with such alarming dyspncea, and intense pain in the side affected, that puncture of the chest is urgently called for in order to preserve life. By this means a quantity of pure, thickish pus is allowed to escape. But this is not attended PLEURITIS.—GENERAL COURSE. 603 with any remission in the course of the disease, for on the very next day we may find as great an amount of exudation as before. If we puncture again, the patient, after supporting the operation but a few times, sinks at the end of the second week ; and if we do not puncture, death ensues more rapidly from suffocation. On one occasion I determined, after the second ineffectual punc- ture on the tenth day of the illness, to proceed to the radical operation of incision into the pleural cavity, but the young patient died on the fourteenth day, of acute ichorization (Ver- jauchung) of the pleural sac. This operation was performed in the year 1868, at a time, therefore, when operative procedure in these cases had not revealed the perfection which it has recently attained. It must, on that account, remain doubtful whether the unfavorable result did not depend on the imperfection of the treatment. Cases of pleuritis acutissima are, however, ex- tremely rare,1 so that I have not had another case of that kind under my care since, and I have not been able therefore to form any opinion as to the success of our latest therapeutic methods in such cases. Acute pleuritis generally runs a less stormy course. There is a moderate amount of fever, increased frequency of pulse, dysp- noea, pain in the affected side, loss of appetite, great prostration, so that by the end of the first week the patient is compelled to remain altogether in bed ; while during the first eight to twenty- eight days more or less effusion is poured out into the pleural cavity. The fever begins to subside when effusion takes place, and as the fever disappears the effusion becomes gradually absorbed, and with the disappearance of the exudation there is usually an increase in the secretion of urine. In the most favor- able cases from fourteen to twenty-eight days may suffice for this, but, as a rule, it is some months before the patient is restored to his usual health. If the effusion is not absorbed, the fever may disappear for a time, but there is a steady loss of strength, and commonly some complication arises which, after an illness of variable dura- 1 I have hitherto observed three cases only of this kind, and my attention was directed to the peculiar course of the first of these as long ago as the year 1860, by Traube. 604 FRAENTZEL.—DISEASES OF THE PLEURA. tion, leads to a fatal issue. Should the exudation assume a purulent character, this is often indicated, at a very early period, by the presence of unusually high fever, intense pain, and mani- fest oedema of the subcutaneous tissue on the affected side. After some time, generally from two to six weeks, the fever assumes quite an intermittent character, the morning tempera- ture being always normal or subnormal, while the evening tem- perature is much higher. During this hectic fever the patient loses strength continuously, and if left to himself will, sooner or later, sink from exhaustion, unless the empyema bursts into the lungs, and is discharged through the bronchi, or finds its way to the surface through the pleura costalis and the soft parts of the wall of the chest, the latter forming the so-called empyema necessitatis. Recovery, though it rarely occurs, is certainly possible in both these cases, but not till after many months or years. Should the pus discharge itself in any other way, the patient is irrecoverably lost. We shall deal with this subject again further on, and enter into more circumstantial details. Often in the first week of the illness, a circumstance may occur which calls for our special attention. The patient is observed to present a remarkable pallor, accompanied with rapid loss of strength, high fever, and a considerable degree of pain in the side affected. This should lead us to conclude that a hemorrhagic exudation has taken place. And this, in young people, must be regarded as the product of a tubercular pleuri- tis. In old people it may occur without any tubercular disease, but in that case it has a very great tendency to become purulent. If, therefore, the symptoms clearly point to the occurrence of a hemorrhagic effusion, we must, of course, be prepared for the worst results. For should the case be one of tubercular pleuri- tis, which has culminated in a hemorrhagic exudation into the pleural cavity, although in very rare instances the effusion may be partially absorbed, yet, seeing that this occurs in lungs already diseased, it usually has the effect of hastening the already anticipated fatal issue, either by the compression of hitherto permeable portions of the lung, or by the rapid advance of pulmonary collapse, or in some other way. PLEURITIS.—ANATOMICAL CHANGES. 605 Double-sided pleurisy, even when it appears to occur idio- pathically, is really always of tubercular origin. It rarely, however, of itself, reaches a development to threaten life, but, for the most part, must be looked upon as a serious complica- tion of an already more or less advanced lung disease. Diaphragmatic pleuritis is the disease of which a very expres- sive general description has been given by the ancient physicians, under the name of paraphrenias, and which has been adopted in a slightly altered form by Andral. According to this author, it is evidenced by a pain in the right or left hypochondriac region, about the cartilages of the false ribs, at the level of the dia- phragm. This pain may extend to the epigastrium and beyond it. The respirations are short and quick, the inspiratory expan- sion is confined to the upper ribs, the body is inclined forwards, the expression of the countenance is much altered, and exhibits occasional twitchings, especially about the lips. It is sometimes accompanied by hiccough, nausea, and even actual vomiting. The risus sardonicus described by Boerhaave, van Sweiten, and others, has not been noticed by Andral and the later physi- cians, certainly not by those of recent date. The group of symptoms here enumerated are not, as Win- trich has stated, characteristic of diaphragmatic pleurisy, since they may be produced by inflammation of one or more of the organs lying in the upper part of the abdominal cavity, nor are they constant, for there are cases of diaphragmatic pleurisy which run their course without one or other of these characteris- tic signs. Anatomical Changes. We have abundant opportunity, in the post-mortem theatre, of observing the anatomical changes which accompany the various stages of pleuritis. Hand in hand with these direct anatomico-pathological observations many experiments have bensation curvatures (one, two, or more) may be absent in certain cases of long standing retrecissement thora- cique; they are, however, more commonly present, but scarcely ever in such regularity that curves and counter-curves deviate, in their projection, equally from the perpendicular. The small circumscribed retractions and other deformities of the thorax, the result of secondary pleuritis arising in the course 1 Wintrich, L c, p. 265. 668 FRAENTZEL.—DISEASES OF THE PLEURA. of pulmonary consumption, gangrene of the lung, etc., are so various in their forms, and are so closely connected with the primary disease, that they cannot be described here in further detail. If it is now asked, through what anatomical changes this retrecissement thoracique arises, with or without spinal deform- ity, of which we are treating, we must answer that without doubt the false membranes produced by the inflammation con- stitute the most active cause; these become organized and act through the contractile process taking place in them, which finally converts them into pure cicatricial tissue. We must also admit, at the same time, that here and there, and especially in the production of the spinal deformity, the spontaneous position of the patient, and in other cases the effect of atmospheric pressure, etc., excite a subordinate influence. By inspection and mensuration we can very easily detect the narrowing of the chest, especially when the patient stands or sits upright. After what has just been said, we need not again describe the appearances which are in this case observed. So far as the position of the heart is to be determined by inspection, we find it either in the place to which it was formerly forced by the effusion, and where it is fixed by adhesions, or it is nearly in its normal situation, or it advances to fill the space which the decrease of the effusion tends to leave vacant. In deep inspira- tion the retracted part of the chest is more or less retarded in its movements, while the portion of the affected side of the chest which has remained intact, and especially the sound side, makes powerful respiratory movements. The percussion sound varies a great deal in proportion to the intensity which the contraction has reached on the affected side. Generally it is much the same as in moderately large effusions, only that the resonant areas remain unaltered for weeks, months, and even years. The drawn-up position of the liver and the dislocation of the heart can also be easily ascertained by per- cussion. But the most certain evidence is given of the contrac- tion of the left half of the chest when the half-moon-shaped space is very evidently enlarged and the anterior lower edge of the left lung is immovable. PLEURITIS.—COMPLICATIONS AND SEQUEL.E. 669 The auscultatory signs correspond with those furnished in moderately large effusions. Breath-sound is generally wholly absent at the base, anteriorly, laterally, and posteriorly; above it is indistinct or bronchial in various degrees. These signs remain for weeks and months unchanged, before at certain spots in the upper parts of the lung natural breath-sounds return. Here and there the voice is strongly or weakly bronchophonic, and sometimes segophonic. Frequently rales are heard which have no further diagnostic significance, or they are a sign of already existing infiltration of the lung tissue. Friction sounds are rarely heard, but where they exist they can be heard for a very long time. Auscultation always affords important aid in detecting the cardiac displacement we have mentioned above. Pleuritic membranes alone, when no fluid is to be found between them, do not diminish or destroy the vocal fremitus. The changes in form of the thorax and of the spine will naturally be more accurately distinguished by palpation than by inspection. Palpation also will readily detect the occur- rence of a strong friction sound, as well as the setting in of empyema necessitatis, which frequently occurs in this stage of the disease, by the cedema of the affected side of the chest, and the fluctuations which accompany it. We have here described in the most comprehensive manner possible the very various physical signs of this disease, as well as their diagnostic value in its different stages. We must now pass to the consideration of those complications and secondary affections which sometimes arise in connection with it. Complications and Sequela. Pleurisy may become complicated with almost any acute or chronic disease, but more frequently with some than with others. In the first place, we must consider those cases in which pleu- ritis appears independently, but is followed by one or more local diseases. Pericarditis is one of the most frequent and important of these complications. It is developed by an extension of 670 FRAENTZEL.—DISEASES OF THE PLEURA. the inflammatory process to the pericardium, and whether the inflammation of the pleura be simply sero-fibrinous, or puru- lent, or hemorrhagic, an analogous exudation will appear in the pericardial sac. The pericardial effusion sometimes reaches a greater amount than the pleuritic ; sometimes the reverse is the case. Endocarditis is rarely developed in connection with pleuritis, and when it is, it is generally closely associated with an attack of pericarditis. Hitherto I have only met with this complication of primary pleuritis in children. The extension of the inflammation from the pleura primarily attacked to that of the side at first unaffected, is, as a rule, only observed when the former is the seat of tuberculosis. Hence we may establish with tolerable certainty this diagnostic fact, which is based on experience, that when pleuritis appears simultaneously on both sides it is commonly of tubercular nature. As, however, tubercular pleuritis seldom appears as a primary affection, the extension of the disease from one pleura to the other in primary pleuritis is of very rare occurrence. Affections of the pulmonary parenchyma on the side dis- eased, especially peribronchitic and broncho-pneumonic pro- cesses—the latter, as a rule, of a caseous nature—must be regarded rather as sequelse than as complications, and must be considered under that head. For it is only in the rarest cases that we shall succeed in showing that diseases of the paren- chyma of the lungs are, in the true sense of the word, com- plications of primary pleuritis. As a rule, it is only when the pleuritis has partially subsided that we are enabled to convince ourselves of the existence of lung disease on the side affected. It is much more common to observe changes set in in the pulmo- nary parenchyma on the sound side, when pleuritis is at its height, and we may follow them through their development by physical examination. It can never be clearly proved that simple croupous pneumonia exists as a complication of primary pleuritis on the side affected ; on the sound side it occurs but rarely—not so rarely, however, as people are inclined to believe. Another affection of the sound lung frequently accompanying pleuritis—the so-called pulmonary cedema—we ought, following PLEURITIS.—COMPLICATIONS AND SEQUEL.E. 671 Traube's example, to regard as, in many cases, a kind of pneu- monia, in which, however, the exudation that escapes into the alveoli and the bronchia, in considerable quantity and extent, has a prevailing serous character. The best designation for this process is the one adopted by Traube, viz., pneumonia serosa— a process which may easily and rapidly prove fatal by flooding the bronchia with fluid, while the expiratory efforts are not strong enough to free the air-passages by fits of coughing. The patient is attacked, frequently after obvious exposure to cold, and often without any such exposure, somewhat suddenly and without premonitory rigor, with a feeling of great oppression, which rapidly becomes unendurable ; orthopnoea is accompanied with violent fits of coughing, which lead to the expectoration of ver}' large quantities of a thin, pale, rose-colored fluid, sometimes of almost watery transparency, and highly albuminous. Slight tracheal rattling is often soon observed, and when the expecto- ration is insufficient, it rapidly increases as death approaches. At the same time the frequency of the pulse is greatly increased, the extremities are cool, and the temperature is sometimes some- what raised (to 100° F.). If we examine the lungs we find no decided changes on the side affected by pleurisy, nor any dul- ness on the sound side; but we have, everywhere, fine vesicular rales, which conceal the natural breath sound. In autopsies of such cases, we find the lung on the affected side showing signs of more or less compression caused by the exudation, while the other lung is very large and heavy—its cut surfaces present a very cedematous appearance ; we also usually find in the lower lobes one or more small spots, in which the tissue of the lung is in an evident state of engorgement, and not infrequently in a state of commencing red hepatization. From experiments which I have made in late years, based on the teaching of Traube, I believe that the pulmonary cedema, which attacks the sound lung in pleuritis, must almost always be regarded as a pneumonia serosa. But the acute cedema which sometimes attacks the lung of the affected side, after the effusion has been let out by puncture, may be otherwise explained. In this case it will always be found that very large quantities of fluid have been either sud- 672 FRAENTZEL.—DISEASES OF THE PLEURA. denly or very rapidly discharged. In both cases the blood- vessels, whose walls have long been more or less compressed and probably damaged in their nutrition, have to bear a sudden increase of pressure, which is sufficient to cause a rapid outflow of blood-serum into the pulmonary tissue, and thus to give rise to oedema of the lung. Quite recently, in two cases, I have cer- tainly seen cedema of the lung set in after puncture of pleuritic effusions in which only 1,600 and 1,500 cubic centimetres, respec- tively, of an hemorrhagic fluid were let out; in these cases it was even manifest by auscultation that the lung which had been compressed shared in the cedema, and post-mortem examination revealed, besides the cedema, several spots in the same lung in which engorgement of the lung tissue was passing into the con- dition of red hepatization. But cedema of the lung on the affected side may arise in the same way as on the sound side, viz., through serous pneumonia. (Edema of the lungs is ob- viously identical with what the French have recently termed albuminous expectoration, and which some physicians sup- posed was caused by injury inflicted on the lung in para- centesis. This subject has been much discussed in the transac- tions of the Academy of Medicine of Paris. A recent work of Terrillon,1 on this subject, containing a collection of the most important observations of French authors, shows that in France also they have given up the view that in these cases the lung has been wounded ; yet they appear in general—with the excep- tion, perhaps, of Moutard-Martin and a few others—not rightly to comprehend this process. Bronchial catarrhs must be mentioned as another complica- tion of pleuritis, which may attack the sound as well as the diseased lung, and, when the effusion into the pleura is so con- siderable as to produce severe dyspncea, the bronchial catarrh may aggravate the symptoms to a degree that may be dangerous to the patient. We must not omit to mention that with puru- lent pleuritis, especially, may be combined inflammations of the mediastinum and of the peritoneum. The latter, which is usu- ally rapidly fatal, arises from the pus making its way into the 1 De l'expectoration albumineuse apr&s la thoracentese. Paris, 1873. PLEURITIS.—COMPLICATIONS AND SEQUELiE. 673 abdominal cavity through the small lymphatics of the dia- phragm. Caries of the ribs and of the spine setting in, in the course especially of purulent pleuritis, is not so dangerous. Hitherto we have only spoken of the complications of pleu- ritis when it appears as a primary disease, and this was all the more necessary, because nothing had been said in the earlier chapters of the complications which we have been speaking of here, whereas we had already mentioned, under etiology, the other conditions under which inflammations of the pleura may arise. Thus we often see pleuritis appear under the influence of some general morbid process, simultaneously with other local processes, especially attacking the other serous membranes. This applies especially to the acute exanthemata, as scarlet fever, measles, small-pox, and to acute articular rheumatism. We have already considered, in some detail, these relations, and have pointed out how erroneous it is to place in this category the inflammations of the pleura which occur in connection with puerperal processes, and in so-called pysemia. In connection with the latter we must always be careful how we say that pleu- ritis is a complication which arises through scarlet fever, or arti- cular rheumatism, for it is quite as justifiable to regard the pleuritis as a complication of the general disease. In a third series of cases pleuritis appears as secondary to other diseases, and especially to diseases of the pulmonary parenchyma. We have already' dealt fully with these cases, and shown how inflammations of the pleura, and frequently the most severe cases, arise as complications of quite circumscribed pneumonias in the form of pneumo-pleuritis. It is, of course, unnecessary to repeat here what has already been said. Fourthly, we see inflammations of the pleura arise side by side with other existing local affections as a purely intercurrent disease, without any causal connection existing between them; the pleuritis in such cases must be regarded as a primary dis- ease, in the causation of which the physical weakness induced by the pre-existing malady, at most, may have had a share. Of the sequela? of pleuritis we must place in the foremost rank the complete adhesion of the two pleural layers to one VOL. IV.-43 674 FRAENTZEL.—DISEASES OF THE PLEURA. another, and this occurs not so commonly after severe inflamma- tions of the pleura and extensive effusions, but very frequently quite imperceptibly and accompanied with very slight symptoms of indisposition. In consequence of the defective expansion of the lung caused by these adhesions, inveterate chronic catarrhs of the bronchial mucous membrane readily arise, and tliese, becoming more and more severe, gradually give rise to an obstruction in the circula- lation which may finally lead to a fatal issue. The diagnosis of such cases, in which, as a rule, we are not in the least assisted by the.patient's account of himself, is very difficult, and is based essentially on the diminished movement of the bony thorax, and on the complete immobility of the lower limits of the lungs, as ascertained by percussion, and in the absence of all other causes for the general obstruction in the venous circulation. The most frequent sequela of pleuritis is caseous pneumonia in every variety of extent and course. In many cases also it precedes the pleurisy, and in many it exists as a complication of it. "Vyhen the inflammation of the pleura leads to the formation of false membranes, then we not infrequently observe a shrink- ing of the affected lung with or without the development of bronchiectasis; at the same time the sound lung frequently increases in volume, which is commonly, but strictly speaking incorrectly, termed emphysema of the lung. Those diseases which are indeed the consequences of pleuritis, but which essentially affect the tissue of the lung itself and its functions, will be more fully dealt with by another author in another part of this work. The same remark applies to the amyloid degeneration of the kidneys, spleen, liver, and various other organs, which arises in the course of purulent exudations that are discharged externally, and in connection with which a general cachexia arises, which for the most part ends fatally. Diagnosis. The diagnosis of a pleuritic effusion, based on the symptoms given above, is, in the great majority of cases, an easy matter, and, indeed, by the help of the morbid appearances which have PLEURITIS.—DIAGNOSIS. 675 been described, it becomes tolerably easy to distinguish the sepa- rate forms from one another and their complications with other local or general diseases. It is true that the quality of the pleuritic effusion can only be ascertained with perfect certainty when it is artificially let out (by puncture or the like), or when it is discharged by a spontaneous opening. If it comes to an empyema necessitatis, or if we have unmis- takable signs of a communication with the lung or the bron- chia, we have certain evidence that the effusion is purulent or ichorous. If, in the course of acute pleuritis, with rapid and great effusion, a very striking ansemic condition suddenly appears, or if this happens in connection with chronic pleuritis, which is attended with the general and local symptoms indicative of the existence of caseous pneumonia or pulmonary phthisis, the con- clusion is rendered almost certain that the effusion is hemor- rhagic and tuberculous. An inflammation of the pleura is more readily confounded with some other disease the less prominently its symptoms stand forth, or the more they correspond to the symptoms of other affections. Blunders in diagnosis, however, will rarely occur, if our examination is conducted with great accuracy, if we follow the course of the disease with great care, and if we thoroughly attend to the history of the case. It would lead me far away from my present purpose if I were to bring forward, in this place, the symptoms of all the diseases with which inflammation of the pleura might possibly be confounded : Intercostal neuralgia ; periostitis of one or other rib; caseous inflammations of the tissue of the lung and their results ; pul- monary atelectasis both in children and in adults ; pneumo- thorax and pyopneumothorax; abscesses of the chest wall; aneu- rism of the great vessels within the chest; tumors of the liver, especially abscesses and echinococcus cysts,—neither of these can easily be mistaken for pleurisy by an observant physician. The knowledge of the fact that in extensive pericardial effusions, in consequence of the pressure that is thereby produced on the lower part of the left lung, the percussion note over the lower and back part of the left chest wall is rendered duller, and the breathing less vesicular, than on the right side,, without the 676 FRAENTZEL.—DISEASES OF TIIE PLEURA. existence of an inflammatory exudation in the left pleural sac, will, in the management of such cases of pericarditis, preserve us from diagnostic errors. When, however, it is clear that there is an accumulation of fluid in the pleural sac, it will be more difficult to determine whether it is of inflammatory origin or a simple hydrothorax. This question can, of course, only arise when there is general dropsy, and, therefore, especially after scarlet fever and in cardiac and renal disease. We know that an accumulation of dropsical fluid in one or other pleural sac may act directly as an exciter of inflammation, and so lead to pleuritic effusion. The question in such cases, therefore, is, whether we have to do with an exudation or a transudation. Our diagnosis will be assisted by always bearing in mind that transudations are usually double-sided, that they are slowly developed, and that they do not produce dyspncea until the greater part of the lung tissue is compressed, and that they are not accompanied with fever. The latter is never absent in pleu- ritis, the advance of which is characterized by the obvious symptoms of cough, stitch in the side, and dyspncea. Hsemato- thorax is distinguished by its sudden appearance, by its causes —wounds, aneurisms, etc., and by the subsequent development, six, ten, or fourteen days afterwards, of symptoms of inflamma- tion of the pleura excited by it. It has happened to some of the ablest physicians, as, for instance Boerhaave, Corvisart, and even Laennec himself, to confound pleuritis with extensive intra-tho- racic tumors, especially cancerous growths, whether or not the}^ have affected the mediastinum or the bronchial glands. Graves' was the first to pave the way for a more exact diagnosis, which has been more clearly laid down by Walshe and Stokes.2 But even nowadays, when the physician scarcely ever neglects to apply auscultation and percussion to the elucidation of such cases, it is difficult to avoid error. The distention of the thorax, the displacement of adjacent organs, the absolute dulness of the percussion note, the absence of all respiratory murmur, of bron chophony, etc, may easily induce one to diagnosticate incorrectly 1 Clinical Lectures. Philadelphia, 1838. 2 Dublin Med. Journal, Vol. 13. PLEURITIS.—DIAGNOSIS. 677 the existence of an extensive pleuritic effusion. As a rule, pec- toral fremitus may still be observed, in certain spots, over a lung infiltrated with cancer ; the area of dulness and the displacement of adjacent organs will not be so regular as in pleuritic effusions. If, however, the whole side of the chest is filled up by the new- formation, then a correct diagnosis will frequently only be pos- sible after an accurate investigation into the history of the case, into the succession of the physical signs, and into the course it has followed ; while at the same time we keep in view the gen- eral symptoms of the case as well as the casual appearance of cancerous deposits in other parts of the body, which are accessi- ble to direct observation. But the converse mistake may be made; we may take an extensive pleuritic effusion for an intrathoracic tumor, especially if the patient, when he comes under treatment, is unable to give us any reliable account of the history of the case; if he has no fever, and is in a condition of the greatest possible prostration, while the displacement of adjacent organs, on account of abnor- mal adhesions, is slight and irregular. About a year ago an excessively decrepid old man, seventy-five years of age, came into my department in the Charite, stating that he had only come to the hospital for the purpose of being transferred to an infirmary. His chief symptom was great shortness of breath. The right side of the chest was dull from apex to base, breath-sounds and fremitus were entirely absent. Heart and liver were scarcely at all displaced. There were several enlarged and indurated lymphatic glands in the right supra-clavicular region. The patient insisted that he had never felt ill, and had never suffered from pains in the chest, but only complained of exhaustion. The obvious diagnosis in this case was the existence of a malignant new-growth in the right side of the chest. To establish the diagnosis with cer- tainty, I made an experimental puncture and discovered the existence of a large hemorrhagic effusion in the pleural cavity. It is sometimes very difficult to distinguish between croupous pneumonia and an extensive pleuritic effusion. Every expe- rienced physician will be able to confirm this statement, for he must have seen cases in which, if the diagnosis of extensive pleuritic effusion had been clearly established, immediate opera- tive interference would have been demanded on account of the imminent danger to life ; and cases have been recorded in which 678 FRAENTZEL.—DISEASES OF TIIE PLEURA. such a diagnostic error has led to the puncture of a lung infil- trated by pneumonia. Wintrich 1 mentions such a circumstance, and I myself, when I was a very young physician, witnessed another, in which a teacher of mine, now, alas, dead, whose diagnostic acumen I may, over his grave, justly extol, on account of impending suffocation proceeded to puncture the chest, but unsuccessfully; for all the morbid appearances were caused by pneumonic infiltration of the lung from top to bottom, without a trace of liquid effusion in the pleural sac. If we are acquainted with the whole course of the illness, and know that the attack was ushered in with a rigor which was immediately followed by continuous high fever and a temperature above 104° F., and this in the first week of the illness, together with the pres- ence of rust-colored expectorations; certainly scarcely any one would diagnosticate a pleuritic exudation. Another important point in connection with the differential diagnosis between pneu- monia and pleuritic effusion is, that in pneumonia the percussion note scarcely ever appears absolutely dull over the whole side of the chest, and scarcely ever is the area of absolute dulness bounded by that peculiar curved line, with its concavity turned upwards and inwards, as is the case in pleuritic effusions. A hepatized lung increases the pectoral fremitus or leaves it unal- tered; pleuritic effusion weakens it or annihilates it entirely. In pneumonia bronchial breathing and bronchophony are gener- ally heard louder and nearer the ear, and at the same time most frequently a crepitant rale is also heard, which is never heard in the effusion stage of pleuritis. The distention of the thorax, the tense or projecting state of the intercostal spaces, the extreme displacement of neighboring organs, and the more or less complete disappearance of the semilunar space, are pecu- liar to great pleuritic effusions. It is very difficult to judge of the conditions wdiich exist when a fibrous pneumonia is complicated with a very extensive pleuritic effusion, which we have described above as the so- called pneumo-pleuritis. But there are, after all, very few cases of pleuro-pneumonia, in which not a drop of fluid collects in 1L. o., p. 299. PLEURITIS.—DIAGNOSIS. 679 the pleural cavity; in such cases the erroneous diagnosis of co-existing pleuritic effusion can only be avoided by the great- est caution. A most instructive case in regard to these diagnostic diffi culties has been recorded by Traube.1 The entire absence of expectoration, a condition which is almost always present with children, increases the difficulty of differential diagnosis in their case; the percussion sound may be absolutely dull over the whole of the affected side of the chest; no vesicular murmur nor indistinct breath-sound is to be heard; pectoral fremitus may not be felt at all, or only very feebly ; the semilunar space may be considerably diminished, the heart considerably displaced towards the sound side, and yet we may only have to do with a pneumonia, without any fluid effusion into the pleural sac. How, in such cases of pneumonia, the almost entire absence of pectoral fremitus, the displacement of the heart, and the simul- taneous diminution of the semilunar space, are to be accounted for, still requires a few words of explanation. Traube has long maintained, in opposition to many others, that the vocal fremitus may appear weakened even over hepa- tized portions of lung. Its complete or almost complete disap- pearance he explains in this way, that in such cases numerous bronchia are occluded by fibrinous coagula, and the alveoli are abnormally stretched by the inflammatory products deposited in them. This last condition still further interferes with the perme- ability of the bronchia and the free communication between them and the trachea. Moreover, that in general the strength of the fremitus is diminished not only by liquid and gaseous accumula- tions between the pulmonary and parietal pleura, but also by anything which leads to constriction or occlusion of the bronchia, is best exemplified, according to Traube's experience, by certain cases of bronchial catarrh, in which, at the posterior and inferior parts of the thorax, so far as the mucous rales extended, the fremitus was found considerably weakened. The displacement of the heart and the diminution of the semilunar space may be explained by the fact that the paren- 1 Ges. Abb.., II., p. 854. 680 FRAENTZEL.—DISEASES OF TIIE PLEURA. chyma of the lung is very greatly increased in volume through infiltration with the products of inflammation. Of course it is by no means every pneumonia that leads to increase in the volume of the lung, and it is only rarely that it reaches such an extent as to cause displacement of adjacent organs. A careful consideration of the conditions here described is, however, always necessary, if we would avoid serious diagnostic errors. Duration, Results, and Prognosis. The average duration of an attack of acute primary pleuritis varies from fourteen days to three or four weeks. Death, how- ever, sometimes occurs even during the first fortnight, when, for instance, it is a case of so-called pleuritis acutissima, the course of which we have already described under the head of Symptom- atology, or when a very extensive sero-fibrinous effusion has become rapidly developed, and has led to fatal syncope. Trous- seau attempts to explain this occurrence by referring it to tor- sion of the blood-vessels, especially of the aorta, while Bartels' believes that it is especially the great venous trunks that are here concerned, the permeability of which is endangered by the pres- sure of the effusion. The ascending vena cava particularly, where it perforates the central tendon of the diaphragm to reach the pericardium, and where it is firmly attached to the margins of the quadrilateral foramen, may, through the displacement of the heart, suffer an almost rectangular twist. Bartels has repeatedly observed this condition of the ascending vena cava in post- mortems of cases of left-sided effusion, and I have also seen it in three autopsies, and these were cases of left-sided effusion. I therefore believe that Bartels's explanation is the correct one, at least in the case of left-sided effusions, and hitherto I have never observed a case of death from syncope in right-sided effusions. " Such a twist in the inferior vena cava must necessarily present a great impediment to the return of venous blood from the lower half of the body to the heart, and thus lead to an imperfect filling of the heart with blood. This deficiency in the 1 Deutsch. Arch. f. klin. Med. IV., p. 265. PLEURITIS.—DURATION, RESULTS, AND PROGNOSIS. 681 natural blood supply of the heart will be all the more dangerous, because on the one hand a rapid diminution of the whole mass of blood is a necessary consequence of a quickly increasing pleu- ritic effusion; and, on the other hand, the pressure which the effu- sion exercises on the affected lung, as well as the loss of the vital movements of the lung itself, restricts and interferes with the conveyance of blood from the right to the left side of the heart. If in addition to these conditions, so unfavorable to the proper filling of the arteries of the body, there is superadded an acci- dental and even quite transitory disturbance of the circulation, as, for instance, a hasty movement of the body, a violent fit of coughing, by which the diaphragm may be suddenly driven up- wards, and the twisted inferior vena cava, above the diaphragm, be quite compressed, such a disturbance would certainly suffice to bring about an absolute insufficiency of the arterial blood pressure, which becomes manifest either by the occurrence of serious fainting fits or is followed by immediate death." In a third series of cases, an cedema of the sound lung may bring about a fatal issue even in the first fourteen days of the illness. If an acute primary pleuritis terminates in recovery within from two to four weeks, the effusion into the pleural sac cannot have reached any considerable height. For in the latter case the acute pleuritis gradually becomes chronic, and may possibly require many months or years for complete recovery. It is a very rare circumstance for an inflammation of the pleura, with great effusion, to end in complete recovery in four weeks. A remarkably rapid absorption of the exudation may be observed in connection with intercurrent diseases, which are attended with abundant watery secretions, as is especially the case in cholera. A secondary acute pleuritis, even when attended with exten- sive effusion, may run its course in the same way as a primary attack, and end in complete recovery ; but this result is not common. As a rule, no matter what the primary disease on which the pleuritis has supervened, its appearance may be regarded as the beginning of the end ; if, for example, it occurs in a patient suffering from phthisis, the respiration, already 682 FRAENTZEL.—DISEASES OF THE PLEURA. greatly embarrassed, becomes so impeded that death results from suffocation, or the patient, already debilitated by fever, with the fresh escape of nutrient juices, sinks from utter exhaus- tion. A more detailed description of all the possible cases in which an acute secondary pleuritis may lead to a fatal issue would carry us too far from our present purpose. The duration of chronic pleuritis, primary as well as sec- ondary, varies from eight weeks to a year, up to five, ten, and eighteen years. Sometimes a pleuritic effusion will advance slowly during many weeks, accompanied with a moderate amount of fever, and usually the absorption of the fluid will extend over a still longer time as it proceeds more slowly than the effusion. So long as the situation of the fluid is fluctuating we must not give up the prospect of a favorable issue ; yet sud- den death is always possible from cedema of the lungs, or from syncope. If, however, a considerable effusion, after continuing for four weeks, remains stationary for a longer period, we may antici- pate that the course of the disease will be protracted, because either the effusion will be surrounded by structures through which absorption is almost or quite impossible, or the effusion itself is little or not at all prone to absorption, or finally, because the inflammation is associated with incurable disease of the pleura, as, for example, tuberculous infiltration. The absorp- tion of the effusion may, for example, be rendered impossible, because the pressure on the surrounding tissue is so great that the orifices of the lymphatics become completely compressed, and therefore impenetrable. In this case, if a portion of the fluid is let out by puncture, the hitherto compressed lymphatics will again become permeable, and the absorption of the remain- ing portion of the effusion will follow rapidly. In another class of cases thick, non-vascular false membranes prevent the absorption of the fluid contents of the pleural cavity. These, however, even after many months, may slowly become vascular, and thus the absorption of the existing fluid effusion becomes possible. Hemorrhagic effusions, as we have already seen, are, for the most part, of tubercular nature, and they lead sooner or later to PLEURITIS.—DURATION, RESULTS, AND PROGNOSIS. 683 a fatal issue. We have already pointed out, in treating of the pathological anatcmy of pleuritis, that purulent effusions only terminate favorably, unless relieved by operative measures, when the pus is insensibly discharged outwardly. We have also already alluded to the dangers which arise when it pene- trates into the bronchia. Should the pus force an exit through one or other of the intercostal spaces, and give rise to an em- pyema necessitatis, or should it sink towards the abdominal cavity, and break through some spot there, a fatal result usu- ally follows, though it may not be in some cases till after long years of suffering. Many cases are on record of thoracic fistula, as a consequence of purulent effusion, in which patients have lived for ten, fifteen, or seventeen years. In cases of chronic pleuritis, if after some time the fluid is not absorbed, and recovery does not take place, almost the only resource left to us in order to ensure a complete cure is an operation, either puncture or incision, the former in sero-fibrin- ous, the latter in purulent effusions. If the patients recover without operative interference, the recovery is imperfect, as it is always attended by a retrecissement thoracique. This hap- pens if the effusion, sooner or later (perhaps not till after months, or even two or three years) becomes partially or entirely absorbed, and the lung re-expands somewhat, and the chest wall is sufficiently elastic and yielding to allow of retraction. The breathing capacity of the lungs which then exists is suffi- cient for quiet occupations, and it is still further augmented by the enlargement and vicarious activity of the sound portions of the affected lung, and especially of the lung on the sound side. The prognosis can readily be deduced from what we have already said. It is of the first importance in every case of pleuritis to be watchful in this respect, for we never know whether the course of the case may not be quite foudroyant, or the effusion very great, or whether a fatal result may not be possible in consequence of cedema of the lung or syncope. As this result is to be feared at any moment in cases of great effu- sion, our prognosis in such cases should be carefully guarded. The prognosis in primary acute pleuritis is on the whole favor- able when it attacks people of healthy and strong constitutions, 684 FRAENTZEL.—DISEASES OF TIIE PLEURA. who have no hereditary tuberculous tendencies, and when the general symptoms are not severe, and when after the first three or four weeks the commencing signs of absorption are observed, unaccompanied with any tendency to contraction of the chest. Should such cases be complicated with pericarditis, endocarditis, or pneumonia, these complications, and not the pleuritis, may possibly require a less favorable prognosis. On the other hand, the prognosis is unfavorable in all cases of chronic and second- ary pleuritis, in cachectic persons of bad constitution, or in those who have been brought low by other illnesses, and in ansemic and tuberculous persons, especially when the effusion is puru- lent or ulcerous. In the latter case a fatal result is almost cer- tain. Often, however, we can only decide with certainty in a later stage of the illness whether the pleuritis wTill become chronic or attended with serious complications. The following are always unfavorable signs : 1. A double-sided pleuritis, as it almost always indicates tuberculous disease of the pleura. 2. Continued high fever. 3. Rapid increase of the effusion, accompanied with high fever and with great displacement of adjacent organs, unless, after a course of from four to six weeks, signs of commencing absorption are observed. 4. Symptoms of impending suffocation. 5. Discharge of the pus either into the bronchia, with the simultaneous production of pyopneumotho- rax, or externally through one of the intercostal spaces. 6. The rapid increase of an effusion which has for a long time remained stationary, because in that case the pleuritis, as a rule, has assumed a tuberculous and hemorrhagic character. 7. A rapid return or increase of the effusion after spontaneous or a single or repeated artificial discharge of the same, especially where the quality of the discharged fluid degenerates and becomes puru- lent, bad-smelling, ichorous, chocolate-like, etc. Treatment. There are many physicians even nowadays who adhere to the expectant method which came into vogue now more than thirty years ago, and who recommend that pleuritis should not be submitted to medical treatment unless special symptoms are PLEURITIS.—TREATMENT. 685 present which threaten life. They assert that inflammations of the serous membranes — pleuritis and pericarditis—unless at- tended by very great effusion, are not dangerous diseases, and will get well of themselves. What infinite mischief has the adoption of this view already inflicted on such patients ! It is only necessary to have observed one case of adhesion of the layers of the pleura or of the pericardium ; it is only necessary to have once seen with observant eyes how such patients inevita- bly, and with the direst sufferings, are condemned to certain death, to induce us to strive with all our might, in every fresh case of pleuritis or pericarditis, to quickly reduce the inflamma- tion, and bring about as complete an absorption as possible of the deposited exudation. To attain this end, we shall naturally endeavor to avail ourselves of the experience of our predeces- sors, many of whom were endowed with pre-eminent powers of observation, and have handed down to us the fruits of their practical experience. They also adopted the method to which our reflections lead us : a severe antiphlogistic treatment, com- bined with means which promote absorption. Only when there is very high fever and very rapidly increasing effusion will venesection,1 to the extent of from six and a half to nine and a half ounces, be advisable. Generally, in the beginning of the ill- ness, the application, once or oftener, of from eight to twelve cupping-glasses will suffice—in the case of children, leeches— combined with the internal administration of digitalis and cal- omel, the former to act purely as an antiphlogistic, the latter, in addition, to promote absorption. I am usually in the habit of giving a grain each of digitalis and calomel until either a considerable lowering of the pulse or 1 To enter more fully here into the question of the utility of bleeding in general, and in pleuritis in particular, would carry me too far away from my subject. The oldest writers, from Hippocrates, Galen, Aretaeus, Aetius, Alex. Trallianus, the Ara- bians, then Sydenham, Huxham, Callisen, Baglivi, Dover, and Stoll, down to Bouil- laud, Chomel, and Walshe, have discussed this question minutely in their works. Opinions as to the utility and occasional application of bloodletting have, during the last twenty years, been entirely transformed and placed m a new light as compared with former times. The pros and cons would be out of place here. Suffice it to remark that I am of those physicians who even in the present day do not shrink from bleeding in suitable cases. 686 FRAENTZEL.—DISEASES OF TIIE PLEURA. symptoms of commencing salivation demand the cessation of one or other of these drugs, or until the intensity of the fever has considerably abated. Digitalis and calomel are contraindicated if, from the first, severe gastric complications coexist, if the tongue is thickly furred, if the appetite fails, and if diarrhoea be present. We must then confine ourselves to the internal administration of nitrate of potash or soda, dissolved in some mucilaginous decoction, in the proportion of ninety grains to four fluid ounces of the menstruum, which medicines, when the fever is slight, are usually sufficient from the outset, or, when even these cannot be borne by the digestive apparatus, we can fall back upon the milder-acting acetate of potash. In order to obtain the effect of mercury without disturbing the digestive organs, mercurial ointment may be rubbed into the skin, as formerly recommended by Laennec. This plan should be carried out very methodically, by rubbing in fifteen grains of mercurial ointment every two hours, day and night, into the fol- lowing parts in regular succession : first, on the inner surface of the upper part of one and then of the other thigh; next, in the same way, on the inner surface of the lower part of the thigh, then on the upper arm, and then on the forearm. It is better to leave the skin of the trunk untouched, as generally other out- ward medications may have to be applied here.- These frictions with gray ointment are to be continued until the first symptoms of salivation appear, then it is to be discontinued. If we see reason to avoid further abstraction of blood by cup- ping, we can continue a decided antiphlogistic plan of treatment, in the beginning of pleuritis, by dry cupping and by blistering. Both these expedients act by dilating the vessels of the skin, and so diminishing the over-distention of the vessels of the pleura. We should remember never to place blisters on the back or on that part of the surface of the chest on which the patient is in the habit of lying, because when he lies on the sore part he suffers constant pain. It will generally be sufficient to let the blister remain on for three hours, whereby we obtain an intense derivation to the skin without the production of large vesica- tions, the patients suffer less pain, and the spot on the skin is soon again in a condition to bear the application of another PLEURITIS.—TREATMENT. 687 blister. In very sensitive persons it may be necessary sometimes to abstain altogether from the application of blisters, and to supply their place by the more frequent use of sinapisms, as had already been advised by Celsus. Some individuals cannot even endure the pain of a sinapism ; only last summer I experienced this in the case of a very deli- cate lady, whom I attended, with a very large pleuritic effusion, and who, when a mustard plaster was applied, soon complained of the most unendurable pain, and finally fell into the most violent convulsions. I must mention here that the mustard papers used in private practice in Berlin, in which mustard is glued upon a sheet of paper, have the disadvantage, compared with the ordinary mustard plaster, that they often, after they have been kept on a very short time, produce such intense pain that they have to be removed, though the skin is very little or not at all reddened, and before, therefore, the object of the sinapism is attained. I cannot say on what this torturing effect of the inustard papers depends. The application of dry-cupping, of blisters, and of mustard plasters is also indicated when, from the first, the attack of illness is not accompanied with very violent fever, and their con- tinued use is attended with the best results when the pleuritis has become chronic, or when occasional pains in the chest indi- cate that inflammatory conditions still exist, or that the absorp- tion of the effusion proceeds very slowly. In this case it is best to use flying blisters, i.e., we apply a cantharides plaster, the size of the palm of the hand, to the front or side of the chest, and as soon as the sore produced by it is healed, we put on a fresh blister in another place, and so on, as many as six or even eight, sometimes one after the other. In this stage of the disease it is also often of use to paint the affected side of the chest with tincture of iodine, which naturally produces the same effect, viz., a great distention of the vessels of the skin, and a consequent draining of the pleura. Tliese applications of iodine paint are apt, however, to produce, if used too frequently, or in too great strength, very severe pain; it is always better to dis- continue it for two or three days if the skin becomes broken in any place. With these precautions I have used the tincture 688 FRAENTZEL.—DISEASES OF TIIE PLEURA. of iodine in the most extensive manner, and with the utmost success. Amongst the other antiphlogistic remedies which we may have to take into account in the treatment of pleuritis, we have yet to mention the application of cold, large doses of quinine and strong aperients. The application of cold bandages or ice-bladders in pleuritis, I do not in general consider advisable, because the cold very often brings on violent fits of coughing, and thus an increase of the inflammatory action may easily be induced. But after the removal of the effusion by operative measures, either puncture or incision, I am in the habit of applying a small ice-bladder over the situation of the wound for twenty-four or forty-eight hours. Large doses of quinine will perhaps produce a reduction of the temperature for a short time, but it can scarcely exercise a really beneficial influence on the affection of the pleura itself. On the other hand, the administration of drastics in the treat- ment of pleuritis is, in many cases, most successful. We must not give them at the very onset of the illness, as at that time they are without effect; but if the inflammatory process has reached its height, and the fever is beginning to decline, then the latter will be still further rapidly reduced under the influence of powerful aperients, while the pleuritic effusion diminishes con- siderably in quantity. I prefer in these cases to use the com- pound infusion of senna,1 of which I give from four to six table- spoonfuls, so as to secure from six to eight or ten watery motions daily. We continue with this for two or three days consecu- tively (unless violent gastric disturbance, or a very feeble condi- tion, such as is commonly present, especially in secondary pleu- ritis, forbids the use of strong aperients), and then omit a day, or we give the compound infusion of senna one day, omit it the next, recommence the third, and so on. The use of emetics recommended by Biverius, Morgagni, Tissot, St oil, and by Laennec even, for a time, and the prepara- tions of antimony, have been rightly discarded. In children, where pleuritis is very often complicated or secondary, the use of antiphlogistic measures requires special caution, otherwise 1 An infusion of senna, containing also Rochelle salt and manna. PLEURITIS.—TREATMENT. 689 serious collapse may suddenly present itself and require the administration of stimulants. Sometimes there are certain symptoms which require special therapeutic management. Should the pleuritic pain be very severe, we must try to relieve it by dry or wet cupping applied especially to the painful spot, or a blister, or a sinapism, or by rubbing in warm oil, to which, if necessary, an equal quantity of oil of henbane has been added, and covering the side with cotton wool. Should all these means fail to subdue the severity of the pain, the best results sometimes follow the application of warm bandages, as long ago recommended by Hippocrates. It is better not to use cataplasms for this purpose, as their applica- tion is always inconvenient, tedious, and somewhat messy, but to lay on the painful side compresses wrung out in hot water instead, and cover them with some water-proof material. They will thus be kept for a long time quite warm, and will not re- quire to be renewed more than three times in twenty-four hours. With the relief of the pain the dyspnoea will disappear, sup- posing that it has been really caused by it. But if it is caused by the amount of the effusion, then it is time to think of its removal by operative procedure. We must never give opiates in acute pleuritis to relieve the dyspncea, and even in chronic cases of secondary pleuritis it can only be given with the greatest caution, for the dyspncea which may already exist is only too frequently suddenly aggravated by opiates. So, also, if we determine to give opiates because of persistent sleeplessness, they must be administered with special caution; the best form is the subcutaneous injection of morphine. If this does not increase the dyspncea and the fever, then the whole course of the illness is favorably influenced by the rest which the patient procures. We may sometimes, however, succeed in getting rid of this sleeplessness by placing the patient in a cool, quiet room, and taking care at the same time that the bowels are regularly evacuated every evening. If the irritation of the cough is very severe, we should give internal^ a few drops of bitter almond water,1 or small doses of 1 The German bitter almond water is a strong preparation prepared by distillation. One thousand parts contain one part of hydrocyanic acid. VOL. IV.—44 690 RAENTZEL.—DISEASES OF THE PLEURA. extract of henbane, and when these means fail, some morphine, which it is still best to apply subcutaneously. So long as the pleurisy is accompanied with fever, the patient must be kept in bed, fed on milk and broth, to which, as the fever subsides, the yolks of one or two eggs may be added, also some white bread and stewed fruit. In primary pleuritis, while the fever lasts, meat and wine must be entirely avoided. But if the effusion becomes purulent, or if the pleurisy was from the first secon- dary, we cannot continuously withhold meat and wine even though the patient be feverish. Effervescing drinks are not well borne, as the carbonic acid which is thus conveyed into the system increases the dyspncea. If the fever is subsiding, or if it has quite disappeared, while a considerable effusion remains in the pleural sac, we must adopt means to promote its absorption. Sometimes, and especially when there still remains a certain amount of feverish excite- ment, most excellent results are obtained, as we have already mentioned, from the use of drastics, as well as from the external application of blisters, sinapisms, and painting with iodine. If the fever has quite disappeared, we may try the effect of diu- retics. Rarely, however, do these alone produce a decided result. Apart from digitalis, to which some erroneously attri- bute a direct diuretic action, whereas its diuretic effect is only secondary to its influence on the cardiac muscle and the walls of the blood-vessels, remedies like acetate of potash, acid-tartrate of potash, boro-tartrate of potash, and the vegetable diuretics, are by themselves of little efficacy. On the other hand, their action is often very striking if they are given in combination with tonics. I have constantly seen the most successful results, in the way of increase of diuresis and diminution of the effusion, from a combination of decoction of cinchona with acetate of potash. We must, however, when we begin the use of these remedies, watch the temperature closely, as occasionally, if the fever is not quite extinguished, it may be renewed by this medi- cine. Should this be the case, we must, of course, discontinue it. A very favorable effect is also produced in this stage of the dis- ease by pills of muriate of quinine and squill (one grain thrice daily). At the same time, squill is apt to irritate the stomach. PLEURITIS.—TREATMENT. 691 I have repeatedly given iodide of potassium internally (from sixty to ninety grains in four ounces of fluid—one tablespoonful three or four times a day), but I have never observed any marked result in the absorption of the effusion. Diaphoretics are scarcely ever used now, as they have long been found useless in promoting absorption. Finally, upon the recommendation of the late F. von Nie- meyer, who saw a pleuritic effusion, which had long resisted all treatment, quickly diminish when the patient was submitted to Schroth's method, i.e., placed upon as dry a diet as possible, and the use of liquids almost entirely prohibited, the attention of many physicians was directed to this treatment.1 By means of this method, Pimser, in eighteen cases, obtained eleven com- plete successes. He limited the food of the patient to lean roast veal and stale rolls, kept them two days without any drink, and not until the third day allowed half a pint of red wine, on the seventh and eighth day a whole pint. The urine decreases con- siderably under this treatment. The decrease of the effusion is said to be observable even from the commencement of the treat- ment. Not many patients will have the will and the energy necessary to submit to such a cure, which is seriously injurious to the entire constitution, without it being at all probable, from the observations hitherto made, that the absorption of such effu- sions could not be brought about in some other way. If the effusion is reduced to a minimum, or there only re- mains perhaps an imperfect expansion of the lower margins of the lungs, then complete restoration may usually be secured by a prolonged residence in a high-lying Alpine health-resort, such as Engelberg, Stachelberg, Tarasp, etc., or in some of the higher localities on the lake of Lucerne, or at Meran, Botzen, Kreuth, Aussee, and such little places, or even on higher spots in the North-German mountains, in short, wherever, on account of the rarity of the atmosphere prevailing there, patients are forced imperceptibly to take deeper inspiration, in order that they may inspire an equal amount of oxygen in a given time. By means of this respiratory gymnastic the last residua of former exuda- 1 Niemeyer-Seitz, Lehrbuch der Pathologie und Therapie, Vol. I., p. 298. 692 FRAENTZEL.—DISEASES OF THE PLEURA. tions become absorbed, and the existing adhesions between the pleural surfaces are set free, while the invigorating mountain air itself rapidly and visibly strengthens the constitution of the patient convalescent. Even when the absorption of the effusion proceeds uninterruptedly, yet patients will frequently complain of a decided sensation of oppression and tightness on the chest, which is especially felt during deep inspirations, coughing, and yawning, and this does not disappear till the very last physi- cally discoverable trace of effusion is gone. But in .other cases of acute and chronic pleuritis, when the effusion is sero-fibrinous and hemorrhagic, as well as when it is rmrulent, we have been taught by very numerous instances that we should not hesitate to remove the fluid by operative meas- ures. Ever since the time of Hippocrates, the operation has often been performed by the ancient physicians and surgeons, and with strikingly favorable results. Later on, as physicians became separated more and more from surgeons, the spirit of opposition arose ; the surgeons supported the operation while the physicians condemned it. And this spirit of antagonism, as Wintrich very justly remarks, may still be distinctly recognized even in the Transactions of the Paris Academy on this subject, of the year 1836. It was reserved for quite modern times to lay down the indications for operative interference and to settle the methods that should be adopted ; thus it has been more and more perfected, so that now, even in the hands of less expert and less experienced practitioners, the operation is performed wTith excellent results. The principal French clinical physicians, in the first place Laennec, Monneret, Fleury, and then especially Trousseau and Reybard, and later on Sedillot, Marrotte, and Boinet, must be recognized as having led to the wider acceptance and diffusion of the method of puncturing pleuritic effusions. Also the sharper distinction as to the treatment of pleuritic effusions, according as they are fibrino-serous or purulent, and the con- viction that in the former, removal by puncture, with exclusion of air, is indicated, while in the latter it is almost always only the radical operation of incision that leads to a cure, first gained firm footing in France, and found numerous followers, as ap- PLEURITIS.—TREATMENT. 693 pears from the Report of Marrotte (1857) and from the Transac- tions of the Societe Medicale des Hopitaux in Paris of the year 1864. In Germany it is only very lately that the treatment of pleu- ritic effusions by operative measures has found any acceptance, and even at the present time, we may see in the most popular and celebrated manuals of surgery, that direct danger to life from approaching suffocation, and the bursting or the imminent burst- ing of an empyema outwardly, are the exclusive indications for operative interference. Skoda and Schuh] have indeed published a series of cases in which the thorax has been punctured for pleu- ritic effusions, and at the same time recommended their trough apparatus, and Krause,2 Riecke,3 and Wintrich 4 have, in most distinguished works, supported operative treatment; but it is only during the last ten years, through the treatises of Roseis' Kussmaul,8 Bartels,7 and Quincke,8 in which additional observa- tions have been continuously reported to show that the radical operation in most purulent effusions is the only really effectual method of cure, that it has found a wider acceptance with Ger- man physicians. But even still with this, as with every other surgical procedure, we are in the habit of waiting until life ap- pears endangered or the pus threatens to discharge itself out- wardly. For the same reason puncture of sero-fibrinous effusions is but little practised by German physicians, and it is only by a few clinical physicians, as, for example, by Traube,9 that it has for many years been adopted, in accordance with the same indi- cations as those given by Trousseau, and of which we shall have to speak more in detail presently. Even when Bowditch, of Bos- 1 Oesterr. Jahrbiicher, 1841, 1842, 1843. 3 Empyem. Danzig, 1843. 3 Journal fiir Chirurgie und Augenheilkunde, 1846. 4 L. c, 1854. 6 Zur Operation des Empyems, Arch. f. Heilkunde, 1865. 6 Deutsches Arch, f. klinische Medicin, IV., p. 1 et seq. 7 Ditto, p. 263 et seq. 6 Verhandl. der Berl. medic. Gesellschaft, 1874, p. 17 et seq. B Gesammelte Beitrage, II., p. 1122.—When I first attended Traube's clinique, more than seventeen years ago, puncture of the thorax with a trocar, and with exclusion of air, had already been frequently performed. 694 FRAENTZEL.—DISEASES OF THE PLEURA. ton,1 introduced into practice the greatest improvement in xunc- turing pleuritic effusions, viz., the use of capillary trocars and the withdrawal of the fluid by means of an exhausting syringe, this did not incite to more frequent adoption of puncture. In- deed, the new method remained quite ignored among us, because other physicians, such as Scultet,2 Guerm, Stansky,3 and Wint- rich4 had tried the method of aspirating the effusions, but had soon laid it aside again, partly from theoretical considerations, partly because they did not attain any decidedly good results in carrying it out. And even when Bowditch in a later contribu- tion 5 reported 150 similar operations, which he had performed on seventy-five persons in this way, and when in France Dieula- foy,6 in Denmark Rasmussen,7 and in England soon afterwards Mayne 8 obtained a more general adoption of the method by the construction of ingenious and practical apparatus, and stimu- lated the zeal of many other physicians to the description and application of very various instruments, yet, strange to say, Bowditch's method only slowly found acceptance in Germany, although, through it, the results of puncture were essentially better and surer. At the session of the Berlin Medical Society, on the 29th of November, 1871, Quincke9 communicated six cases of exudative pleuritis which he had punctured according to Bowditch's method. In May, 1871, on the recommendation of an American colleague, a friend of mine, who had long been a pupil of Bowditch, I myself first performed the operation of puncture of the chest according to this method, and since then I have undertaken it, or had it performed under my guidance, 164 times in eighty-five different cases. But even in the year 1872 so little was the method of puncture with aspiration valued for 1 American Journal, April, 1852. 2 Trousseau, Clin. med. (p. 669 of Culmann's German translation). 8 Bardeleben, Lehrbuch der Chirurgie, III., p. 614. 4 L. c., p. 326. 5 American Journal, 1863. 8 Traite de Inspiration des liquides morbides. Paris, 1873. ' Virchow's Jahresbericht, 1870, p. 118. 9 Dublin Quart. Journal, 1871. 9 Verhandl. der Berl. medic. Gesellsch., 1874. PLEURITIS.—TREATMENT. 695 its favorable results by German physicians—chiefly, no doubt, because in general only very few of them had collected very con- siderable experience of this mode of treatment—that Lichtheim,' for example, says " the forced discharge of the effusion by the application of exhausting apparatus must be rejected." It is only during the last two years that this method has found warm supporters even among German physicians ; but I have had vari- ous opportunities of convincing myself that we are not yet, by a long way, in a position to say of our medical men, what Ras- mussen says of those in Copenhagen, that every medical prac- titioner in the city possesses his aspiration-apparatus and uses it in suitable cases. It appeared to me necessary, in the first place, to give this general account of the history and development of operative procedures in the treatment of pleuritic effusions, before pro- ceeding to the discussion of details.2 We are chiefly indebted to Trousseau3 for laying down precise indications as to when operative interference should be had recourse to in the removal of effusions into the pleural cavity. The operation is called for not only when there is danger to life from immediate suffocation, but also generally when the effusion is very large, i.e., when there is absolute dulness over the whole of one side anteriorly, or where there is only a small strip where the dulness is not absolute, and this yields a high-pitched tympanitic note ; for we are taught by experience that in the case of such extensive effusions death may often supervene quite suddenly either from syncope or from acute cedema of the sound lung. Therefore in such cases there should be no delay in operating. Other authors have related circumstances similar to the one which occurred to me in 1867, when, as clinical assistant in the Charite, late in the evening I had a case put into my hands, in which, after close examination, I believed an operation was indicated, and only on 1 Ueber die operative Behandlung pleuritischer Exsudate, Volkmann's Sammlung klinischer Vortriige, 1872, p. 168. 2 It may here be mentioned, in order to complete the history of the operation, that Hippocrates sometimes opened the pleural cavity with a red-hot iron, and that this method has been in later times frequently practised by the Arabian physicians. 3 Journal de Medec., Xov., 1840, and Bull, de l'Academie de Med., 15. Avril, 1846. 696 FRAENTZEL.—DISEASES OF THE PLEURA. account of the lateness of the hour I was led to postpone it until the next morning. During the night the patient hastily called to the attendant on duty for help, and when the latter hurried up, the patient was dead. The effusion was, moreover, on the left side, and as post-mortem examination showed, the lower part of the vena cava in the neighborhood of the foramen quadrilaterum was twisted almost at right angles. One such sad experience is sufficient to induce us never to delay an opera- tion, even for an hour, when once we are satisfied that it is called for. And this is all the more obligatory when the patient either suffers continual dyspncea or complains of attacks of oppression coming on from time to time. Thirdly, removal of the fluid by operation is indicated in moderately large effusions if absorption is long delayed, for frequently in tliese cases the reason why absorption does not set in is because the pressure which the pleuritic effusion exerts on the orifices of the lymphatics is too great for any absorption to be possible, and as soon as this pressure is relieved by the out- ward discharge of the effusion, the absorption of the remainder proceeds of itself rapidly and completely. If, moreover, absorp- tion is delayed, patches of caseous pneumonia are very readily developed in the compressed lung, to which miliary tubercle is sometimes added, or very thick pleuritic membranes remain behind as residua of the effusion, and these forever impede the re-expansion of the lung, and generally lead to contraction of the chest. Therefore in such cases, following Trousseau's advice, we must puncture. We must also puncture when we are satisfied that the effusion is purulent, no matter whether it is large or small in amount. But the operative treatment of purulent effusions is essen- tially different from that of other inflammatory exudations, and especially of sero-fibrinous effusions. In the latter case the evacuation of the fluid by means of a trocar is all that is necessary. Yet in this case there is always one impediment to be taken into account. We cannot withdraw a large quantity of fluid from the pleural cavity by means of such a puncture, unless the pressure on the fluid from within the cavity is greater than that of the atmosphere ; if, however, PLEURITIS. —TREATMENT. 697 this pressure only just balances that of the atmospheric air, wTe shall only find a few drops of fluid discharged externally, and that during forced expirations, especially during fits of cough- ing. This I have observed in some cases in which the quantity of the pleuritic effusion amounted to several litres. The more feeble the expiratory power, the less effusion escapes externally. Sometimes not a drop of fluid is removed. I remember a case of this kind in a man, seventy-five years of age, who was not able to cough at all. There is no means of ascertaining with accu- racy, before puncturing, what is the amount of pressure within the pleural sac. It is true that we know by experience that in recent effusions the pressure is generally great, whilst in old ones it is small, and that the displacement of adjacent organs is indicative of great pressure. But all these conclusions are entirely untrustworthy ; I have punctured, in recent effusions, with considerable displacement of adjacent organs, and yet found the pressure so slight, that by simple puncture only a very small quantity of fluid could be removed. The withdrawal of the effusion by suction-power had, as we have stated above, been already advocated in early times, as a means of securing the object we have in view in puncturing without being dependent on the amount of pressure to which the fluid is exposed; but Bowditch was the first to introduce aspiration into practice as a reliable therapeutic resource. The fears which formerly prevailed, on theoretic grounds, that, as a result of aspiration, the lung might be two violently expanded, and in this way laceration of its substance, dangerous hemor- rhages, or the development of pulmonary cedema might occur; the experience of Bowditch himself, which has since been con- firmed on all sides, has proved to be unfounded. The fear also that in aspiration of the pleuritic effusion the lung might be drawn into the trocar, and the pleura pulmonalis in this way injured, is practically proved to be without foundation, especi- ally if we are careful to use a thin, really capillary trocar. Moreover, in order to try the strength of the aspiration, I have often made the experiment of placing the tube of the trocar on the skin of my hand, and so convinced myself of the slight force with which the suction, on and off, acts. But a special 698 FRAEXTZEL.—DISEASES OF THE PLEURA. value of the method of aspiration is just this: that we can use quite capillary trocars for the removal of the effusion. The operation is naturally thus rendered so little formidable that even a possible injury to the lung or diaphragm, such as has happened many times to Bowditch, is attended with only very slight disadvantages. Bowditch has never seen any ill results from it. The assertion that thick, purulent effusions cannot be withdrawn through the capillary tubes, is also an unfounded objection to the method. I have repeatedly aspirated quite thick purulent masses out of the pleural sac through the capil- lary canula of a trocar. I regard it as but of little importance what particular apparatus for aspiration we make use of; they are all useful, and one has but very little advantage over another. Naturally I shall not attempt to criticise minutely all the different modifications of the method of aspiration described and recommended, especially in France, of late years, but I propose rather to confine myself to those in most general use. The most simple arrangement is that which goes by the name of Weiss's stomach-pump, which is used by Bowditch, but under the erroneous name of Wyman's. It is a common syringe with a doubly perforated cock; through one aperture the fluid is sucked into the syringe and through the other, by a quarter turn of the cock, it is discharged externally. The same result is, of course, obtained by a syringe with two cocks, one of which is always open while the other is shut, an instrument which for years has been in use among us for various surgical purposes, and which Quincke has also used for puncturing the chest. The canula of the trocar must not be in direct communication with the end of the syringe, but connected to it by means of a pretty strong India-rubber tube of moderate length. In this way all those move- ments of the syringe, which, with the greatest care, cannot be avoided, will not be communicated to the canula so as to give pain to the patient. A similar elastic tube is attached to the discharging aperture, so that the fluid withdrawn is con- veyed into some convenient vessel at hand, and prevented from wetting the patient. For a medical man who cannot afford to spend much in instruments, such a syringe, with a double cock, or a doubly perforated cock, will suffice for the aspira- tion of pleuritic effusions. The syringe devised by Dieulafoy is more complicated, in this, while the double-aperture cock is shut, the piston is forcibly pulled out and kept secure in this position by a check, and then the rarefied space is put into com- munication with the pleural cavity. Here also both apertures of the syringe are pro- vided with India-rubber tubes. This apparatus is very suitable to the purpose, and well constructed; but in my opinion it offers no kind of advantage over the above- mentioned syringes, even though Dieulafoy attaches quite a special importance to the production of a rarefied space before the discharge of the fluid. The rarefied PLEURITIS. —TREATMENT. 699 space is much too small to justify this claim. On the other hand, the aspiration apparatus designed, much at the same time, by Potain and Castiaux, in Paris, and by Rasmussen, in Copenhagen, and which differ only in trifling details from one another, in which a large glass bottle is in direct communication with a small air- pump, has been very much approved. By this arrangement the air in the bottle can be more or less rarefied, and the rarefied space thus produced, by means of a long India-rubber tube, provided with the necessary stop-cocks, is placed in communica- tion with the canula, and so with the pleural cavity. A glass tube inserted into the India-rubber one allows us to see the quality of the effusion and its rapidity of flow, even before it flows into the bottle, and collects at the bottom of it. If, through the glass tube, we see the outflowing stream evidently slackening, then we must shut off the bottle from the tube by means of a cock placed close to the junction of the tube with the trocar-canula, again exhaust the air in the bottle, and then reconnect it with the tube. This Potain's, or Rasmussen's bottle, as we are in the habit of calling it, com- bines the utility of a syringe with two cocks with the advantage that the whole aspiration process can be carried on without the smallest inconvenience to the patient. If we place the bottle behind the patient's back, and at some distance from his bed, and perform the necessary rarefying process there, the patient, apart from the mere prick of the puncture, often does not know what is being done with him until the evacuation is complete, and he is shown the fluid which has been withdrawn. It is always advisable to attend to this last point, because when the patient has become conscious, by seeing it, that a great part of the contents of his pleural cavity has been let out, he is very much encouraged and richly compensated for the distress which has been caused him by the idea of having a puncture made into his chest. Repeatedly, already, in this discussion of methods of aspirat- ing, we have stated that we have placed the apparatus em- ployed in communication with the canula of the trocar, and thus anticipated the decision of the question with what instru- ment the puncture should be made. To do this with the point of a knife has long been given up, because the conviction gradu- ally gained ground that the admission of air into the pleural cavity might convert a sero-fibrinous effusion into a purulent or even an ichorous one. Strange to say, universal as this experi- ence has proved, the opinion that the same injurious influences which extensive admixtures of air exercise on pleuritic effusions may also be produced by a few bubbles of air, has not yet gained universal acceptance among physicians. The simple fact is, that with the air certain excitants of infection make their way into the pleural cavity. That this may happen through only a single 700 FRAENTZEL.—DISEASES OF THE PLEURA. bubble of air, every one must at once admit from our present scientific stand-point with regard to various affections. I there- fore hold the opinion to be a false one which has been main- tained even in late years by Lichtheim (1. c.) and Lebert,1 that the entrance of a few air bubbles into the pleural sac during the puncture is harmless. Certainly there are cases in which such an admission of air does no harm, and I have myself seen such ; but then the air was not charged with infection germs ; on the other hand, in other cases that I have watched, through the admission of very small quantities of air into the pleural cavity, simple sero-fibrinous effusions have become in a foudroyant manner converted into purulent or sometimes even into ichorous ones. This want of care in avoiding the admission of a few bub- bles of air causes many cases of puncture in pleuritic effusion to take an unfavorable turn, and interferes with the results of a method of treatment which in and by itself promises the greatest success. Therefore, in order to prevent the entrance of a considerable amount of air into the pleural cavity, we have for many years given up the practice of puncturing with a knife, and adopted the trocar. It is only recently that we have employed, instead of this, a perforated needle—the so-called " hollow needle " — especially in conjunction with aspiration. This has been more particularly made use of in France, on the suggestion of Dieu- lafoy. Bresgen, some years ago, advocated its adoption in Ger- many, and more recently, in a modified form, it has been adopted by Tutschek.2 In choosing, however, between the hol- low needle and the trocar, we must unconditionally give the preference to the latter. For if one is not particularly careful in the use of a hollow needle, the point of which must necessarily, in order to be used conveniently, be considerably longer than the point of the trocar, which projects beyond the canula, and if one is not an adept at puncturing the thorax, or if one is induced to follow the advice of certain authors, and for special reasons to make more extensive excursions in the pleural cavity 1 Berl. klin. Wochenschr., 1874. 2 Die Thoracocentese mittelst Hohlnadelstichs. Miinchen, 1874. PLEURITIS. —TREATMENT. 701 with this hollow needle, serious injury to the lung may very easily be done. At the time when large and not capillary trocars were used for puncturing the thorax, and no aspiration apparatus was employed, the fluid contents of the pleural cavity were allowed to flow out through the canula as long as it was possible, that is, so long as the pressure to which the effusion was exposed was greater than that of the atmosphere. This pressure might be momentarily increased by fits of coughing. So soon, however, as it was in equilibrium with the atmosphere, or below it, natu- rally nothing more flowed out, however great the column of fluid within the pleural sac might be. Corresponding with the fluc- tuations of pressure within the thorax, during inspiration and expiration, it would often happen, either from the commence- ment or very soon after the effusion had begun to flow out, that only during expiration was the internal pressure greater than that of the atmosphere, whilst during inspiration it was, on the contrary, less. It then would follow that fluid flowed out only during expiration, and during inspiration air would actually be drawn into the pleural sac ; in this way not only was a pneumo- thorax produced, but as, with the air, parasitical or other irri- tant matters gained admission to the pleural cavity, the pleuritis might thus become purulent or ichorous. It was from such observations as these that people first began to consider what means might be devised for preventing the entrance of air into the pleura during inspiration. To meet this difficulty, Schuh- Skoda's trough apparatus came into use, but as it was not con venient to handle, it gained but little acceptance. Biermer had the external end of the tube bent somewhat downwards and placed in a medicine bottle filled with tepid water. This, besides being, in the first place, inconvenient, is, in the second place, dangerous in itself, since during inspiration, when the pressure in the pleural cavity becomes less than that of the atmosphere, water may be drawn into the pleura. Reybard' s advice, on the other hand, was very soon widely diffused; he recommends that a piece of catgut or goldbeater's-skin should be fastened to the canula of the trocar. By this means, while no impediment will be opposed to the outflow of the effusion, at the moment 702 FRAENTZEL.—DISEASES OF THE PLEURA. when the pressure within the thorax becomes less than that out- side it, and the air presses towards the canula, the goldbeater's- skin will then be driven into it and act as a perfectly secure air-valve, and so prevent all entrance of air. With some pre- caution this method never fails one. At least I made use of it in every case of puncture of the thorax, up to the year 1871, and never saw any air gain access to the pleural sac. Since we have employed aspiration, such a plan as the above is naturally out of the question ; on the other hand, since we can through aspiration produce rarefied spaces in a far more energetic manner than by simple outflow of the effusion, unless the whole apparatus is made to close hermetically, air out of the neighborhood rapidly presses into these spaces and may probably convey infective particles into them. In the aspira- tion method it is therefore of the first importance to provide the canula of the capillary trocar with a hermetically closing cock, because the atmospheric air in the tube connecting the canula with the syringe or flask is only too apt to make a reverse move- ment into the pleural cavity, especially when a large quantity of fluid has been discharged. If the canula is provided with a cock, then the worst that can happen is that a minimum of air may enter just at the moment when the stylet of the trocar is drawn back behind the cock, in order that the latter may be immediately closed, since such a trocar never moves absolutely air-tight in the canula. But even this minimum of air may, as we have explained above, be associated with the greatest danger to the patient, therefore a really good trocar should secure us against such a possibility. The danger of entrance of air into the pleural sac is still greater if, during aspiration, the canula should become blocked, and again made permeable. This obstruction occurs with com- parative frequency since capillary trocars have been in use, because it is exceedingly easy for a small piece of fibrine, and other like substance to be arrested in the narrow tube. Most authors who have frequently performed paracentesis by means of capillary trocars and aspiration, mention the occurrence of these unpleasant obstacles in carrying out the process, and sug- gest various remedies for overcoming them. PLEURITIS.—TREATMENT. 703 Bowditch, Dieulafoy, and Tutschek advise that, after we have allowed the air-bubbles that may possibly be present in the syringe to escape, we should syringe back a part of the extracted fluid towards the pleural cavity, and in this way drive the obstructing plug out of the tube. But in this case, while on the one hand one runs the risk of infecting the pleural sac, on the other hand, often a very considerable pressure, which for evi- dent reasons must not be too much increased, will not succeed in making the tube again permeable. Bowditch has often found this to be the case, and he therefore advises in such cases that another puncture should at once be made in the neighborhood of the first; as this would naturally be very disagreeable to the patient, it is on that account not very advisable. If, in order to make the tube again permeable, we pass the stylet of the trocar, or a thin, blunt, metal needle again along the tube, here also the simultaneous entrance of a small quantity of air into the pleural sac cannot be avoided. In order that the canula may be at any moment again ren- dered permeable, without the rein traduction of the trocar, and without the necessity of again syringing back into the pleural sac the already aspired fluid, the trocar must be constructed with a lateral tube, so that the stylet in the canula will be drawn back only so far as to clear the aperture of this lateral tube, and may at any moment be thrust forward again, and thus the fluid flows away by the lateral aperture. I have been led by these considerations to have a trocar con- structed according to my own designs, and which I have de- scribed in the Berliner klinische Wochenschrift.1 It answers completely to all the requirements to be looked for in a service- able trocar, as explained above. It is capillary and applicable to any of the methods of aspiration, it closes absolutely air- tight, and it allows any obstruction of the canula to be safely removed, in the simplest manner, without the possibility of any entrance of air, and without the smallest inconvenience to the patient; moreover, the instrument is easily cleansed without the aid of an instrument-maker. 1 Fraentzel, Ein neuer Troicart zur Entleerung pleuritischer exudate. Berl. klin. Wochenschr, 1874, 12. 704 FRAENTZEL.—DISEASES OF THE PLEURA. I have now had paracentesis performed 106 times in forty- seven different cases with this instrument, and I have always found it stand the test. Many also of my colleagues who have used it have been very well satisfied with its working. For the sake of completing the account of the operative procedures, I shall give a detailed description of the apparatus; but a clearer idea of it will be gained by reference to the drawing given in the Klin. "Wochenschrift (1. c.).1 The anterior part of the canula of this trocar consists of a capillary tube five centimetres in length, and at this point, in order to add to its firmness, its walls increase in thickness, while the diameter of the lumen remains unaltered ; and here the canula gives off, at an angle of 45°, a short, lateral tube, with a canal of the same width, which can be shut off by an air-tight cock. Close on the other side of the cock this lateral pipe ends in a short metal tube, into which is fitted air-tight the metal end-piece of the India-rubber pipe, which forms the beginning of the aspiration apparatus. About half a centimetre beyond the connection of the lateral tube the canula ends in a screw, which is closely fitted into a "worm" that forms the summit of a hollow cylinder notched at the side. By means of this screw the latter is firmly connected with the canula, and so really forms simply a continuation of it; beneath the screw there is also a small space, intended for the reception of small India-rubber plates. The hollow which forms the "worm'' of the screw is closed below by a plate, having a small perforation in its centre, through which the stylet of the trocar passes. TI13 whole of this screw apparatus forms the upper lid of the hollow cylinder, the lower being formed by a large button, which can be unscrewed, and thus the cleansing of the whole hollow cylinder be effected. Through the capillary canula described above moves the fine stylet of a trocar, fit- ting in as tightly as possible, and this extends downwards through the screw combi- nation, and there ends in a knob. In the side of this knob a button is screwed which, when it is pushed back as far as possible along the side-notch, draws back the whole stylet till it comes behind the point of connection of the lateral tube. If the capillary canula becomes obstructed, the obstruction is overcome by simply pushing forward the stylet by the button; and if we wish to prevent the sharp point of the stylet from projecting beyond the canula, we can measure exactly by the posi- tion of the button when the point of the stylet has reached the extreme end of the 1 An instrument similar to my trocar had already been introduced in the year 1858, in the Medical Times and Gaz., by Dr. Charles Thompson, of Westerham, and recom- mended by Spencer Wells for puncturing in ovariotomy. But Thompson's trocar natur- ally does not answer to our present wants. It is not capillary, it does not close herme- tically, nor is it adapted to simultaneous aspiration. After the publication of my paper in the Klin. Wochenschrift, I learnt that Potain (Peter, 1. c, 637) had also con- structed a similar trocar, over which, however, mine has the advantage of the India- rubber plates and the cock at the lateral tube. PLEURITIS.—TREATMENT. 705 canula. The presence of three small thin plates of India-rubber, pressed in between the screw and the screw cylinder, by which the stylet is shut in absolutely air-tight, enables us to move the stylet of the trocar backwards and forwards, without the admission of any air from without into the pleural cavity. After every time of using, the India-rubber plates are taken out, and replaced by new ones. They may be cut out of any piece of India-rubber tubing you please. The taking to pieces and cleaning the apparatus are just as easy. Before we describe the mode of making the puncture itself, two questions have to be considered: when should we operate, and where ? The first question is partly answered already by what has preceded, as is evident. If there is danger to life, or if the effu- sion is very considerable, and this is accompanied by dyspncea, we must puncture at once ; but even if there is no dyspncea, we ought not to hesitate in the case of very large effusions. On the other hand, if there is but little displacement of adjacent organs, and not much more than a medium amount of effusion, in that case it will be desirable to delay the operation until the height of the inflammation is over.1 Generally, therefore, it is better not to puncture before the end of the third week. If, in such cases, it is done earlier, it often happens that the fever is increased still more ; at any rate, the effusion constantly returns again to its former level after the puncture. If, on the other hand, the pleuritis is attended with but moderate fever and little pain, the operation may be ventured on sooner, even before the end of the second week, and will conduce to a favorable recovery. If the symptoms justify the supposition that the effusion is purulent, then the diagnosis can only be made abso- lutely certain by puncture, which must not, therefore, be long delayed. Much discussion has arisen as to the place where the punc- ture ought to be made. In my opinion it is best to follow Laennec's advice and puncture between the mammary and the axillary lines, tolerably near the former, and just above the sixth rib. If we choose a lower position in the anterior chest wall, we may easily injure the diaphragm or the abdominal organs, as has happened to Laennec. For this reason I am in the habit of 1 Traube, Gesammelte Beitrage, II., 1122. VOL. IV.— 45 706 FRAENTZEL.—DISEASES OF THE PLEURA. selecting the fifth interspace on the left, and the fourth inter- space on the right side, in order to keep clear of the liver. To puncture at the posterior wall of the chest as low down as pos- sible, viz., between the ninth and eleventh ribs, as recommended by Bowditch, is, according to my experience, unadvisable. In the first place, it will sometimes be impossible, in this situation, to avoid wounding the diaphragm ; and in the second place, the muscles on the posterior surface of the thorax are sometimes so thick and tense that they interfere with the accurate discovery of the position of the intercostal spaces, and with the subsequent free movements of the canula in the pleural cavity. In the third place, moreover, it happens not seldom in punctures in this situation that although the trocar or canula moves freely in the pleural sac, yet, on aspiration, not a drop of fluid is withdrawn. It is evident that in this case the trocar has punctured, at the same time, a thick layer of fibrine, for if we repeat the punctures higher up, large quantities of effusion are let out. The fibrinous strata of the exudation, simply by their own weight, will natur- ally, in the recumbent position of the patient, accumulate espe- cially on the posterior wall of the chest, and when we puncture there, they will often be met with and may render the operation of no effect. The best position the patient can assume for puncturing is the semi-recumbent one; the objection to his sitting up is that a sensitive patient may easily faint in that position. It is not necessary to give chloroform, or to apply local anaesthetics, as the operation is a very slight one. It is equally unnecessary to make a preliminary incision through the skin, as Trousseau has recommended, if the trocar is a good one. We need not nowadays even anticipate a displacement of the skin, if only capillary instruments are used, as the wTound is quite insignificant. After having accurately marked the point of puncture in the previously selected intercostal space, and in doing so, carefully avoided, as much as possible, the lower margin of the upper rib,' the trocar above described, previously rubbed with freshly boiled oil, is inserted into the pleural sac at the selected spot, the stylet being completely pushed forward beyond the canula, PLEURITIS.—TREATMEXT. 707 and the cock of the lateral tube closed. In inserting the trocar, the thumb of the right hand is pressed against the lateral but- ton, and so the stepping back of the stylet is prevented, while the first and middle fingers are stretched out along the canula, keeping the cock exactly between them, and the lower button of the instrument rests in the palm of the hand. The trocar is thus thrust in vigorously to the contemplated depth; by slow pressure we might perhaps separate the costal pleura from its attachments and push it in front of the instrument. We then immediately draw back the stylet as far as it will go, and see if the canula is freely movable in the pleural sac; if the walls of the thorax are not completely bored through, we thrust in the stylet once more ; then, if we are sure that the canula is in the pleural cavity, we fix the aspiration apparatus, air-tight, to the lateral tube and withdraw the air that is present in the com- munication-pipe ; in this way we immediately ascertain whether the whole aspiration apparatus closes hermetically; we then open the cock of the lateral tube and aspire the fluid out of the pleural sac. In doing this we must remember carefully, each time, to close the cock of the lateral tube before we let out the contents of the aspirating syringe, in order to prevent any retrograde movement of air or fluid in the communicating-piece between the trocar and the aspirator. If we employ the Potain or Ras mussen flask for aspirating, the whole process is more simple. If wTe find, during aspiration, that the discharge of the fluid is arrested, and if, on examination, we find that the canula is still below the level of the column of fluid in the pleural cavity, then, in all probability, the canula is stopped up. In that case, we shut the cock of the lateral tube, push forward the stylet for a moment, and then, on drawing it back again, aspiration pro- ceeds successfully as before through the lateral tube. When we have removed the quantity of fluid we intended, and for reasons to be hereafter given, I do not advise more than 1,500 cubic centimetres to be removed at once, then we again shut the cock of the canula, again remove the aspiration apparatus, and slowly withdraw the canula from the intercostal space, place a finger of the left hand on the wound, and then, immediately, a little cross 708 FRAENTZEL.—DISEASES OF TIIE PLEURA. of sticking-plaster, and this may be secured with a few more strips of plaster and some collodion. Thus the whole operation is completed. Even in withdrawing the canula, the entrance of air into the pleural sac is impossible. Various circumstances may arise during and after the opera- tion for which the physician should be prepared, in order that he may not be taken by surprise when they appear, or even compelled to desist from the operation. In the latter case, not only does the physician lose credit in the eyes of his patient, but the patient generally is henceforward afraid to submit anew to the operation, much to his own disadvantage. In the first place, we should always satisfy ourselves, before beginning the operation, that our apparatus is in good working order, and that it closes perfectly air-tight. I cannot urge this advice too strongly, since many times I have myself, too confid- ingly, left the examination of the apparatus to my assistants, who were well versed in the operation, and by so doing I have found myself in very awkward positions ; on one occasion I was even compelled to put off the operation to the next day, because the necessary apparatus was defective. We should never neg- lect, immediately before puncturing, either ourselves to disinfect the whole apparatus, or at least to see this done under our superintendence. Only the most earnest care on the part of the physician in this particular can protect the patient from serious ill effects. It is also important, each time before using the trocar, to see that the canula fits quite close to the stylet at its anterior extremity, and that its edges are here finely bevelled off. Trocars are often very defectively finished in this respect, and then these are, from the first, more or less unserviceable, or they soon become so from the fact that the material of which the canulse are made by our instrument-makers (generally new silver) is too soft, and therefore, after repeated use, the orifice of the canula widens. Such a canula, not closing tightly round the stylet, catches, with its anterior extremity, against the skin, and either causes the introduction of the trocar into the pleural cavity to be only possible with great suffering to the patient, or absolutely prevents its penetrating further, even with the exertion of the greatest force. In such a case, the resistance PLEURITIS.—TREATMENT. 709 offered by the skin is sometimes so considerable that if the trocar is pushed forward with some energy, it will actually bend in the hand of the operator. If there is any difficulty in forcing forward the instrument, it is best to make a little incision in the skin, as Trousseau has recommended in all cases ; after the resistance of the skin is overcome, generally the inter- costal muscles and the pleura costalis offer no considerable hin- drance, even with a badly constructed trocar, having a yielding canula. The most practical method of testing a trocar, with respect to the possible resistance of the canula, is to thrust it through a piece of sticking-plaster. If it passes through this without resistance, it will also go smoothly through the skin. If we could make the canulae of capillary trocars, as we do those of stronger instruments, somewhat springy by means of a slit at the side, or use a harder material for their fabrication, a remedy would be provided for the drawbacks just mentioned, which we can now escape only by careful preliminary trial of the trocar. But all the instrument-makers declare that it is impossible to make these capillary canulse springy, or to manu- facture them out of harder metal. Another unpleasant incident which may sometimes happen to the most skilful operator, in the case of very sensitive patients who change their position considerably the moment the trocar is inserted, is that he may strike against a rib instead of entering the intercostal space. If one is prepared for this possi- bility, and skilled in performing the operation, a slight turn of the hand is sufficient to divert the trocar from the rib, and make it pass into the intercostal space selected. Should it happen that the patient faints at the moment the trocar pierces the chest, or during the withdrawal of the effusion, a circumstance which occurs very rarely, then let the instrument lie quietly, with the stylet drawn back, bring the patient round with some stimulant, and afterwards resume the operation. I have never seen the intercostal arteries wounded during paracentesis, and with the use of capillary trocars I think it is scarcely possible for such an accident to happen. It occasionally arises that after paracentesis, and when the canula can be felt to be freely movable in the pleural cavity, 710 FRAENTZEL.—DISEASES OF THE PLEURA. that not a drop of the effusion can be drawn off by aspiration, even after one has repeatedly pushed forward the trocar so as to be sure that there is no obstruction in the canula. In such a case it is probable, nay, almost certain, that some coagulated fibrine is lying close to the wall of the thorax, into which the trocar has penetrated. This seldom occurs at the anterior wall of the chest, whereas it is not an uncommon event at the pos- terior wall. In such a case, one is naturally obliged to with- draw the canula and repeat the puncture in another spot. Before the method of aspirating pleuritic effusions had been employed, it was often observed, that during the outflow of the effusion, and sometimes not until it was ended, fits of coughing frequently came on, which often required an opiate to subdue them—Hie best being a subcutaneous injection of morphine. The only way of accounting for these fits of coughing was, that by the discharge of the effusion the lung was rather quickly rendered again permeable to air, and the renewed contact of air with the bronchial tubes set up cough irritation afresh. Since I have employed the method of aspiration, and by its means emptied the pleural cavity very slowly, I have only observed these violent attacks of cough in two or three cases, whereas formerly they were almost characteristic of puncture of the chest. The hypothesis put forward in some quarters, that these fits of coughing were excited by the canula touching the pleura pulmonalis, is quite erroneous, for I have formerly seen the most violent paroxysms of cough come on, while the quantity of fluid in the pleural cavity was so great that the pleura pul- monalis and the canula could not touch one another; while, on the other hand, I have quite recently, after the employment of aspiration, been able several times to feel distinctly the friction of the canula against the roughened pulmonary pleura without any cough following. If we take great care that the aspiration proceeds slowly, and that, at most, not more than 1,500 cubic centimetres of fluid are withdrawn at one sitting, then we shall be pretty certain to avoid another unpleasant incident, which is liable to follow puncture, and which we have already more fully spoken of, viz., PLEURITIS. —TREATMEXT. 711 cedema of the hitherto compressed lung.' But on other grounds also it is advisable that the evacuation of the fluid should be gradual and the quantity removed limited. For the vessels in the inflamed pleura are, precisely on account of the inflam- mation, abnormally distended, and in consequence of certain changes in their walls, not yet fully explained in detail (Cohn- heim), are especially prone to permit the emigration of lymph corpuscles. If we now, suddenly and very considerably, reduce the pressure which has hitherto rested on these vessels, there is great danger of a large extravasation of serum and lymph cor- puscles ; in other words, after a rapid evacuation of a very large quantity of fluid, not only may the effusion very quickly in- crease in volume, but it may also become purulent. These more delicate anatomical conditions are, in my opinion, not suffi- ciently thought of, as well in the operation itself as in the after-treatment. Finally, let me mention here one more acci- dent which I once saw set in eight hours after paracentesis, and which is not more fully described in the literature of this sub- ject, that is, a fatal hemorrhage from the lungs. It was in the case of a phthisical patient, twenty-three years of age, with large cavities in the left lung, and tolerably extensive caseous infiltrations in the right, who, already in a state of the greatest exhaustion, was attacked with left-sided pleuritis. After a course of only eight days this pleuritis had to be pronounced purulent, on account of the enormously high fever (104.1° F.), the intense pain in the chest, and a slight cedema of the affected side of the thorax; but, in spite of the rapid increase of the effusion, an operation had to be avoided, in consideration of the simultaneous affection of the lungs. After fifteen days' continuance of the pleuritis, the imminent danger of suffocation compelled me to puncture the chest, and by the operation 1,420 cubic centimetres of moderately thick pus were removed. The patient felt himself very much relieved after the operation; eight hours later he was attacked by a profuse haemoptysis (about 1J litres = 44 oz.) from which he died before the physician who had been sent for could reach the ward. When, on my visit the next morning, I was informed of the nature of the death, I imme- diately suspected that in this case there had been an aneurism situated in the walls of one of the cavities in the lung, and that this, in consequence of the great rush of blood which, after puncture, took place into the hitherto compressed lung, had burst, and so led to death by haemoptysis. 1 It is difficult for any physician to imagine that aspiration can ever be conducted so violently as to cause laceration of the lung tissue. As I have no knowledge of any reli- able observation on this subject, I mention this casualty only as a theoretical one. 712 FRAENTZEL.—DISEASES OF THE PLEURA. I was supported in this hypothesis by the general experience that in hemorrhages which prove rapidly fatal, coming on in phthisical patients in whom cavities are known to exist, the source of the hemorrhage is constantly to be found in the rupture of an aneurism situated in the wall of one of the cavities. Indeed, in the post-mortem examination in the case just described, it was found that an aneurism, about the size of a cherry, in the wall of a cavity, had burst, and had been the cause of the hemorrhage. Certainly a rare and remarkable event! This observation and two others, in which, notwithstanding the most careful disinfection of the trocar, carried out by myself, and the greatest caution in the performance of the operation, the effusion became purulent, have now induced me, whenever I puncture, not only to keep the patient quiet in bed and on low diet, but also, as Traube' advises, to apply to the place of punc- ture, twice in twenty-four hours, an India-rubber bag containing pounded ice, entirely without reference as to whether the patient suffers pain or not after the operation. Thus we must endeavor to cause contraction of the walls of the vessels distended by in- flammation and inclined, after the removal of the pressure caused by the pleuritic effusion, to allow of emigration of lymph cor- puscles and greater effusion. How very necessary this anti- phlogistic treatment is, is best illustrated by the fact that very often, after puncturing, patients without fever become feverish for a day or two, and in feverish cases a moderate rise of tem- perature takes place, while even the effusion sometimes increases not inconsiderably. But, as a rule, the increase of the effu- sion comes to a stand-still, and in simple pleuritis absorption very quickly sets in. That the value of this method of treatment should have been called in question lately in certain quarters, is wholly due to want of caution, levity, and even also, in some cases, ignorance of the details of the process, as I have described them, in remov- ing the effusion, as well as the defective after-treatment; where- as this method in its present advanced state evidently belongs to the greatest of therapeutic resources. When Behier and Peter state that in the last six years the mortality from pleuritis in the Paris hospitals has doubled, and seem disposed to attribute this result to the extension of the operative mode of treatment; in ■Lc, II.,p. 1123. PLEURITIS.—TREATMENT. 713 the first place, we cannot admit, without further proof, that the increased mortality is the result of this treatment; and in the second place, we must inquire how many physicians perform the operation, and with what precautionary measures. It may be inferred from various French publications that sufficient attention is not paid to this latter point. And in my opinion it is precisely upon this point that chief weight must be laid, for the more delicate our therapeutic methods become, and the better the results that we may obtain from them, the more minute is the care necessary in carrying them out in order really to obtain these results. In order to show what results I have obtained by the method I have just described, I need only call attention to the cases of paracentesis which I have performed, or the performance of which I have superintended, with my own trocar, abstaining from all mention of the great number of observations in which I have performed aspiration, but writh a common capillary trocar, or with a trocar furnished with a tap. Of forty-seven cases six- teen were cases of primary pleuritis with sero-fibrinous effusion, in which I performed paracentesis twenty-two times, viz., in eleven cases once, in four cases twice, and in one case three times. In the latter, on puncturing for the third time, the effusion was found to be hemorrhagic; the patient, who was over seventy years of age, finally died of exhaustion. The autopsy exhibited a recent tuberculous eruption in the diseased pleura, which had evidently originated in the course of the pleuritis. All the other cases ended in recovery. One patient, who was operated upon on the fifteenth day of the illness, on the twenty-sixth was dis- charged cured ; another patient was punctured for the first time on the thirty-fourth day of the illness, and a second time on the forty-seventh day, and on the seventy-fifth day was discharged cured. Tliese were the extreme limits; in the other cases the day of operation and of dismissal lay between them. In eight cases, also of secondary pleuritis, cure of the pleuritic effu- sion followed puncture, and in one case after puncture had twice been performed, in spite of the existence of caseous pneu- monia. After paracentesis there is generally a feeling of heat and 714 FRAENTZEL.—DISEASES OF TIIE PLEURA. smarting at the seat of puncture, and an indefinite sense of pres- sure on the affected side of the chest. The smarting usually dis- appears in a few hours, and in the worst cases does not last more than a day or two. It is only when the effusion becomes purulent that violent pains, accompanied with high fever, not infrequently supervene. As we have already observed, there is usually a slight rise of temperature noted for a day or two, which the effusion increases somewhat. On the second, third, or fourth day this increase ceases, and absorption commences somewhat rapidly, and is attended by a greatly augmented flow of urine. Slight cutaneous stimulation, and especially painting with iodine, together with the internal administration of decoction of cinchona and acetate of potash, tend considerably to promote absorption. If there was a very large amount of effusion, absorption proceeds but slowly until puncture has been a second time performed. Then, as a rule, the remainder of the effusion disappears pretty rapidly, leaving only a small quantity unabsorbed. As in the case of pleuritic effusions which do not call for operation, this residuum will be absorbed very slowly, often not for months, but most rapidly, as we have already said, if the patients select a high mountain residence for a considerable time. If the pleuritic effusion rises continuously after paracentesis, and is attended with high fever, there is strong reason to suspect, apart from the other symptoms, that the effusion is hemorrhagic or puru- lent. If the first puncture has shown the effusion to be hemor- rhagic, then, according to all probability, a tuberculous pleuritis exists. Nevertheless, if the fluid rises again rapidly, we must attempt a second, or even a third operation, for even in tuber- culous pleuritis we must not exclude the possibility of an incom- plete cure, i.e., an entire disappearance of the fluid effusion, and, moreover, we must not conclude that every hemorrhagic effusion is the result of tuberculous inflammation. If, however, the effusion, even after the second or third puncture, attains in a few days its former height, and possibly exceeds it, then the operation must not be repeated, since it will, probably, only lead to the sudden exhaustion of the patient. If, after paracen- PLEURITIS. —TREATMENT. 715 tesis, the hemorrhagic effusion undergoes purulent changes, then, naturally, it must be treated as a purulent one. Of the symptoms and the various results of the latter we have already spoken. We can scarcely prove by direct observa- tion, that a purulent effusion may result in simple recovery, as the diagnosis is always open to dispute. Since pus corpuscles undergo fatty metamorphosis and become absorbed, theoreti- cally the possibility of the complete absorption of slight puru- lent effusions must be granted. Some authors put forward autopsies which they have made on persons who have died acci- dentally, and who were certainly free from fever before their death, and in whom smaller or larger encapsulated purulent exudations were found, as proof of the assertions that such exu- dations are capable of absorption. These observations are very rare, but doubtlessly accurate. I have myself seen two cases in which an encapsulated purulent effusion had existed for more than a year without any feverish symptoms, and was only dis- covered at the autopsy, the patients having died from other causes. In these cases I believe the absence of fever was due to the circumstance that the purulent masses were surrounded by very thick non-vascular membranes, which made it impossible that the constituent parts of the pus could reach the circulation and act as excitants of fever. Such cases, however, do not prove that purulent effusions are capable of absorption, for there are also non-encapsulated purulent effusions which for whole months neither increase nor diminish, and, evidently for the same reason as when the pus is encapsulated, run their course quite without fever, but eventually terminate fatally. I have seen several such cases, but I have never been able to con- vince myself of any kind of absorption. Another process by which a purulent effusion may result in recovery has also been already mentioned, viz., where by necrosis of a small portion of the pulmonary pleura the pus infiltrates the lung tissue, and so reaching the bronchi is gradually dis- charged, but it is only rarely that recovery takes place in this way, and then after a tedious illness ; much more commonly the lung tissue becomes seriously diseased at the same time. If, however, the purulent contents of the pleura break directly into 716 FRAENTZEL.—DISEASES OF THE PLEURA. a bronchus, or externally through the pleura costalis, a fatal ter- mination may generally be looked for, often after years of failing health; if the contents do not escape outwardly, the patient usually sinks in consequence of exhausting purulent fever. It is on account of tliese sad experiences, taken in connection with the fact that puncture in purulent effusions but very rarely leads to recovery, that what is called the "radical operation," that is, the withdrawal of the pus by means of an incision into the pleural sac, has come more and more into favor, and it has frequently been attended with favorable results. The general adoption of this mode of treatment has been greatly promoted in Germany by the valuable works of those two eminent clinical physicians, Kussmaul and Bartels, and since, in late years, the rapid improvement which has taken place in the surgical treatment of wounds has been utilized in the management of purulent pleuritic effusions, this plan of dealing with such cases has become more popular, and its results more certain. The diagnosis of a purulent exudation is rendered probable when, as we have clearly said, such symptoms as high fever, intense pain, and cedema of the affected side of the chest are present, but it can only be rendered certain when, after puncture with our trocar, pus has been drawn into the aspirator. It is rash, without such an exploratory puncture, to conclude that the diagnosis is established, or, as has happened in France, to proceed to the radical operation, and then, after incision, to find that a sero-fibrinous fluid only has escaped. Naturally, by such a proceeding, nothing but serious disadvantage can occur to the patient, especially as the radical operation is not indicated in every individual case of purulent effusion. If, however, we are once convinced of the probability of the existence of a purulent pleuritis, we must no longer lose time with other measures, for it will often happen, quite suddenly, that the pus will force its way into the bronchi and induce suffocation ; or if this does not happen, a pyopneumothorax is frequently developed, in which case the chances of the radical operation become much less favorable than when the pleura is uninjured. The same holds good with regard to empyema necessitatis. PLEURITIS.—TREATMEXT. 717 When we suspect a purulent effusion, we must, in the first place, puncture, and in the same cautious manner as we should adopt were the effusion sero-fibrinous, we should withdraw, at most, 1,500 cubic centimetres of pus ; then we should remove the canula, close the wound with adhesive plaster, and pursue pre- cisely the same antiphlogistic after-treatment. Sometimes com- plete recovery follows a single puncture, sometimes two or three are necessary to bring about this result. On the whole, there- fore, it is always better to try the effect of two or three punc- tures before proceeding to the radical operation, although the cure of purulent effusions by means of such punctures is a very rare event. The more rapidly the effusion reaccumulates after puncturing, the less chance is there of bringing about a cure in this way. Still, however, it is possible that by repeated punc- ture the pleural surfaces which come in contact, after the removal of the fluid, may partially cohere, so that when we are compelled subsequently to have recourse to the radical opera- tion, there may be a less extensive suppurating surface of pleural membrane. If, after puncturing, the pus in the pleural cavity quickly re-collects, or if the fever runs very high, or if there is fear of exhaustion, we should, without delay, make an incision into the pleural cavity. For this purpose the patient should be raised somewhat—avoiding, however, any great pressure on the sound side, so as not to compress the healthy lung and induce a violent attack of dyspncea—and then chloroform should be care- fully administered. The incision should be made in the fourth or fifth intercostal space, midway between two ribs, and parallel to them, unless a pre-existing thoracic fistula, or a very considerable narrowing of one or other intercostal space, in consequence of the duration of the illness, compels us to choose another place for the incision. The incision, from six to seven centimetres in length, should be commenced somewhat external to the mammary line and carried towards the axilla. After division of the skin, an assistant should separate the muscular layers by means of two hooked forceps, and if the muscular structures are very strong, the margins of the wound must be kept open by means of broad, 718 FRAEXTZEL.—DISEASES OF THE PLEURA. blunt hooks, while all bleeding arteries must be carefully liga- tured. When the pleura costalis is thus freely laid bare, and is seen as a grayish-white membrane, the point of a knife is intro- duced into it, and then, with a Pott's knife, the incision is immediately widened and carried forwards and backwards to the whole extent of the external wound. In opening the pleura we must bear in mind that sometimes it may be itself thickened to the extent of over a centimetre. All through the operation, and also during the dressing of the wound, a spray of carbolic acid (one per cent, solution), by means of a Lister's apparatus, ' should be kept constantly directed on the wound and the sur- rounding parts. As soon as this wide opening is made into the pleural sac, the purulent contents rush out, more or less mingled with larger and smaller shreds of fibrine. In order, however, to avoid the serious disadvantages to the patient which might result from a too sudden outflow, we should immediately intro- duce two or three fingers into the wound, so that the discharge may take place very gradually, while the patient recovers from the influence of the chloroform and is revived with some wine. As soon as the effusion is, so far as possible, cleared out of the pleural sac, we must proceed to cleanse this cavity, and this we can do by introducing two Nelaton's catheters, having several openings at their lower ends, as deeply as possible into the pleural cavity, in the direction of the spine, and then through one of tliese catheters allow pure distilled water of a tempera- ture of 100° to 103° F., out of an irrigator, to run in till the pleural sac is full; then withdraw this fluid again through the other catheter, by means of a double-cock exhausting syringe, and repeat this cleansing process until the water withdrawn from the pleural cavity is quite pure. Four or five cleansings, immediately after the operation, will generally suffice for this. In the meantime shreds of fibrine, small or large, sometimes the length of one's hand, thickly infiltrated with pus corpuscles, having been washed out of the dependent parts of the pleural cavity, make their way into the wound and are to be carefully removed. If possible, leave no fluid whatever behind in the pleural cavity. The wound is then to be dealt with in the following manner : We place in the wound a silver canula, PLEURITIS.—TREATMEXT. 719 which can pass easily between the two ribs, but which is wide enough in the other direction to allow two of Nelaton's catheters of medium size to pass through it. The canula should be sufficiently long to allow its free extremity to reach a little beyond the level of the pleura costalis in the cavity of the chest. The canula rests on the outer wall of the chest, firmly soldered into a circular silver plate, which is made so as to lie evenly on the chest wall, and so that it can be closed by a small movable lid. This canula, provided with an obturator, must be introduced, and must fit the patient accurately ; at first, until such an instrument can be prepared, a provisional one of similar construction will suffice, even though it does not fit quite closely to the patient's body. Directly over the wound, under the canula, a piece of Lis- tef s protective is placed, and the plate of the canula is fastened to the wall of the chest by means of crossed strips of plaster; then the canula is closed by pushing forward the little silver lid, and this also is covered with a piece of protective; the whole wound is then covered with a large compress of carbolized gauze, eight times folded, and a suitable bandage attaches the whole to the wall of the chest. On the region of the wound, under or over the bandage, according to the strength of the patient, we place an India-rubber bag filled with pounded ice, insist on absolute rest, and administer easily digested animal food and a moderate quantity of wine. The dressing must be renewed twice every twenty-four hours, in the following manner: using the spray all the time we remove the old dressing, and leave only the silver canula lying in the wound. Through this we introduce two of Nelaton' s catheters, and, in the first place, allow distilled water, of the temperature above stated, to run through one of them into the pleural sac, and when the cavity is quite filled we withdraw it again through the other catheter by means of an exhausting syringe. We re- peat this process until the water runs out of the pleural cavity quite pure. Then we remove, for a moment, the silver canula as well as the catheters, and cleanse it in the most careful man- ner in boiling water, introduce it again by the aid of an obtu- rator, and apply the same dressings as at first. 720 FRAENTZEL.—DISEASES OF THE PLEURA. In order to keep Nelaton's catheters serviceable for a long time, they must be cleansed directly after use, first with hot water and then put in a one per cent, solution of carbolic acid till the next time of using. Every time before using them we should notice whether the catheter has not, perchance, become brittle at the anterior extremity. As soon as we remark this, of course we must choose a new one. We must be careful that the dressing is thus changed twice daily, always under the disinfecting influence of the carbolic acid spray, so long as the patient remains free from fever, and the pus does not become putrid. The fever naturally disappears immediately after the discharge of the pus ; if it return in the course of the illness, it points either to imperfect cleansing of the pleural cavity, and the presence of stagnating pus therein, or that the inflammatory process has started up elsewhere, either in the pleura or the lung. In the first case, the contents of the pleural cavity will be putrid, and will require more frequent (even to five times a day) and more thoroughly disinfecting cleansings; in the latter there is generally a fetid condition of the pleural contents, together with other symptoms of disease. But even if the case runs altogether a normal course, and there is no fever, it is advisable, two days after the operation, to remove the ice-bladder from the wound, and to cleanse the pleu- ral cavity for several days with a solution of common salt, two and a half grains to the ounce, instead of distilled water, and, if possible, we should place the patient on the sound side w7hile we are washing out the pleural sac, so that the wound in the thorax may lie highest, and bus the fluid we introduce may reach every part of the pleural walls. Of course while the patient is in this position we must be very careful, if the slightest dyspncea super- vene, to arrest the flow of water from the irrigator into the chest, and we must also be careful that the direction of the inflowing stream is never turned toward the heart, as thereby we might possibly induce syncope. After a few days, even if there is no fever, and the contents of the pleural sac are not fetid, we should replace the solution of common salt with compound tincture of iodine, diluted with from twenty to fifty times its bulk of water, or we may use a solution PLEURITIS.—TREATMENT. 721 of permanganate of potash (one grain to the ounce), or a solu- tion of carbolic acid (two grains to the ounce).1 Under this treatment fewer and fewer flaky or shreddy masses are discharged from the pleural cavity on the dressings, and the wound becomes cleaner and granulates more and more, so that (Mght or ten days after the operation it is only with a certain force that the canula can be pressed through the granu- lating wound. At the same time the pleural sac daily admits a somewhat smaller quantity of fluid. If, in the first few days after the operation, we observe that the lung is adherent to a portion of the pleura, we may be pretty sure that the diminu- tion of the pleural cavity will proceed more rapidly than if, by the operation, we had converted the whole extent of the pleura into a suppurating surface. Paying strict attention to the method of dressing the wound we have above detailed, we must continue to cleanse the pleural sac twice a day, and if the dimi- nution of the pleural cavity comes to a stand-still for a few days, it will be as well to change the lotion used in the dressings ; for example, instead of the solution of iodine use a solution of carbolic acid or of permanganate of potash. We must also endeavor, in introducing Nelatons catheters into the pleura, as it becomes more and more filled with granulations, to get them into the pleural cavity as far as possible, so as to avoid any possible stagnation of pus in its lowest part. We should also be careful that the fluid flows into the pleural cavity under the least possible pressure, and, especially when the space for the introduction of the catheters has become very limited, that, at the same time, air should flow out steadily through the free catheter; this is important in order that the freshly formed adhesions of the pleural folds may not be torn asunder by an increase of pressure within the pleural cavity. Through any negligence in this respect we may readily undo the healing processes of a week or longer. The introduction of the canula must not be remitted (and the thicker the granulations the more disagreeable it becomes to the 1 Washing out with a solution of common salt will often be sufficient to lead to a perfect cure, as Traube has pointed out in a case which he orally communicated to me. VOL. IV.—4G 722 FRAENTZEL.—DISEASES OF TIIE PLEURA. patient) until the pleural cavity is quite filled with granulations ; should the inner end of the canula come to strike upon the lung, we must endeavor, by placing a few layers of gauze between the plate and the wall of the chest, to prevent its passing so deeply into the pleural cavity; but we must not remove the canula altogether until the catheters can absolutely no longer penetrate into the pleural cavity. If this is done just at the right time, the wound will be completely healed in a few days. During the whole course of the treatment, the patient must be made to lie as straight as possible, to prevent any deviation of the spine, and he must be well nourished. When the w7ound is quite healed, we may find at the upper part of the affected side of the chest a normally loud percussion note and pure vesicular breathing, but there still remains at the lower, and especially the posterior parts, a marked dulness com- bined with feeble breathing. It is only by degrees that these residua disappear, while the patient himself daily gains strength, and ultimately, especially if during the after-treatment he can have the advantage of residence in a suitable health-resort, every trace of the former illness, even to the scar, may disappear. So far I have described only the therapeutic procedure which I regard as the most rational, and with which I have obtained exceedingly good results. I first became acquainted with the details of the method I have here described in the beginning of the year 1873, when, in conjunction with Traube and Wilms, I treated the case of a girl, thirteen years of age, in this way and found it eminently successful. It was a case of pneumonia, in the course of which a purulent effusion was developed in the pleural cavity, and by Traube's advice, I, in the first instance, punctured with a capillary trocar, and by means of Rasmussen's flask three times subsequently withdrew the pleural effusion by aspiration. Wilms then performed the radical operation. Traube directed that the after-treatment should be such as I have sketched above; it was carried out with the most conscientious care, and the cure of the patient was complete. Since the first case which I saw treated in this way in 1873, I have had the radical operation carried out in eleven patients with purulent effusions, following the same principles both with regard to the operation and the after-treatment. Complete recovery ensued in five; a sixth, in whose case the canula had PLEURITIS.—TREATMENT. 723 been removed somewhat too soon, and, on account of his foolish resistance, the strict after-treatment had been interfered with, wras dismissed with an incompletely healed thoracic fistula. He was afterwards, for five months, entirely without medical super- vision, and at last returned to the Charite with amyloid degen- eration of the liver, spleen, and kidneys, and died there a few weeks ago. Four of those who had been operated upon died; one of ichorization of the pleural cavity with severe tubercular pleuritis and circumscribed caseous deposits in both lungs ; another, who at the time of the operation was suffering from amyloid degeneration of the kidneys, and had a thoracic fis- tula, and for whom the radical operation, with resection of a piece of rib, had been performed, died of secondary peritonitis; a third, who had been attacked with purulent pleuritis as he was recovering from a severe form of typhoid, succumbed to an attack of pneumonia in the lower lobe of the uncompressed lung, which had probably arisen in consequence of catching cold during the operation ; and finally, the fourth patient, who in the course of a caseous pneumonia had become the victim of pyopneumothorax, and who had not been operated upon till some months later, when the purulent effusion began to increase considerably, sank from dysentery, which set in the day after the operation, and which was at that time endemic in the hos- pital. An eleventh case was operated upon not quite a fortnight ago, and gives hopes of recovery; this was a case in which an extensive purulent effusion supervened as an attack of pleuro- pneumonia, and after twice puncturing reaccumulated in a very short time. I will now adduce, for the purposes of comparison, the thera- peutic results obtained by Moutard-Martin, who has performed the radical operation in seventeen cases, but without adopting that particular mode of after-treatment which I have recom- mended. Five of these died ; two of the five sank from exhaus- tion, one on the thirty-second day, the other on the forty-seventh day after the operation ; in neither were any pathological changes in the lungs discoverable on post-mortem examination. Two others died in consequence of caseous inflammation of the lungs which it was not possible to diagnosticate before undertaking the 724 FRAENTZEL.—DISEASES OF THE PLEURA. operation. In these five patients the pleural cavity was subdi- vided into several sacs by false membranes, and these could not be sufficiently cleared out in the rinsings ; in consequence of this the pleural sac ichorized. Of the remaining twelve cases, two had thoracic fistulae with pneumothorax at the time when the incision was made; in a third case the pleural cavity was filled with hydatid cysts which had suppurated ; the other nine were cases of purulent pleuritis without fistulge. In these twelve cases Moutard-Martin considers there was a satisfactory recovery, although he himself allows that five of them were dismissed with thoracic fistulaa. But he does not mention in what state the remaining seven were after the cure, as to configuration of the thorax and capacity of pulmonary expan- sion ; therefore it is doubtful whether one is justified in speaking of them as complete cures, as I can do in the case of my five patients. It would be out of place here, and it would lead me into a protracted surgical discussion, if I were to describe more in detail and to criticise all the propositions that have been made as to the mode of treatment of purulent effusions. I must con- fine myself, therefore, in detailing further the minutiae of the mode of treatment I have already described, to setting forth its advantages over other methods. Any one would certainly give the preference to the new method who has seen, as I have during past years, as many as eighteen cases in which the radical opera- tion for the relief of purulent effusions was performed, with only two recoveries, and one of these after a tedious course of a year and three-quarters, with serious deformity of the whole thorax. A different mode of treatment to the radical operation here advocated has been recommended from various quarters. In the first place it was suggested that, after puncturing, a canula should be introduced through the puncture into the pleural cavity, and that this should be left there or replaced by a metallic or elastic canule a double courant, and by this means the pleural cavity should be cleared out. For this purpose we were to use distilled water or some kind of disinfecting fluid. Woillez has specially recommended this method ; but he, and others, have not obtained PLEURITIS.—TREATMENT. 725 any good results. The same may be said of drainage of the pleu- ral cavity, as first advised by Chassaignac, and afterwards also practised by Gosselin. No physician would now carry out drain- age in the way it was proposed by Chassaignac. In the third place, it has been recommended to make only a small opening into the pleural cavity, and to attempt to clear it out from out- side. The simplest way of effecting this consists in opening the pleural cavity while the patient is sitting in a bath, so that the pus escapes into the water of the bath, and during inspira- tion water rushes into the pleural cavity and gradually clears it out. Hoppe-Seyler was the first to think of thoroughly cleansing the opened pleural cavity by aspiration of water or solution of common salt, while he placed the canula of the trocar in connec- tion with an India-rubber tube which led into a vessel containing water or a solution of common salt. This method answered well in the case in which Hoppe tried it.1 Bardeleben, however, has reported a case which came under his own care, in which a fatal result followed the same treatment.2 Weber3 has simplified this method by making the incision of the empyema in a warm bath; but here also the observations reported by Quincke show how dangerous this proceeding is, as death may arise from syncope. Moreover, Potain, in France, and Roser, and subsequently Vogel and Quincke, in Germany, have proposed a method of treatment for clearing out the pleural cavity by the alternate injection of air and fluid. Quincke's plan is to introduce a com- mon syringe between an irrigator and a double tube, which is conveyed into the pleural cavity, so that its longer limb shall be connected with the pipe of the irrigator, and its shorter limb with one arm of the double tube. If the tube is carried as deep as possible into the pleural cavity, and the syringe left standing upright in the usual manner, then, as the fluid flows out of the irrigator, the air is drawn through the short shank into the pleural sac ; and in proportion as the air is drawn into the pleural cavity the fluid in the cavity is driven out through the 1 Virch. Archiv, IX., p. 254. 2 Lehrbuch der Chirurgie, IIL, p. 637. 3 Naturforscher-Versammlung in Giessen, 1864. 726 FRAENTZEL.—DISEASES OF THE PLEURA. free arm of the double tube. The fluid will continue to flow out so long as the level of the fluid in the pleural sac remains above the inner opening of the outflow tube ; it is advisable, therefore, to bring it to as sloping a point as possible. In the mean time the syringe has more or less completely filled itself with the irri- gation fluid out of the irrigator, and if we now turn it round, while the canula is drawn so far back that its mouth comes close behind the syringe, then the fluid streams out of it into the pleural cavity. The more frequently these manipulations are performed in succession, the more complete will be the cleans- ing of the pleural cavity, especially if the operator, following Quincke's advice, for this purpose closes the pleural incision quite air-tight by an India-rubber ring pessary. But the whole of this method (and Potain's plan is very similar to Quincke's) has this obvious disadvantage, that if the outflow is checked from any unforeseen cause, the pressure in the pleural sac may become so great that not only may those adhesions which have possibly taken place be soon torn asunder, but the life of the patient may even be seriously endangered; and, in the second place, the pleural cavity is never so thor- oughly cleansed as in the process I have already described, and therefore a putrid decomposition of the residue of the exudation is quite possible. The treatment that is adopted must afford the distinct guar- antee that no pus is left anywhere in the pleural cavity to undergo decomposition. It is therefore of the first importance that the opening into the pleural sac should be a large one. It is true that the danger of wounding the intercostal artery, or a considerable branch of it, is increased by a large incision. The first I have never seen, and it can always be avoided, if the operator is careful to keep as much as possible in the middle between two ribs. The latter, on the other hand, has happened to me twice; and in one case, when, on account of great mus- cular development, the wound was very deep, considerable hemorrhage occurred before we were able to stop it. We can scarcely ever succeed in ligaturing the bleeding vessel; we must therefore trust to compression to arrest the hemorrhage, taking care that the bleeding does not continue, behind the plug, into PLEURITIS.—TREATMEXT. 727 the pleural sac. Should the intercostal space be so narrow that it is difficult to introduce the knife between the ribs, and that the wounding of the trunk itself of the intercostal artery could not with certainty be avoided—a condition that we sometimes observe after long continued pleurisy, especially in children—in that case we must not attempt to carry out the radical operation by simple incision, which would be ineffectual on account of the impossibility of subsequently cleansing the pleural cavity. It is better at once to resect a portion of a rib large enough to allow of the convenient introduction of the silver canula we have described above. In children, in certain very rare cases, when the ribs lie close together, it is necessary to remove a portion of two ribs. Having made a sufficient opening into the pleural cavity, with or without the resection of a rib, if it seems desirable to keep it so far open that every time we wish we can cleanse it com- pletely, then, in the first place, we must introduce into the wound a circular metal canula of the form described above, and leave it there night and day. Only in this way can we prevent that steady, ra})id, and forcible spontaneous approach of the ribs to one another, which plugs of lint, catheters, and the like are quite unable to prevent. If the canula has not been quite securely fixed in the intercostal space, it may, possibly, over night be forced out of the wound, and then it can only be re-in- troduced the next morning with the greatest difficulty. Even if a portion of a rib has been removed, yet if we do not insert a metal canula, the opening will very soon be so narrowed by the approach of the ribs that a sufficient cleansing of the pleural sac becomes impossible. This has led to some advising (as, for example, Roser') that, in every radical operation for a purulent effusion, a rib should be resected, in order that the incision may be kept wide open; a bad piece of advice, as it not only does not secure the desired object, but also enhances con- siderably the danger of the operation by the presence of two wounds of bone. Bardeleben 2 was the first to apply such tubes to the purpose 1 Archiv f. Physiol. Heilk, VI., 1. SL. c, p. 637. 728 FRAENTZEL.—DISEASES OF THE PLEURA. of keeping open wounds of the pleura, and Franz Hoffman' was the first to describe the process. Traube was the first to suggest that the canulas should be made sufficiently large to afford the means of cleansing the pleural cavity through them. In order to avoid the inconveniences which arise from this tendency of openings into the pleural cavity to contract again, von Langenbeck has adopted the plan of trephining a rib, and he recommends it as leading to satisfactory results. *' In this way injury to the intercostal nerves and arteries is avoided, and the pain in the wound in the rib is insignificant, and it is some time before any callus-formation commences."3 This method, which had been already practised by the disciples of Hippoc- rates and termed terebration, was especially recommended by Parpeus and Severinus. Quite recently this operation has been again commended as an effectual one by Reybard and Sedillot. I do not recommend it myself, as the opening made is not large enough to admit of the thorough cleansing of the pleural sac. If an attempt is made to make it large enough for this purpose by trephining the rib in two different places, then the portion of rib lying between the two openings loses all sup- port, and breaks down, as happened in the only case of double- trephining that has come to my knowledge. The insertion of the canula is thus the most certain method of attaining our object. At first the patient is sometimes a little annoyed by the whistling sound made by the air as it passes by the tube in inspiration and expiration, but any infec- tion of the pleural sac by the air which thus enters is rendered impossible by the Lister's bandage. If, however, the wound granulates completely, as is usually the case after about eight days, the canula then comes to fit air-tight in the wound, and this annoyance to the patient ceases. This method of cleansing the pleural cavity, especially when the patient can lie in such a position that the wound in the pleura occupies the highest position in the thorax, thus allow- ing the fluid from the irrigator to reach every part of the pleural cavity, I maintain is the only one which affords a guarantee that 1 Ueber Empyem, etc., Berl. klin. Wochenschrift, 1869, p. 526. 2 Deutsche militararztliche Zeitschrift, 1874, p. 366. PLEURITIS.—TREATMENT. 729 no pus can become stagnant therein, always supposing that Nelaton's catheters are long enough to. reach to the deepest parts of the pleural sac. But special attention must be paid to this point. I have often heard my most esteemed colleagues, to whom, when looking on at the after-treatment of such cases, the whole process of cleansing the pleural cavity has appeared a troublesome and useless waste of time, object, that by simply allowing the disinfecting fluid to run through a catheter d double courant inserted into the pleural sac, it could be cleaned out more rapidly and just as thoroughly ; if the water flowed out pure, it was evidence that the pus had been removed. The direct trial proves the absurdity of this objection ; for if, when the water flowing out of the catheter a double courant is quite clear, we introduce a Nelaton's catheter into the bottom of the pleural cavity, and then connect it with an aspirator, wre can fre- quently withdraw one or two syringefuls of pus, which has gravitated to the most dependent parts of the sac. Nelaton's catheters are the best to use because they are the softest, and therefore least likely to injure or separate any adhesions of the pleura which already exist, when we are obliged to push them onwards through canals already narrowed and filled with granu- lations, or perhaps over the greatly elevated diaphragm. Since, in the progress of the case, the diaphragm frequently returns, at least to some extent, to its normal position, while pus still collects in the posterior part of the pleural sac, it appears especially advisable to make the incision not lower down than the fifth interspace; for if the wound is made lower down, it is sometimes impossible to reach with the catheter, across the diaphragm, to the purulent accu- mulations behind it. For the purpose of introducing the catheter, we leave the silver canula lying in the wound, to avoid the irritation which the contact of the India-rubber would cause. In the whole after-treatment we must, in the first place, be guided by the temperature of the patient. After the pus is let out, the patient, as soon as the effect of the chloroform has passed away, feels himself very much relieved and free from fever. Should a rise of temperature occur in the next few days, it is to be feared that there is a stagnation of pus some- 730 FRAENTZEL.—DISEASES OF THE PLEURA. where; if we then repeat the washing out more thoroughly, we sometimes succeed in discovering the spot where the pus has accumulated. If the pus has already a putrid odor, disinfect- ing solutions must be immediately employed, or those already in use strengthened; and we must repeat the washing-out of the pleural sac not merely twice, but three, four, or five times a day. Should all these efforts prove fruitless, should the patient again become feverish, the contents of the pleural cavity become still more fetid, the appearance of the wound still worse, the general debility progressive, then we may safely assume that more severe progressive affections of the pleura itself, especially tuberculosis, are imminent, and that we may anticipate with certainty a fatal result. I have never myself seen, since I have adopted the plan of treatment I have here described, such a fatal result in an uncomplicated case of purulent pleuritis. A putrid odor of the pus secreted by the pleura, however, appears not only in severe affections of that membrane, but also during slight gastric disturbances, and generally also in slight feverish conditions, but then it generally disappears entirely after one or two days. At all events such a patient must be treated with the greatest watchfulness and care until after the removal of the canula. If we make the slightest concession in the treatment of the patient, because perhaps he is very sensitive, or for other rea- sons, the progress of recovery may not only be actually retarded, but it may be disturbed to such an extent that a thoracic fistula may eventually be left behind. In one of the cases I have already mentioned this result followed, because I allowed my- self to be persuaded to remove the canula before the proper time, out of regard for the patient, who was constantly com- plaining of severe pain in the wound. Finally, the question remains to be considered, How does such a purulent pleuritis heal, and how does the previously com- pletely compressed lung become again permeable to air ? For- tunately, as I have not had an opportunity of dissecting any one of those who have been cured by radical operation, or to lose any of those who have remained under my observation, of an intercurrent affection, I can only answer the question theoret- PLEURITIS. —TREATMENT. 731 ically, and with reference to the abundant granulation forma- tions which we observe in these cases in the pleural cavity. I believe that the whole of the pleura pulmonalis and cos- talis, after it has thrown off the various necrosed masses lying upon it, becomes covered with granulations, and at first those which lie close to one another become here and there adherent. Tliese adhesions appear to commence most frequently near the root of the lungs, and spread from thence; whilst the hitherto compressed lung, by fits of coughing and other expiratory efforts, with a more or less closed glottis, fills itself with air from the sound lung. When the adhesion of the pleural layers and the healing of the external wound are complete, there yet remains, for a long time, a considerable retraction of the affected side, during inspi- ration, compared with the sound side; and especially over the lower parts of the lung which have been compressed, the reso- nance on percussion is greatly diminished, while over the upper part it is scarcely less loud than natural; vesicular breathing may be heard above, but below the breath-sound is indistinct or very nearly absent. All these symptoms slowly but steadily diminish if we make such patients practise a sort of lung gym- nastic ; at first, in their own rooms, placing their arms upon a table or chair to fix the thorax, and then taking from twenty to thirty deep inspirations ; this should be done six or eight times a day ; afterwards, to promote the further expansion of the lung, they should for several weeks take up their abode in a high mountain district, where, free from work and with good food, they can daily spend many hours in the open air. If we see such patients after the lapse of some months, we often find that the scar of the operation is the only remaining sign of their former serious illness ; even the edges of the lungs are again normal and expand freely. We cannot explain how all this happens until we have accurate pathologico-anatomical observa- tions to guide us. For the present we must be content with the fact that we can see such patients, who four or six months pre- viously would certainly have died if left to themselves, cured, entirely through our treatment, in this comparatively short time. It is true that one such case demands endless time and trouble, 732 FRAENTZEL.—DISEASES OF THE PLEURA. but the consciousness of having preserved a human life through our own skill alone, compensates the physician richly for his pains, and fills him with just pride. HYDROTHORAX. J. Frank, Prsecepta, Pars H., Vol. II., Sect. I.—Copland, Dictionary of Practical Medicine, Vol. III. London. 1858.—Trousset, Memoire sur I'hydrothorax. Montpellier, 1806.—Comte, De l'hydropsie de la poitrine et des palpitations du cceur. Paris, 1822.—Schroeder van der Kolk, Sammlung auserlesener Abhand- lungen XXXVI.—Ziemssen, Die Punktion des Hydrothorax, Deutsch. Arch. f. klin. Medicin, V., S. 457 et seq. Most of the works enumerated under the head of pleuritis are also to be referred to in reference to hydrothorax. Introductory Observations. By hydrothorax we understand the accumulation of a trans- udation, a so-called dropsical fluid, into one or both pleural cavities—the latter is the more common—without the existence of any inflammatory process in the pleural sac. Since we are in the habit of calling tliese non-inflammatory collections of serous fluid dropsical, then the correct name for hydrothorax is dropsy of the chest, or dropsy of the pleura, terms which are often erroneously employed to designate inflammatory effusions into the pleural sac. The pleural exudation therefore contains, it is unnecessary to say, no admixture of fibrine, or of pus corpus- cles, or the like. History. In former times, before the existence of accurate pathologico- anatomical knowledge of disease, and before physicians had become familiar with physical methods of investigation, it sufficed for a patient to complain of dyspncea, aggravated in assuming a horizontal position, or by the slightest exertion, or on starting out of his sleep, or who showed signs of incipient dropsy about the joints and eyelids, to diagnosticate the exist- ence of hydrothorax.1 1 J. Frank, Prsecepta, Part II., Vol. IL, Sect. I., p. 676 et seq. HYDROTHORAX.—ETIOLOGY. 733 How unfounded such a diagnosis appears to us nowadays it is scarcely necessary here to remark ; but it is deserving of observation that at that time, and with physicians for whom medicine did not form a part of natural science, the diagnosis of dropsy of the pleura and pericardium played a prominent role, while the cases were generally those of heart disease, chronic pulmonary catarrhs, emphysema of the lung, and the like. As scientific progress gradually made clear what is to be under- stood by hydrothorax, some physicians, as for instance, Mon- neret, Fleury, and in more recent times even Peter, supported by the slight or scarcely detectable chemical difference in the constitution of pleuritic exudations and transudations, quite lost sight of the distinction between them. It is, however, unjustifiable to do this, as in the one case an inflammatory process exists, and in the other it does not. On the other hand, we must admit the truth of the view which regards hydrothorax not as a disease of itself, but only as one of the evidences of a general dropsical condition. It is only for the purpose of discussing the actual diagnostic and therapeutic distinctions between a pleuritic exudation and a transudation into the pleural cavity that we deem it practically serviceable to devote a separate chapter to the consideration of hydrothorax, in connection with inflammation of the pleura, for water in the chest never appears as a disease by itself. Etiology. All those conditions which are capable of producing general dropsy may also give rise to transudation into the pleural cavity as soon as the serous effusion extends to the upper part of the body. Since both pleural cavities are subject to the same conditions, we find hydrothorax limited to one side only in those instances where the other pleural cavity is obliterated by adhe- sions between the pleural folds. If we consider more carefully the conditions under which the symptoms of general dropsy present themselves, we notice, in the first place, those rare cases in which a general dropsy attacks individuals who, when heated, have laid down on damp 734 FRAENTZEL.—DISEASES OF THE PLEURA. ground, and perhaps slept there for hours, and in whom we are unable to discover any local affection to account for the drospy. Hitherto I have had opportunities of seeing but very few cases of this kind. In one such case there was an unmistakable and not inconsiderable double-sided hydrothorax, which disap- peared together with the disappearance of the general dropsy. Secondly, to this class those scarlet-fever patients belong, in whom in the course of the disease general dropsy appears, and in many cases proves fatal, without the existence of any renal affection or hydraemic condition. In such cases also, as the dropsy increases, transudations into the pleural cavities are apt to take place. In the third place, hydrothorax appears in all those cases in which a general dropsy, dependent on distinct and evident ana- tomical changes within the body, reaches a considerable extent. The general dropsy may arise either from direct obstruction to the flow of lymph, and especially from compression of the tho- racic duct in its upper part, which is sometimes caused by intra- thoracic tumors ; or it may be the result of abnormally high pressure in the general venous system ; or thirdly, it may arise from a poorness of the blood-serum in solid constituents, and especially in albumen. Such tumors, compressing the thoracic duct, are exceedingly rare. I have seen only one case of the kind fourteen years ago. General dropsy, together with hydrothorax, arises in con- sequence of abnormal^ high pressure in the general venous system, brought about in the first place, in a great number of cases, by heart disease, with or without incompetence of the valves, when compensatory effects fail and the right ventricle empties itself so imperfectly that the blood is, in consequence, dammed up in the right auricle and in the whole venous system. In consequence of the abnormally high pressure in the veins, the serum of the blood flows through their walls and accumu- lates in the subcutaneous tissue, and in the different cavities of the body. The same condition is developed in a considerable number f cases of chronic disease of the lungs, in which the cir- culation of blood in the lungs is interfered with, and then natur- HYDROTHORAX.—ANATOMICAL CHANGES. 735 ally results a consequent blocking up of the blood in the right side of the heart, with the consequences we have just described. Lastly, we see general dropsy, together with hydrothorax, come on in the course of inflammation of the kidneys, or other chronic diseases of these organs, as, for example, amyloid degen- eration, in which there has been a loss of albumen for a long time, and the blood-serum has thereby been rendered poorer in solid constituents. This leads to the transudation of the serous fluid through the walls of the veins into the surrounding tis- sues. A great number of cachectic conditions are attended with analogous results, as, for instance, cancerous growths, leukaemia, intense malaria, long-continued dysentery, etc. Hydrothorax is invariably only a symptom accompanying general dropsy, and it does not take place until there is no longer any room for the transuded fluid in the deeper portions of the subcutaneous tissue. Even the pressure of a tumor in the thorax, or cancer of the pleura itself, will scarcely ever be suffi- cient, as is maintained in the manual of Niemeyer-Seitz, to pro- duce hydrothorax as the sole and earliest symptom of dropsy. In such a case, where we really find a fluid effusion in only one pleural cavity, it always remains to be determined, especially in cases of cancer of the pleura, whether it may or may not be due to an inflammatory affection. Pathology. Form and General Course of the Disease. As hydrothorax is only an accompanying symptom of gen- eral dropsy, we can hardly speak of it as a distinct form of disease ; its course also depends entirely on the real character of the disease which causes it, and it therefore possesses no charac- teristic appearances. Anatomical Changes. In water on the chest we have always to deal with a free collection of serous fluid in one, or rather, with the exceptions mentioned above, in both pleural sacs. It is only when the transudation takes place into a pleural cavity which is subdivided 736 FRAENTZEL.—DISEASES OF THE PLEURA. into sac-like compartments by old adhesions of false membranes that we can speak of hydrothorax circumscriptus, saccatus of multilocularis. The bands of connective tissue which attach the pleural layers to one another are generally at the same time the seat of serous infiltration. The collected fluid is generally of a bright yellow or yellowish-green color, and transparent. So soon as it appears turbid, and shows an admixture of blood- corpuscles, flakes of fibrine, and the like—and such descriptions of dropsical effusions we very often find even in modern litera- ture—it is with an exudation we have to do, and not a transu- dation. The quantity of dropsical fluid effused varies from a quarter to nine kilogrammes (from nine to three hundred ounces). We must be careful not to consider the few ounces of serous fluid which we find in dissections in almost every pleural cavity, as anything more than a simple post-mortem appearance. Whether it is really the case, as Wintrich * maintains, that in hydrothorax there is a greater accumulation of fluid on the right side than on the left, I cannot venture positively to de- cide, as I have undertaken but few comparative measurements. Where I have done so, I have not found Wintrich's statement confirmed, but have always found the greater quantity on that side on which the patient lay towards the close of life. The subpleural connective tissue is often swollen and vari- ously thickened by watery infiltrations, and is easily torn asun- der ; for the same reason the pleura itself is thicker and more sodden, it has lost somewhat its transparency, and has become opalescent. The lung is more or less compressed in proportion to the quantity of effusion, and its color depends on the amount of blood it contains, varying from pale gray to reddish brown. In many cases it is oedematous. Its retraction and compression toward the root follow more regularly than in pleuritis. By inflation the lung may be expanded to its ordinary capacity, unless any existing lung affection prevents it. Moreover, we shall be able to discover on autopsy the very various anatomical changes upon which the general dropsy has depended. 1 L. c, p. 366. HYDROTHORAX. —SYMPTOMS. 737 Symptoms. It is often difficult to distinguish the symptoms of pleuritis from those of hydrothorax; in other instances it is easier. In the first place, hydrothorax runs its course without fever; there is often no cough ; sometimes there is cough accompanied with expectoration of thin, watery, and—after violent coughing— frothy mucus. The cough is never so violent as in some cases of pleuritis. The intercostal pain is altogether absent. Hydrothorax is, as we have already mentioned, with few exceptions, double-sided, while pleuritic exudation is one-sided ; the displacement of the diaphragm, of the heart, of the medias- tinum, the expansion of the wall of the chest etc., never stands out so evidently, for the double-sidedness of the pleuritic effu- sion and the accumulation of serous fluid in the abdominal cavity prevent an actual displacement of adjacent organs, and the expansion of the walls of the chest is concealed by the coexisting cedema of the subcutaneous tissue. In percussion we observe that the fluid contained in the pleural sac follows the law of gravity, so that the area of dulness is never bounded by a curved line, as in the case of exudations. In other respects the auscultatory and percussion signs are the same in both cases. On the other hand, the mechanical interference with respiration is greater than in pleuritic exudation, for hydrothorax is on both sides and occurs in individuals whose breathing power is already diminished by the conditions which have given rise to the gen- eral dropsy (diseases of the heart or lungs, anaemia, and hydrae- mia), and their difficulty of breathing is very much increased by the hindrances to the circulation caused by the hydrothorax. Such patients, therefore, are subject to attacks of extreme dysp- ncea immediately they assume a horizontal position, or when they suddenly change their position, or move quickly, or cough, or cry out or speak loudly. The general symptoms are, almost exclusively, those of the primary disease, upon which the general dropsy depends. VOL. IV.—47 738 FRAENTZEL.—DISEASES OF THE PLEURA. Complications and Sequelae. These cannot enter into the consideration of hydrothorax, which is itself only a symptom of other conditions of disease. The diagnosis will naturally be determined by a consideration of the symptoms above described, which will enable us to dis- tinguish it from a pleuritic exudation, with which alone it would be possible to confound it. Duration, Results, and Prognosis. The primary organic disease upon which the hydrothorax depends will also determine its duration, results, and prognosis. If the original malady is removed, as we very often find to be the case in renal diseases, then the water on the chest may also entirely disappear. If, on the other hand, the obstruction to the circulation increases more and more in consequence of the original disease, the hydrothorax, through compression of the lungs, may frequently prove the immediate cause of death. The prognosis therefore depends entirely on the nature of the original malady. Treatment. The treatment must, in the first place, be directed to the relief of the primary ailment, and not until this proves useless must we think of attempting to palliate symptoms in order to prolong the patient's life. Ziemssen has recommended for this purpose, founded on a series of favorable observations, that we should puncture the pleural cavity with a fine trocar, and let out the serous accumu- lation. I think it better in such cases, and less trying to the patient, when the hydrothorax first appears, if the subcutane- ous tissue of the lower half of the body and the abdominal cavity are distended with serous fluid, to make a couple of simple incisions into the subcutaneous tissue, and while the serum is flowing off to protect the wounds from infection by suitable outward applications. Quite recently I have seen, in Traube's clinic here, the opera- ILEM ATOTHOR AX. —ETIOLOGY. 739 tion judiciously modified in this way: Little metallic canulas are placed in the wounds, such as are used with Pravaz's syringes; these are simply provided with a number of lateral openings, and a caoutchouc tube is attached through which the dropsical fluid flows off. In this way we may often succeed, even when the original disease is incurable, in causing the dropsy almost completely to disappear for months, and in keeping the patient in relative ease, whereas the evacuation of one or other pleural cavity by punc- ture can only have quite a transitory effect. For the dropsy will always rise again from below and refill the pleural cavities, whereas when permanent channels for outflow are fixed at the lower extremities, and kept open, the development of dropsy in the higher parts of the body becomes impossible. In all such cases wre must endeavor at the same time to maintain the strength of the patient by a light nutritious diet, accompanied with small quantities of beer and wine, and strengthening medi- cines, such as the preparations of quinine and the like. HiEMATOTHORAX. Marcellus Donatus, Lib. in., cap. 9, p. 263.—Morgagni, De sedibus et causis mor- borum, Epist. IX., 4; Epist. XVIL, 17; and Epist. XXVI, 3, 11, 17, 29.— Stoll, Ratio medendi, Vol. VII., p. 96.—Lieutaud, Histoire anat. mgdic. ; observ. 794, 795, 798, and 922.—Portal, Cours d'anat. medicale, IIL, p. 354.— Frank, Interpretationes clinic, I., p. 379.—Sedilloi, Sur l'opgration de l'empy- eme. These de Paris, 1841. And other authors mentioned under Pleuritis. By haematothorax is meant an effusion and accumulation of blood in one or other pleural sac, without any inflammatory affection of the pleura. We must never, therefore, confound hemorrhagic pleuritic exudation with haematothorax. Etiology. Haematothorax is always a secondary affection, and occurs in very rare cases from internal causes, especially when an aneu- rism of the aorta, after having attained a great size, bursts into the pleural cavity. This generally happens on the left side, 740 FRAENTZEL.—DISEASES OF THE PLEURA. very rarely on the right. Moreover, the aorta may, without the formation of an aneurism, be also laid open by ulceration, as described by Morgagni and Portal, and in this way lead to an effusion of blood into the pleural cavity. The same, it is said, may happen in some rare cases from the veins of the lungs, the vena cava (Portal'), and, as Caldani2 maintains, even out of vari- cose veins on the pleural surfaces. In very rare instances, in the cavities that form after caseous pneumonia, or in gangrene of the lung, a profuse bleeding takes place, destroys the lung tissue, and, breaking through the pleura pulmonalis, finds its way into the pleural cavity. Wintrich3 also mentions a case in which haematopleura arose through destructive caries of the ribs, with erosion of an intercostal artery and breaking through of the pleura costalis. The most frequent causes, however, are external, especially penetrating wounds of the chest; sometimes contusion of the lungs, when followed by great effusion of blood into the tissue of the lung and laceration of the pleura pulmonalis. Pathology. When haematothorax is not quickly fatal through the causes which produce it, it runs its course—we are speaking only of traumatic cases—usually to a favorable result, through entire absorption of the hemorrhage. The attack is sudden; the patient, without any immediately discoverable outward cause, is suddenly attacked with intense pain in the affected side, and a sensation of great loss of strength, often amounting to fainting, while he turns pale, his extremities become cold, and cold perspiration covers his body. Either this condition terminates directly in death, or the patient wakes out of his fainting fit, his extremities again become warm, and his lips only remain pale. He complains of an intense feeling of oppression on the chest. Slowly this feeling becomes less, and his strength gradually returns. Thus by degrees recovery sets 1 L. c, IIL, p. 354. 2 L. c, XII., p. 2. 3 L. c., p. 364. HAEMATOTHORAX.—COMPLICATIOXS AND SEQUEL.E. 741 in ; but sometimes, ten or fourteen days after the commencement of the illness, slight symptoms of an incipient pleuritis arise ; these, however, generally disappear pretty soon. Anatomical Changes. The anatomical changes found on dissection will, apart from the hemorrhagic effusion in the pleural cavity, depend entirely on the nature of the primary disease. Wintrich ! has performed various experiments on rabbits, dogs, and cats, for the purpose of producing in them artificially a haemato-pneumothorax; but from two to eight days after the infliction of the wound he always found the blood had completely disappeared, and he was not able to discover even a pigment formation as a residuum. The air also was absorbed. Lungs and pleura, with the excep- tion of the spot wounded, were as much intact as if nothing whatever had happened. Symptoms. The general symptoms of haematothorax depend, as we have already said, partly on the causes of the hemorrhage, and partly on the direct effects which it may have produced ; later on, how- ever, slight signs of pleuritis are added to these. We have already said that pain and dyspnoea accompany the onset of the hemorrhage. The physical signs are the same as in all collec- tions of fluid in the pleural sac, and vary therefore according to the amount of the hemorrhage, the yieldingness of the chest wall and of the adjacent organs. A more detailed account of these phenomena would only be a repetition of what has been already said in the chapter on Pleuritis. Complications and Sequelae. Since haematothorax is always but a complication of other diseases, it is inconsistent to regard (as some do) the latter as complications of the former. In most cases dependent on a traumatic cause, air enters the pleural sac at the same time, and 1 L. c, p. 363. 742 FRAENTZEL.—DISEASES OF THE PLEURA. from the first we have to deal with a haemato-pneumothorax ; and this—when pleuritis follows, and the extravasated blood, meeting with a purulent pleuritic exudation, undergoes de- composition or becomes wholly ichorous—terminates in a pyo- pneumothorax. If the haematothorax is not complicated with pneumothorax, it is yet apt, after a time, to be attended by pleuritis. This, however, rarely assumes a great extent, but if it once occurs, it may naturally be followed by the same secon- dary diseases as in pleuritis arising from any other cause. Diagnosis. There is nothing, more to be added under this head to what has already been said in speaking of the diagnosis of pleuritis and hydrothorax, and specially in the first section on the dif- ferential diagnosis from haematothorax. Duration, Results, and Prognosis. The duration, results, and prognosis of haematothorax de- pend, essentially, on its causes, its casual complications, and the entrance of air into the pleural sac. If it is caused by the rup- ture of an aneurism, a fatal result usually follows very quickly. In traumatic haematothorax, without at the same time the oc- currence of any dangerous wounds and concussions of other organs, the course, and therefore the prognosis, is for the most part favorable; generally complete absorption of the effusion takes place in from eight days to three or four weeks. When it is complicated with pneumothorax or with secondary pleuritis, the prognosis depends on these affections and not on the hemor- rhage. Therapeutics. The first object of treatment must be to arrest the hemor- rhage and prevent its return. The patient must be enjoined absolute rest. If this cannot be obtained in any other way, small doses of morphine must be administered hypodermically, even should the respiration be somewhat embarrassed, for the HiEMATOTHORAX.—TREATMENT. 743 slightest movement of the patient may directly endanger his life, by leading to a renewal of the hemorrhage. At the same time a bladder of ice should be applied to the affected side of the chest and a strictly antiphlogistic diet prescribed. Subcutane- ous injections of ergotine (from one and a half to two grains at each dose) may be tried in case of need, without, however, expecting too much from them. Yet they have acted success- fully in several cases. If there is no further danger of a return of the hemorrhage, all further treatment must be directed to the primary disease; in simple traumatic haematothorax all further medical treatment, besides rest, is superfluous. But occasionally at the onset of the attack, owing to the magni- tude of the hemorrhage, there is obvious danger of suffocation which compels us to act. In such cases the opening of the pleural cavity by incision has been warmly recommended and successfully carried out by the most eminent military surgeons.1 Larrey, for example, has repeatedly performed this operation with success, but has always removed only a small quantity of blood, just enough to remove the dangerous pressure on the heart and the other lung; he never removed as much blood as possible, because he rightly judged that the remaining blood exercised a beneficial mechanical pressure on the wounded ves- sel, and so prevented, as much as possible, the return of the hemorrhage. Larrey's advice, in my opinion, deserves the full- est consideration, especially in cases of gunshot wounds of the pleural cavity, since no kind of injurious consequences can result from incision into a pleural sac already permeable to air. In the year 1870, I myself, in the field-hospital, had the care of two gunshot wounds attended by hemorrhage into the pleural cavity greatly endangering the lives of the patients. I made a toler- ably large incision into the pleural sac in each case, and let out a portion of the coagulated blood. One of these cases I know for certain made a perfect recovery, the other I left in a very favorable condition ten days after the incision, but I have not been able to procure further information about him. Should pleuritis or pyopneumothorax arise in the course of 1 Wintrich, 1. c, p. 365. 744 FRAENTZEL.—DISEASES OF THE PLEURA. a haematothorax, these processes must of course be met by appropriate therapeutic measures. PNEUMOTHORAX. Hard, Sur le pneumothorax ou les congestions qui se forment dans la poitrine. These de Paris, 1803.—Piorry, Dictionn. des scienc. m€dic, T. XLIV., p. 370. —Davy, Philosoph. Transactions, II.—Bierre de Boismont, These de Paris, 1825.—Louis, Recherches sur la phthisic Paris, 1825.—Laennec, Traite de l'auscultation mediate, 1831, IIL—Martin Solon, Arch. Gengr., IX., pp. 468-469, 1835.—Siebert, Allg. medic. Zeitung, 1835.—Stokes, Dubl. Journ., November, 1849.—James Haughton, Encyclopadie der praktischen Medicin, Deutsch von Fraenkel. Berlin, 1840, Bd. III., pp. 523-531.— Puchelt, Doppelter Pneumo- thorax, Heidelberger medic. Annalen, Vol. VII., No. 4.—Saussier, Recherches sur le pneumothorax. These de Paris, 1841.—Mohr, A Case of Perforation of an enlarged Bronchus, Berl. Medic. Centralzeitung, 1842, No. 25; a second ana- logous case, eodem loco No. 29.—Hughes, Twelve Cases of Pneumothorax, Lond. Med. Gaz., 1844.— Chomel, Du pneumothorax, Gaz. des Hopitaux, 1845, Nos. 144 and 148.—Jul. Hotte, Ueber Pneumothorax. Inaugural Dissertation. Wiirzburg, 1848.—Hamilton Roe, Paracentesis in Pneumothorax, Lond. Med. Gaz., April, 1849.—Rumpf Ueber Pneumothorax. Inaugural Dissertation. Wiirzburg, 1849.—Ounsburg, Ueber Pneumothorax. Dessen Zeitschrift, III., 1852.— Woillez, La Guerison de Pneumothorax, Arch. g6ner., Dec, 1853.— Redar, Ein Beitrag zur Aetiologie des Pneumothorax, Berl. klin. Wochenschr., 1866, No. 39. — Curling, Case of Traumatic Pneumothorax, Paracentesis, Recovery, Med. Times and Gaz., 1867, Oct. 26.—von Oppolzer, Klinische Vor- lesungen iiber Pneumothorax, Wiener med. Presse, 1869, 31-34.—von Oppolzer, Ein interessanter Fall von Pneumothorax, Allg. Wiener med. Zeitung, 1868, No. 52.—Ramskill, Two Cases of Pneumothorax treated by Aspiration, Lancet, 1871, Aug. 19.—Baerensprung, II, Zur operativen Behandlung des Pneumotho- rax. Berlin. Inaugural Dissertation, 1873.—Tanne, Contribution a1 l'etude du traitement de l'hydropneumothorax par la ponction de la poitrine et les lavages de la plevre, Gaz. hebdom., 1873, No. 33.—Ewald, A. Untersuchungen zur Gasometrie der Transsudate des Menschen, Reichert's and Du Bois-Reymond's Archiv, 1873, No. 6.—Compare also the collected literature of Pleuritis. Introductory Remarks. The collection of any kind of gas in the pleural sac we call pneumothorax. If pus or blood should be present, before the entrance of air into the pleural cavity, we speak of a pyo- pneumothorax, or a hemato-pneumothorax ; but if, on the con- PNEUMOTHORAX. —ETIOLOGY. 745 trary, pus or blood enter the pleural sac at a later period, when it is already filled with air, then it is a case of pneumopyo- thorax, or pneumohaematothorax; but in ordinary medical phraseology these distinctions are not always carefully pre- served. History. Mention has been made incidentally by some of the older anatomists, such as Morgagni, Merkel, and others, of collections of gas having been occasionally found in the pleural cavities. Itard, who is said to have composed his work under the influ- ence of Bayle, was the first to describe the accumulation of air in one or other of the pleural sacs as a substantive disease, and to give it the name of pneumothorax. His view, indeed, as to the mode of origin of the disease is not very accurate, for he seems to have seen it developed only in this way, viz., as a residuum in the pleural cavity after the absorption of a pleuritic exudation. Laennec is the first to whom we owe an exact ana- tomical and clinical description of pneumothorax, and observers who have followed him have completed and extended his de- scription but in a few points only, and those chiefly in respect of the percussion signs. Etiology. The opinion has now long been rejected which prevailed in the first decades of this century, that air is secreted by the pleural surface, when it is intact, and accumulates in the pleural cavity; a few physicians, however, still believe that gas may be generated in the pleural sac from decomposition of a purulent exudation therein, without the entrance of air. No direct proof has ever been adduced of the origin of pneumothorax in this way ; indeed, it appears clear from the researches of Ewald' that no development of gas can ever take place in such a manner. There can be no doubt, therefore, that pneumothorax is always a secondary affection, and only arises when the pleura is so destroyed at some one spot that air can enter the pleural sac from udthout, or through the pulmonary alveoli or the bronchia. 1 Reichert's and Du Bois's Arch., 1873, No. 6. 746 FRAENTZEL.—DISEASES OF THE PLEURA. Among the causes which produce such perforations, external injuries must, in the first place, be mentioned ; as, for instance, penetrating wounds of the outer chest wall, wounds produced artificially in the radical operation for empyemas, and so-called "penetrating" wounds of the chest, by which sometimes only the external soft parts and the pleura costalis, sometimes also the pleura pulmonalis with the tissue of the lung, are lacerated. Sometimes, as in gunshot wounds, this kind of injury is inflicted on two different parts of the chest, the ball penetrating the lung on one side and coming out on the other. Thirdly, pneumo- thorax may occur when, without any injury to the external soft parts, the lung and the pulmonary pleura are lacerated by the sharp, piercing ends of broken ribs. If the perforation of the pleura costalis which occurs at the same time does not imme- diately close, more or less extensive emphysema of the subcu- taneous tissue will follow. Lastly, laceration of the lung tis- sue, and consequent pneumothorax, may take place, while the ribs and pleura costalis remain quite intact; as in violent contu- sions of the thorax from severe blows, or falling with one's horse, or being driven over, or the thorax being jammed by car- riages, machinery, or such like. In these cases the external force is sometimes not very great. I remember a case of pneu- mothorax which came on in a young merchant, nineteen years of age, who persisted in rolling a tolerably heavy barrel farther than his strength permitted. While doing this, and without the barrel having ever touched his chest, he had suddenly, when exerting himself the most, a feeling as of something having given way in his chest; he became short of breath and unable to go on with the exercise. The pneumothorax disappeared in about six weeks, and the lungs never showed any discernible pathological changes. Thus, with lung tissues evidently intact, the above-mentioned not very considerable exertion was suffi- cient to produce pneumothorax. Apart from these various traumatic causes, most of which are dependent on outwrard casualties, Laennec has rightly in- sisted that the internal disease which most frequently leads to pneumothorax is pulmonary tuberculosis, or, as we must now say, after the successful elucidation of the pathologico-anatomi- PNEUMOTHORAX. —ETIOLOGY. 747 cal appearances, caseous pneumonia, when decomposition of the caseous masses occurs in any portion of the surface of the lungs. This decomposition, or, in other words, the formation of cavi- ties, must take place pretty rapidly, or else some circumstances must exist which prevent the thickening of the portion of pleura pulmonalis lying over the small cavity, or hinder its adhesion with the pleura costalis. The thin covering of the lungs offers so slight a resistance to an abnormally great expiratory pres- sure, such as may be caused, for instance, by fits of coughing, or by straining at stool, or by any other kind of bodily effort, that it is then easily ruptured, and air passes from the pulmo- nary tissue into the pleural cavity. Therefore, in consumptive people violent fits of coughing and straining at stool are the most frequent immediate causes of pneumothorax. It is fre- quently maintained, by Niemeyer-Seitz for example, that it arises more frequently in pulmonary disease which runs a rapid, subacute course, than in chronic processes of the same kind ; but, in my opinion, this is incorrect. At least, in my depart- ment in the Charite, where every year fifteen or sixteen cases of pneumothorax come under post-mortem observation, most of which have arisen in the hospital itself, I find, in the majority of cases, the escape of air into the pleural sac takes place in ad- vanced caseous pneumonia running quite a chronic course. Certainly in many cases it does not come on till they are very much exhausted by the illness, and within twenty-four or forty- eight hours of obviously approaching death, in which case it may easily be overlooked, since the symptoms, as we shall dis- cuss in detail further on, are by no means conspicuous. Caseous pneumonia is frequently followed by empyema, and this may become the cause of pneumothorax, not by the spon- taneous development of gases from the exudation, but by the exudation breaking through the pleura pulmonalis into the bronchia. If the pus makes its way out through an intercostal space, the narrowness and tortuousness of the fistulous passage, and the distance of the outer from the inner opening, prevent the entrance of air into the pleural sac. It would wrell repay the trouble if more exact statistical tables were drawn up as to the causes of pneumothorax, in 748 FRAENTZEL.—DISEASES OF THE PLEURA. which, as Wintrich justly remarks, a much more prominent role must be assigned to caseous pneumonia, in the etiology of pneumothorax, than has hitherto been assigned to it. The num- bers, as Saussier gives them, supported on an analysis of 131 cases in which pneumothorax occurred, evidently give a too small comparative proportion to pulmonary consumption. From pulmonary consumption........... 81 times. " empyema......................... 29 " '' gangrene......................... 7 " " pulmonary emphysema............ 5 " " " apoplexy.............. 3 " " hydatids......................... 1 " " haematothorax.................... 1 " " abscess in the lung................ 1 " " cancerous ulcer................... 1 " " hepatic fistula communicating with lung........................... 2 " The mode of distributing patients in the different sections of the Charite, by which the greatest number of consumptive pa- tients are to be found in my division, makes it impossible for me to oppose to these numbers a statistical table of my own which would not run the risk of going into the opposite error; but approximatively I can, according to my own experience, venture to say, that of fifteen cases of pneumothorax one at most arises from empyema or other processes, and the remaining fourteen arise from vomicae on the surface of the lungs, in the course of a caseous pneumonia. Pneumothorax arises in connection with empyema in the fol- lowing manner: when, by an expiratory movement, the first pus which escapes into the lung through the perforated pleura pul- monalis is discharged externally, in the succeeding inspiration, when the thorax again expands, a corresponding amount of air is drawn into the pleural cavity. In this way a pyothorax becomes a pyopneumothorax. But from what has been said already as to the result of purulent pleuritic exudations, it will be evident that pneumothorax does not invariably follow the discharge of the pus into the lungs and bronchia. Should it, PNEUMOTHORAX. —ETIOLOGY. 749 however, set in, it may, if adhesions between the pleural layers exist, sometimes occupy only a limited portion of the pleural cavity, and is then a circumscribed pneumothorax. In a third series of cases it follows either direct necrosis of the pleura pulmonalis, or its ultimate laceration, when soften- ing of the lung tissue extends to its surface. We see this in abscesses of the lung, and especially in gangrene of the lungs, when it attacks peripheral portions of the lung tissue. Abscesses of the lungs, which occur almost exclusively after pneumonias, and especially after such cases as are of traumatic origin, occupy usually a central position, and only very rarely lead to such extensive destruction of the lung tissue as to reach the pleural surface, and consequently but seldom cause laceration of this membrane and escape of gas into the pleural sac. Also in cases of gangrene of lung occurring in connection with fibrinous pneumonia, and usually developing in the central portions of the lung, this circumstance seldom takes place. But sometimes even in this case, as I had an opportunity of seeing only a few months ago, the gangrene extends over the greater part of the inflamed lung, and reaches at last its surface, the pleura pulmonalis becomes necrosed, and then air, and with it a not inconsiderable quantity of gangrenous ichor, escapes into the pleural cavity. Somewhat more frequently pneumothorax arises in connection with bronchiectatic cavities lying quite near the periphery of the lung; these become the seat of a putrid bron- chitis, ulcerations of the bronchial walls follow, and by the extension of the putrefactive process to the pulmonary tissue gangrene of the lungs is developed, and this spreads to the sur- face of the lung. Air, however, enters the pleural sac most fre- quently in those cases of gangrene of the lung which occur in consequence of infective emboli being arrested in the smaller peripheral branches of the pulmonary arteries, and by means of which small, wedge-shaped portions of lung tissue at the sur- face of the lungs become broken down. In such cases it is not unusual for the gangrene not to have been diagnosticated at all. It is thus that pneumothorax arises in various kinds of surgi- cal diseases, when infective emboli pass into the circulation. It is most difficult to prove the connection when it proceeds from 750 FRAENTZEL.—DISEASES OF THE PLEURA. caries of the internal ear. Ulcerative endocarditis and pyophle- bitis may naturally in the same manner produce embolic gan- grene of the lungs and pneumothorax. We must enumerate amongst the causes of pneumothorax the cases which, though rare, certainly do occur, wherein emphysematously distended alveoli, lying immediately under the pleura, give way, and the pleura is at the same time lacerated. Pneumothorax may arise from perforation of the oesophagus in the posterior mediastinum, and simultaneous injury of the pleura, an accident more especially produced by ulceration, and chiefly cancerous ulceration, more rarely by the entrance of pointed foreign bodies, and most rarely by spontaneous rupture ; in this case the pneumothorax is complicated by the entrance of various kinds of food into the pleural sac. The following causes of the entrance of air into the pleural cavity are very rarely met with : Suppurating bronchial glands perforating both into the bronchi and through the mediastinum into the pleura at the same time (in the few cases that have been observed it has been into the left pleura); 2d, hydatids of the lungs bursting into the pleural sac ; 3d, an abscess in the abdom- inal cavity discharging itself, at the same time, through the dia- phragm into the pleura, and into an abdominal organ perme- able to air; this has been observed to occur in an echinoccus cyst of the liver, which burst simultaneously into the pleura and the intestine. Form and General Course of the Disease. As pneumothorax is always a secondary affection, its form will be specially modified according to the nature of the primary malady. In many instances it comes on in cases of advanced phthisis, without any particular complaint on the part of the patient, and without any decided aggravation of the previously existing dyspncea ; and it is only on a closer examination that we dis- cover the presence of an accumulation of air in the pleural cavity. Generally, however, at the moment the pleura is lacer- ated, even quite apart from traumatic cases, the patient has a PNEUMOTHORAX.—ANATOMICAL CHANGES. 751 very distinct feeling as if something had given way in his chest. From that moment painful sensations are, for a long time, felt in the lower part of the chest on the affected side, and in fatal cases tliese continue till the end. Dyspncea, increasing in intensity, and often becoming rapidly very distressing, sets in at the same time, and frequently a few minutes after the first feel- ing of pain the patients are obliged to sit upright, or to lie altogether on the affected side, in order to facilitate as much as possible free movement of the sound lung. At the same time deep cyanosis quickly appears, and sometimes in the first few days dropsical swelling of the face and limbs supervenes. The pulse becomes small, the extremities cold. Sometimes patients die of acute collapse, or in consequence of the great impediment to respiration, a few hours after the occurrence of pneumothorax. In other cases death may not follow for days, weeks, or even months, especially when the secondary pleuritis develops in a regular manner, and is attended with abundant exudation. In such cases wTe now succeed in curing even those which are of the most serious nature, by mak- ing incision into the pleural cavity; and even in earlier times some simple cases of pneumothorax, even in phthisical patients, have been known to be completely cured, and this is generally the result in traumatic pneumothorax unattended with serious complications. Anatomical Changes. I cannot, of course, in this place enter minutely into the anatomical changes caused by the various primary processes of disease, but I can only mention those which are peculiar to pneumothorax as such. We generally notice, even in the external examination of the corpse, a considerable expansion of one side of the thorax, espe- cially at the lower part, with intercostal spaces much stretched and strained. As a rule, when we puncture the side of the thorax which contains the air, it escapes from the pleural cavity with a faint blowing or hissing sound. A little flame held in front of the opening is blown out. If we make the opening into the affected pleural cavity under water, or pass into it a per- 752 FRAENTZEL.—DISEASES OF THE PLEURA. forated needle to which an India-rubber tube, opening under water, is attached, the air escapes in separate bubbles. Some- times, however, the pressure to which the air in the pleural cavity is submitted is so slight that there is neither any bulging of the affected side of the chest, nor, when the pleural cavity is punctured, does the air escape under any noticeable pressure. The amount of air in the pleural cavity varies from a few cubic centimetres to two thousand and more. The more easily it enters and the more difficult it is for it to escape, the greater will be its amount (Wintrich). This we see when a moderate-sized perforated opening in the pleura pulmonalis exists, over which fibrinous coagulations, etc., lie and act like a valve, so that in successive inspirations (all the more rapid on account of the dys- pncea) a certain amount of air rapidly escapes, and this goes on until the greatest possible displacement of adjacent organs, and of the thoracic walls, and the greatest j)ossible degree of com- pression of the affected lung are attained. The lung at first recedes very rapidly by means of its power of retraction ; when this is spent it becomes still more compressed if the air is pre- vented from escaping again during expiration. The extent of the accumulation of air in the pleural cavity will depend on the following circumstances : 1. The compressibility of the lung, i.e., the absence of any disease rendering its tissue hard and incompressible ; 2. the expansibility of the thoracic wall and the mobility of adjacent organs, i.e., the absence of any upward pressure from the abdo- minal organs and the absence of any accidental ossification of the costal cartilages ; 3. the capacity of the pleural sac itself ; and, 4. the less incompressible fluid (or only very slightly compres- sible by the gas) it contains. Even when the perforation in the pleural cavity is not covered by a fibrinous flap, making the egress of air in expiration impossible, but allowing it to make its way in inspiration, yet as the retraction of the lung advances and the quantity of air increases, the pressure of the air alone is sufficient to close the perforated openings, so that while air can indeed make its way in during forced inspiration, it cannot pass out again in expiration, and finally both are impossible. The less the lung can contract and the more fluid there is PNEUMOTHORAX.—ANATOMICAL CHANGES. 753 accumulated in the pleural cavity, the smaller will be the quan- tity of gas therein. On analysis by Davy, Martin, Solon, and others, the gas col- lected in the pleural cavity appears to be composed chiefly of carbonic acid and nitrogen, and contains but little oxygen, besides also some sulphuretted hydrogen, if at the same time there should be an accumulation of ichorous pus in the pleural sac. It is, however, very rare for the pleural cavity to contain air exclusively,—according to Monneret and Fleury, only sixteen times in 147 cases. If the patient has survived the entrance of air into the pleural cavity for only a few days, pleuritis will gen- erally be found to exist, and be attended with sero-purulent exudation, which increases rapidly in quantity, and with its increase in volume gradually presses more and more upon the air in the pleural cavity, until finally it may cause it to disap- pear altogether. The question has been much discussed whether in these cases the entrance of air, as such, into the pleural cavity produces the purulent inflammation. This must be denied unconditionally in the case of air which is not charged with infective germs. If, however, we consider the origin of pneumothorax, we shall find that, as a rule, not only air, but also decomposed tissue-elements in greater or less quantity make their way into the pleural sac, and these must be regarded as the excitants of a purulent, or, as for example, when gangrenous ichor flows into the pleural cavity, of an ichorous inflammation. It is only in traumatic cases, or when very small quantities of decomposed lung tissue enter the pleura, that purulent inflammation is absent. Supposing, now, that air alone, or air and fluid are in the pleural sac, we shall find the lung for the most part quite void of air, and reduced to a very small volume lying near the verte- bral column. This is always its position, unless by old adhe- sions it has been fixed to some other part of the wall of the chest. Sometimes, in very rare cases, the perforated spot is found immediately on dissection, and is, occasionally, even as large as a five-groschen piece. In many other cases it is difficult to find, and it is only by inflating the lung under water that it can be discovered, as it is covered over with fibrinous deposits. VOL. IV.—48 754 FRAENTZEL.—DISEASES OF THE PLEURA. Finally, in other cases the opening, which may have been very small at first, is completely closed, and cannot be found again. Displacements of neighboring organs and distention of the wall of the chest are often more considerable in pneumothorax than in pleuritic effusions. These displacements are the same as I have already described under pleuritis, only that the heart is more frequently found displaced from before backwards, a very rare circumstance in pleuritic effusions. Occasionally the escaped air is enclosed in a space of mo- derate extent, shut in on all sides by adhesions; then it is only the adjacent portions of the lung that are compressed, the thorax is only partially distended, the heart and the liver usually are not displaced ; the diagnosis of a circumscribed pneumothorax is difficult during life. Symptoms. Pneumothorax, as such, is never attended with fever. We never, therefore, observe rises of temperature in connection with entrance of air into the pleural sac. Should they appear, then they have either existed before, and are manifestations of the original disease, or they are new, and, occurring in the course of pneumothorax, are signs of secondary pleuritis. Immediately, on the occurrence of pneumothorax, the temperature not infre- quently sinks below the normal to 97° F., and under. This is always a bad sign, especially when associated with a consider- able rise in the frequency of the pulse, up to 140 beats and more in the minute; but even without any remarkable sudden collapse, an accumulation of air in the pleural sac will almost always be attended by a considerable rise in the frequency of the pulse (from ten to twenty beats), at the same time the radial arteries will appear smaller and less tense, for, in consequence of the compression of the lung, there will be naturally less blood arriving in the left auricle and, therefore, in the left ventricle and the aortic system. In the majority of cases, with the occurrence of pneumotho- rax, not only do the respirations become greatly increased in fre- quency, up to from forty to sixty in the minute, but also dysp- noea of the most severe and distressing kind sets in. In a not PNEUMOTHORAX.—SYMPTOMS. 755 inconsiderable number of cases, however, there is no dyspncea, and even the respirations are scarcely increased in frequency; tliese are always very debilitated individuals, generally suffering from advanced phthisis, and on account of their bloodlessness \the medulla oblongata is imperfectly nourished, and therefore of diminished excitability, and owing to the small amount of blood in circulation the greatest embarrassment of respiration is inca- pable of producing any considerable accumulation of carbonic acid in it, and so of abnormally exciting the respiratory nerve- centre in the medulla oblongata. We see, therefore, in these cases the same conditions come into operation as we have already more minutely described in pleuritis. The same amount of compression of the lung by pneumothorax will at one time produce the most formidable dyspncea, while at another time scarcely any noticeable change in the condition of the patient occurs. Thus I often find in my department, amongst persons in advanced phthisis, whose respiratory organs I am induced to re-examine, either because of the position they assume, or because of the frequency of their pulse, or for some other reason, but not because they suffer from dyspncea or make any particular complaint, that a pneumothorax exists, without being able to decide with any certainty the time of its first setting in. In such instances pneumothorax has come on quite impercep- tibly, and has been attended with no kind of inconvenience to the patient. Orthopnoea is generally combined with severe dyspncea, as in pleuritic effusions, so long as the sensorium is unaffected and the strength of the patient is sufficient to support him in an upright position. This, however, is often not the case with consumptive patients, and towards the end of their life. Such patients are then observed to lie invariably on the affected side, in order to facilitate as much as possible free movements of the uncom- pressed lung ; indeed many of them, in this position, have no dyspncea whatever, but are attacked by it as soon as they are compelled to assume any other. These patients are evidently in transition to the condition just described, in which dyspncea is altogether absent. Quite peculiar positions will sometimes be assumed by indi- 756 FRAENTZEL.—DISEASES OF THE PLEURA. vidual patients temporarily for the alleviation of their sufferings. Henoch has described a most striking instance of this: a man affected with pyopneumothorax lay on his back whenever his dyspncea increased with an increase in the accumulation of pus in the pleural sac, and he, at the same time, kept the upper part of his chest lower than the under. Then he discharged, in a stream, a great quantity of pus from his mouth, and felt himself relieved for a long time. In this case dissection showed in the upper part of the lung a wide communication between the pleu- ral cavity and a bronchus which had remained open in the com- pressed lung; the pus could pass into this opening only when the patient assumed the position described. The pain observed in pneumothorax is generally too slight to influence the position of the patient, or to increase at all what dyspncea may already exist. Most patients feel a decided pain the moment when air enters the pleural sac ; they generally say that at this moment they have a feeling "as if something had given way in their chest;" others declare, according to Stokes and Louis, that they felt the entrance of air like a wind stream- ing from below upwards. This sudden feeling of pain can scarcely be explained by the laceration of the pleura pulmo- nalis, which, previously to this, is generally in a state of decay, but by the strong tension which the whole pleural sac experi- ences. Therefore the painful sensation never quite ceases dur- ing the early part of the illness, at least in the lower part of the affected side. Some days later there is often increase of pain with feverish symptoms; an indication that secondary pleuritis has supervened. If the pneumothorax is altogether unattended with symp- toms, or if the sensorium is affected, there is no complaint of pain. Should the pneumothorax be attended with distressing dysp- noea, the voice is apt to become weaker and lisping, and even aphonia may sometimes be observed. The presence or absence of cough and expectoration will depend on the cause of the pneumothorax. If it is caused by the perforation of a purulent exudation through the lung into a bronchus, and in place of the pus air enters the pleural sac, then PNEUMOTHORAX.—SYMPTOMS. 757 the pus is generally discharged from the mouth in streams, attended with most violent fits of coughing. Should the pneu- mothorax arise from some other cause, then the acute lung-insuf- ficiency may so weaken or even annihilate the expiratory power that a vigorous cough becomes impossible. Whenever pneumothorax is attended with much dyspncea, more or less marked cyanosis frequently appears on the visible mucous membrane, as well as on the cheeks, nose, ears, and not seldom also on the hands and feet. If the difficulty and oppres- sion of breathing are very great, the extremities and the tip of the nose become cold, cold clammy perspiration covers the skin, especially of the head, and at last the tongue, deeply cyanosed, becomes cold, and finally death ensues from suffocation. If, on the other hand, a patient with pneumothorax continues to live, notwithstanding an extreme amount of dyspnoea, then, after a few days, cedema of the face and extremities comes on, owing to the great venous obstruction. Sometimes, when pneumothorax has long existed, a general subcutaneous emphysema is devel- oped, and is somewhat rapidly and widely diffused. This hap- pens through the destruction, in some spot or other, of the pleura costalis, so that air from the pleural sac can reach the subcutane- ous tissue. This emphysema is observed most strikingly in the case of rupture of the oesophagus, when laceration of the pleura and admission of air into the pleural cavity, and the diffusion of air through the subcutaneous tissue follow as simultaneous effects. This cutaneous emphysema is, however, sometimes observed in caseous pneumonia, without pneumothorax, in the case of a vomica reaching as far as the pleura pulmonalis, caus- ing adhesions between this and the pleura costalis, and perforat- ing both pleural folds at once. We can never, therefore, look on the cutaneous emphysema as a characteristic symptom of pneu- mothorax. Simultaneously with the appearance of pneumothorax, and in pretty direct relation with the other symptoms of venous stasis, there is a diminution in the quantity of urine ; it becomes red and dense, and often contains, as urine in venous congestion generally does, small quantities of albumen. There are no other morbid symptoms connected with the nervous system or the 758 FRAENTZEL.—DISEASES OF THE PLEURA. digestive apparatus, and characteristic of pneumothorax, which need be mentioned. Pneumothorax is generally associated with displacement of adjacent organs. Inspection and mensuration show us that the affected side is more bulged than the other; the intercostal spaces also are stretched, and sometimes even forced outwards. The affected side moves less in inspiration than the sound side ; sometimes it is quite motionless. On the contrary, we some- times seem to detect a stronger expansion on the affected side, because of the fact that in the front of the chest wall the highest ribs are more strongly elevated than on the sound side ; but, on closer examination, we notice that the whole of the rest of that side of the chest remains unexpanded, and that the phenomenon we have described depends on the circumstance that the inspira- tory muscles on the affected side contract more strongly, and therefore the upper ribs simply are more raised than those on the sound side. The pectoral fremitus cannot be estimated in cases which run a rapidly fatal course, on account of the weakness or loss of voice ; in other cases, it is either entirely absent or very consid- erably weakened on the affected side. But we must not con- clude because of the presence of pectoral fremitus, that the stratum of air is a small one. I have frequently convinced myself of the fact that pectoral fremitus may be present even when there is a great accumulation of gas in the pleural sac ; it is then probably conducted from the healthy lung, or from parts of the affected lung adherent to the wall of the chest. For where the lung is fastened to a part of the chest wall by adhe- sions of the pleural folds, their vocal vibrations not only exist, but are often of normal, and sometimes even of abnormal, strength. Hence vocal fremitus is rarely quite absent at the posterior wall of the chest, where the lung lies closely com- pressed against the spine. If there is fluid as well as air in the pleural sac, the pectoral fremitus will not be influenced by it, but one notices in the inter- costal spaces, corresponding to the situation of the fluid, a greater resistance on palpation, which (as changes of position of the patient change the boundary level of the fluid, according to PNEUMOTHORAX. —S YMPTOMS. 759 the laws of gravity) sometimes enables us to define pretty accu- rately the limits of the exudation. The evidences of displacement of adjacent organs, which are afforded by inspection, palpation, percussion, and eventually also by auscultation, are in no respect different from those described under pleuritic exudations, and need not therefore be dwelt upon again. But we do not find expansion of the chest wall and displace- ment of adjacent organs in every case of pneumothorax. This will entirely depend on the tension of the air in the pleural sac. Should this be slight, we shall find valuable diagnostic support in the little expansion of the affected side in breathing, and in the absence or diminution of the pec toraL fremitus, as ascer- tained by inspection and palpation. Sometimes also the thorax, in spite of the existence of pneu- mothorax, is abnormally depressed. This is generally observed either after the radical operation for empyema, or when an em- pyema bursts into the bronchia, or when, after this accident has happened, the radical operation is performed as a supplementary measure, and occasionally even when the empyema has made its way out externally, although in the latter case the canal through which the pus passes, as we have already said, is nar- row and sinuous, so that, as a rule, the air from without cannot enter the pleural sac. The signs appreciable by inspection and mensuration are, as soon as the thorax wall has sunk in, the same as in purulent pleuritis with retrecissement thoracique. If the affected side of the chest is just sufficiently movable, in inspiration and expira- tion, to allow of the ingress and egress of small quantities of air through the external opening, then the existence of these cur- rents can be prettily shown by means of a light feather, the flame of a candle, and the like. The palpation signs are usually the common ones; but there is nearly always a feeling of greater resistance, on account of the pretty constant existence of thick membranes. The resonance on percussion, at the places where the air lies next to the wall of the chest, is abnormally loud, deep, and tym- panitic, and it is only occasionally, when the tension within the 760 FRAENTZEL.—DISEASES OF THE PLEURA. pleural cavity is very great, that the tympanitic note is absent. This abnormally loud and deep resonance, spread over the whole side of the chest, is one of the most characteristic signs of the presence of pneumothorax. This resonance extends also abnor- mally low down, so that in right-sided cases the liver may lie quite outside the osseous thorax, and in left-sided cases the semilunar space may quite disappear; at the same time the abnormally loud and deep resonance frequently extends beyond the sternum and encroaches upon the healthy side as far as the parasternal line and beyond it. Sometimes, on strong percus- sion, the sound has a metallic echo; but this is only to be heard generally when we auscultate, and, therefore, in so-called auscul- tatory percussion. We place the stethoscope on one part of the chest, and strike the wall of the chest at another part with the broad surface of the plessimeter; in this way we best throw the contained column of air into oscillation. It is here immaterial of what substance the plessimeter is made. We do not always hear the metallic clang in the lifetime of the patient, but it is almost always discoverable in the dead body. The conditions which here come into consideration have been stated with great clearness by Traube.1 The reflection of the waves of sound in the pleural sac is necessary to the production of the metallic echo, and for that a certain degree of tension of the surrounding walls is needful. If this degree is exceeded, the phenomenon can no longer be elicited; therefore it is that it often fails during life. By the cooling of the gas after death the tension must obviously be reduced, and it will then become just sufficient to enable us to hear the metallic clang again. Experiments, easy of repetition on the dead body, give complete proof of the accu- racy of Traube's views. The tension is sometimes, however, too slight to make the reflection of the sound waves in the pleural sac possible, or, in other words, to produce the metallic echo by auscultatory percussion. Biermer has called attention to the fact that the metallic clang of a pneumothoracic space is several tones deeper in standing than in lying. The cause of this he believes to be the lengthening of the column of air through pres- sure on the diaphragm in standing. 1 Beitrage, II., p. 1034 et seq. PNEUMOTHORAX.—SYMPTOMS. 7G1 The appearance of the metallic echo is quite independent of the question whether there is fluid as well as air still in the pleural sac. The percussion sound, on the contrary, is naturally very much influenced by the co-existence of fluid effusions. Wherever these lie close beneath the wall of the chest the sound is intensely dull and forms quite a sharp contrast with the abnormally loud and deep sound, which is always heard when air lies immediately under the thoracic walls. Every change of position of the patient is attended with a change in the level of the exudation, and a consequent modification of the area of dul- ness. If the pneumothorax has been caused by the rupture of an empyema into the bronchia, and if purulent discharges still take place with fits of coughing, then, after every such discharge, the dulness assumes a discernibly lower limit. Should the wall of the chest be lined at any spot with thick membranes, then the resonance will not be very loud and deep, even if pneumo- thorax be present. If a communication exists between the pleural sac and the outer air through an aperture of any con- siderable size, then we shall get, on percussion, an exquisite bruit de pot fete, which again disappears when the aperture becomes firmly closed. Nothnagel has observed this in cases of recent penetrating wounds in the chest. We hear it most beautifully some days after the radical operation for empyema has been performed, and the incision in the chest is still wide open. It is evidently caused by a portion of the air contained in the pleural sac being driven through a narrow aperture by the percussion blow. By means of succussion, i.e., giving the patient a slight jog, a proceeding formerly commended by Hippocrates, and which is best carried out by laying hold of him by the shoulders with both hands, and communicating a few short movements to the thorax, then if there are both air and fluid together in the pleural sac, usually a clear, metallic, splashing sound is pro- duced, similar to that caused by pouring fluid into a partially filled jar. Sometimes a sudden shake or turn on the part of the patient himself will produce this. This sound is sometimes entirely absent, and for the same reasons that the metallic echo is sometimes absent on auscultatory percussion; sometimes it 762 FRAENTZEL.—DISEASES OF THE PLEURA. can only be heard when we listen directly for it; in other cases again it is so intense, that it can be heard at the other end of the room. Occasionally, also, we can feel plainly the washing of the fluid against the wall of the chest. Sometimes the patient himself, when he moves, hears the metallic splashing. All the auscultatory phenomena which arise in the lung, the bronchi, the larynx, etc., external to the pneumothoracic space, take on a metallic reverberation, when between the patulent bronchi or vomicae, etc., rendered more capable of sound con- duction by compression, infiltration, hepatization, etc., and the air-containing pleural sac, the layers of lung tissue are not so thick as to greatly weaken or entirely prevent the transmission of the resonant vibrations. Since patients under the given conditions are for the most part very weak-voiced or quite aphonic, and as the dyspncea is great and the respiratory move- ment arrested, we may often hear nothing whatever on the affected side, or only an aphonic expiratory murmur, and occasionally dry and moist rales, or, if the pneumothorax is on the left side, the heart-sounds with metallic resonance. If there is a considerable amount of fluid in the pleural sac, in addition to the accumulation of air, then we often observe the metallic phenomena that may be present much more clearly when he is sitting up than when he is lying down. This is due simply to the fact that in the latter position a larger stratum of fluid inter- venes between the lung and the wall of the chest, and then, when he sits up, sinks down, and thus keeps the lung and thorax wall further apart. Under these circumstances we sometimes also hear Laennec's tintement metallique (metallische Tropfen- fallen). Complications and Sequela. All those diseases which we have mentioned as possible causes of the entrance of air into the pleural sac may be looked upon as complications of pneumothorax, and we need not now repeat them. Pleurisy may be spoken of as a sequela, and of its course we have already treated. PNEUMOTHORAX.—DIAGNOSIS. 763 Diagnosis. Dyspnoea coming on suddenly, accompanied with pain, dila- tation of the thorax, displacement of the diaphragm and heart, a metallic clang, and deep, tympanitic percussion resonance, merging below in an area of dulness, the level of which changes with the position of the patient, succussion sounds; all these evidences, when they coexist, establish pretty clearly the diag- nosis of pneumothorax or pyopneumothorax. If, however, very isolated symptoms are observable, and especially if the metallic phenomena are entirely absent, then an error in diag- nosis may very easily be made. This remark applies particu- larly to circumscribed pneumothorax, the diagnosis of which I take to be very uncertain in most cases. The conditions most likely to be confounded, diagnostically, with pneumothorax are large vomicae, as they frequently occur in caseous pneumonia, and more rarely in connection with gan- grene of the lung, pulmonary abscess, and bronchiectasis. The former are, as a rule, limited to the upper part of the lung, whereas pneumothorax is scarcely ever so restricted. In pneu- mothorax metallic phenomena of some kind or other are almost invariably present, and the same is often also the case with large vomicae ; but in the former case the chest wall is usually greatly dilated, in the latter it is retracted ; in the former we generally perceive succussion sounds, at any rate when fluid is present at the same time; in the latter it is quite an exceptional phenom- enon ; in pneumothorax the pectoral fremitus is either quite absent or very considerably weakened ; in the case of large vomicae it is generally not weakened and may even be increased. If, however, the healthy tissue of the lung below the large vomica has suffered extreme compensatory distention, then the percussion sound may become abnormally loud and deep, and reach unusually low down, while displacement of the heart towards the other side may be produced by retraction of the other lung. If we get this percussion sound in a man with extreme dyspnoea, and who is so weak that the test of pectoral fremitus cannot be applied, and in whom, together with com- mencing stertor, a metallic clang may be heard in any part of the 764 FRAENTZEL.—DISEASES OF THE PLEURA. chest on auscultatory percussion, we are in the habit of con- sidering ourselves justified in diagnosticating pneumothorax, and even here we may be in error, as is clearly seen from what we have just said. I have myself twice made this mistake, and I have since become incomparably more cautious in diagnosticat- ing pneumothorax. This is all the more imperative before we accept the existence of a circumscribed pneumothorax, for in this case, even if all the symptoms are present, they are less marked, more especially the signs of displacement. Even the Hippocratic succussion sound is not, as many suppose, charac- teristic of pneumothorax. It may be heard in some cavities which contain a great deal of secretion. I observed this two years ago, in a consumptive girl, twenty three years of age, who died in the Charite, in whom, on autopsy, no pneumothorax was discovered, but only an enormous cavity in the upper part of the right lung, whence proceeded the succussion sound. When there is considerable retraction of the left lung, and, in consequence, a greatly elevated diaphragm and distended stomach, succussion sounds may be heard over the latter organ, and this, taken in conjunction with the absence of respiratory murmur, and perhaps the transmission of the rales (generated in the contracted lung) through the stomach, with a metallic rever- beration—as well as the presence of an abnormally loud, deep, tympanitic percussion sound—will often mislead beginners into making a diagnosis of pneumothorax ; but the simple considera- tion of the course of the disease, of the retraction of the chest, of the absence of cardiac displacement, etc., ought to afford sufficient protection against such an error. If we wish to be quite certain, we may, in addition, follow the advice of Piorry, and make the patient drink a large draught of liquid; by this means, if the above phenomena proceed from the stomach they will be made to undergo a very striking change. Still less likely are we to find any difficulty in distinguishing it from simple enlargement of the lung, the falsely so-called emphysema of the lung. For this is commonly double-sided, and is very slow in developing. It leads, as a rule, to much less displacement of the diaphragm ; distinct pectoral fremitus is to be felt, and breath sounds without any metallic resonance may PNEUMOTHORAX.—PROGNOSIS. 765 be heard, although the percussion sound over the lungs appears sometimes as loud, deep, and tympanitic as in well-marked pneumothorax. Wintrich mentions yet another case in which he erroneously diagnosticated pneumothorax : it was a case of perforating ulcer of the stomach, in which the perforation communicated with the sac of an abscess situated between the diaphragm, liver, and spleen. This is naturally a very rare event, and not very likely to come under observation again. In the diagnosis of pneumothorax, as well as in all other cases, we must lay to heart the old medical axiom, not to attach too great a value to individual symptoms—and in this case, especially, to the metallic phenomena—but always base our diagnosis on the sum of the symptoms. The greater the num- ber of the positive symptoms of the disease on which it is based, the more certain will our diagnosis be. Duration, Results, and Prognosis. The duration of the disease depends, in the first place, upon whether it has arisen in a previously healthy person, in conse- quence of a wound, or whether it is secondary, and has come on in the course of a serious primary affection. In the latter case it will depend on the severity of the primary illness, and at what stage of it the pneumothorax appeared. We must also take into consideration the amount of the gas and the rapidity with which it accumulated, the compression of the lung, and after- wards of the adjacent organs ; the extent of the secondary pleu- ritic exudation, and finally, the general condition of the patient. Death may sometimes occur a few minutes after pneumo- thorax has set in. The danger is greater the more powerful and more robust the individual, and the less accustomed he is to pulmonary insufficiency, as we have pointed out more circum- stantially when speaking of dyspnceic symptoms. In other cases the patient may live for weeks, months, and even years, so that it seems impossible, in general, at the beginning of a pneumothorax, to determine what may be its precise course; and in the same individual case we may meet with the greatest 766 FRAENTZEL.—DISEASES OF THE PLEURA. fluctuations in the severity of the local as well as the general symptoms, without, at any time, being justified in coming to any definite conclusion as to the further duration of the illness. Death is the most common result. If the pneumothorax has been caused by gangrene of the lung, the fatal event usually occurs within the first twenty days. The fatal result may be deferred for months, if it depends on the entrance of air into the pleural sac, as an event of pulmonary consumption, or if it is caused by the secondary development of a purulent or ichorous pleuritic exudation. Recovery is a much rarer event, and it is either incomplete, —that is, when the original disease is not overcome, as in caseous pneumonia,—or it is complete, as in the case of traumatic pneu- mothorax, or in those cases in which an empyema discharges itself into the bronchia. In the one series of cases the perfo- rated openings close up, and the gas in the pleural cavity is gra- dually absorbed; thus we may sometimes discharge consump- tive patients, who have come under hospital treatment for pneu- mothorax, in a few weeks as cured, that is, incompletely cured. If a pneumothorax arises in the course of a purulent pleuritic exudation, in consequence of its rupture into the bronchia and admission of air into the pleural sac, a perfect cure may often be brought about by the radical operation for empyema, as we have already mentioned, if no complication spring up. It is clear from what has been already said, that in individual cases of pneumothorax, when we are not fully acquainted with the particular conditions on which it depends (and even in cases where this is possible) the prognosis must often remain doubtful. Generally it must be very unfavorable, but less on account of the mere presence of air in the pleural sac than on account of the incurable and dangerous nature of the original maladies. The extension of the pneumothorax, the pressure which it exercises on important organs, and the consecutive results (purulent or ichorous formations in the pleural cavity, etc.), will naturally influence considerably the prognosis. The prognosis is relatively most favorable in traumatic cases, and cases which have arisen out of a purulent pleuritis ; it is least so when the primary disease is gangrene of the lung or cancer of the oesophagus. PNEUMOTHORAX.—TREATMENT. 767 Treatment. In the different forms of pneumothorax treatment must in the first place be directed to the original diseases, and to the secon- dary pleuritis, with its various consequences. This, of course, is not the place to discuss the treatment of the original diseases, and, with regard to pleuritis, we must refer generally to what has already been said on that subject. As soon as a pyothorax has become a pyopneumothorax, in consequence of the discharge of a purulent pleuritic exudation into the bronchia, then we must not lose a moment's time in performing the radical opera- tion by incision. The earlier this operation is undertaken, the more favorable are the results we may expect from it. The same advice applies to traumatic cases of pyopneumothorax. As soon as this view obtains universal acceptance in our field- hospitals, the results which attend penetrating wounds of the chest will take a more favorable form. It must be admitted that every such case requires for its perfect treatment (and that alone furnishes success) an enormous expenditure of time, and this, in the first days and weeks which follow a battle, is only too sparingly measured out to the overworked ambulance surgeons. It is much more difficult to determine whether we should or should not operate in those cases in which a purulent pleuritic exudation is superadded to pneumothorax, when this has been caused by some internal malady, as is most frequently the case with phthisical patients. In favor of operating it may be urged, in the first place, that the patient often suddenly relapses when a purulent pleuritis develops, even when the lung disease is not very far advanced ; and, in the second place, that the exudation frequently reaches such a height that danger to life necessitates an operation. Against operating, however, it may be stated that consumptive patients ofte nlive for years with a pyopneu- mothorax, if the absorption of pus be prevented by the pleural cavity becoming closed over with a thick pyogenic membrane, and thus the occurrence of purulent fever has become impos- sible ; while on the other hand they generally succumb very rapidly after the radical operation, through ichorization of the 768 FRAENTZEL.—DISEASES OF TIIE PLEURA. pleural cavity, to prevent which, in such cases, all our care in dressing, and all disinfecting agents have proved of no avail. In my own mind, since I have adopted the method of treating purulent exudations which I have already described, the ques- tion is not yet decided one way or the other, for I have had but few opportunities of carrying out the after-treatment I have detailed in cases of this kind. Such experience as I have hitherto had has been unfavorable, and would lead me to abstain from the operation, unless it was rendered imperative by the presence of symptoms dangerous to life, for hitherto such patients as I have operated on in the circumstances described have all sunk rapidly. In future I should not unhesitatingly attempt the radical operation, except in cases where the primary lung affection had made but very little progress, and especially when the uncompressed lung remained free from disease. In such cases I should attempt it, even if there were no immedi- ately threatening symptoms present. As to the escape of gas itself, and its effects, we can only here speak of a symptomatic and palliative treatment. To relieve the pains which are pres- ent at first, and the distressing dyspncea, we should use small subcutaneous injections of morphine. The patient should also be dry-cupped, and if he be still strong and well nourished, some blood may be taken at the same time, with the view of pre- venting the supervention of secondary pleuritis, or at least moderating its development. We should give mild antiphlogis- tic remedies internally, especially potassium or sodium nitrate (a drachm and a half to about three and a half ounces of water). Even in cases attended with extreme dyspnoea I would not recommend venesection, because it could at best produce only transient relief, and is always attended with the danger of increasing the tendency to collapse. When the first and most pressing danger is over, we must be careful to order the patient a nourishing diet, easy of digestion, and to take care that the bowels are daily relieved by enemata. If we do not attend to this last point, an increase of dyspncea often comes on in consequence of constipation. If death from suffocation seems imminent on account of the pneumothorax, a portion of the air must be let out by punctur- PNEUMOTHORAX. —TREATMENT. 769 ing the pleural cavity with a capillary trocar. We may in this way succeed, at least for a time, in averting the danger which threatens the patient's life. The operation can, of course, only be of use when the wound in the pleura, through which the air has entered the pleural sac, is closed again, and the pressure within the pleural cavity is greater than under normal condi- tions. It is impossible to ascertain both these points before operating. There are no data whatever for determining the first; with regard to the second, the principal indication is derived from the displacement of adjacent organs, but this is often very considerable in protracted pneumothorax, without the pressure within the pleural cavity being greater than that of the atmos- phere ; in other rare cases, however, no symptoms of displace- ment exist, while the tension of the gases contained in the pleural sac is very considerable. We rarely obtain a favorable result if we are compelled, on account of threatening asphyxia, to puncture the chest even after the onset of pneumothorax, because the pleural wound is not yet healed. If, however, the perforation be very small, and readily united, the healing process is generally complete in three or four days, and by this time there is, as well as considerable displacement of adjacent organs, almost always a great amount of intra-pleural pressure. At this time, therefore, we obtain the best results by puncture. It is, therefore, my habit, when a pneumothorax comes under my treatment from four to eight days after its onset, and is attended with evident displacement of adjacent organs, to puncture, even if there is no present dan- ger to life, because by so doing we greatly diminish the pressure on the sound lung, and on the heart, and after we have let out a portion of the air the remainder will naturally be absorbed more easily and rapidly. Proof that I have obtained good therapeutic results in this way may be found in Baerensprung' s' inaugural dissertation, in which a series of cases treated by me in this way are cited. Should the pleural wound be very large, and not closed, puncture with a capillary trocar has no kind of ill effect. 1 Zur operativen Behandlung des Pneumothorax. Berlin, 1873. VOL. IV.—49 770 FRAENTZEL.—DISEASES OF THE PLEURA. I am in the habit of using in this operation my capillary trocar which I have already described, and I cover its lateral opening with a piece of gold-beater's skin. The trocar, in the manner before described, is introduced between the fourth and fifth ribs, somewhat outside the mammary line, the stylet is drawn back, and then the top of the lateral tube is opened, while the end of the gold-beater's skin is sunk in water. We then see the air escape out of the water in separate bubbles, until the pressure within and without the pleural cavity is equally balanced. During inspiration the gold-beater's skin acts as a valve, and applies itself to the opening of the lateral tube, so that neither air nor water can be drawn into the pleural cavity from without. When this point is reached we remove, in the manner already mentioned, the trocar from the pleural sac, and close the little puncture-wound with a strip of adhesive plaster, and apply an ice-bladder to the wound for twenty-four hours, keeping the patient completely quiet. It is not unusual for violent fits of coughing to come on during the escape of the air, as in the withdrawal of pleuritic exudations. Should this be the case, do not remove the trocar till the cough has entirely ceased, and for this purpose admin- ister subcutaneous injections of morphine; or, remove the instru- ment and compress the passage it has made, for a time, until every trace of irritative cough has disappeared. If wre are not careful about this, then air passes out of the pleural cavity in coughing, enters the canal made by the puncture, and thence passes into the subcutaneous connective tissue. The cutaneous emphysema which is thus produced sometimes spreads with remarkable rapidity over the greater part of the body, and proves most distressing to the patient. Since I have carefully attended to the above precautions, I have never again had to deal with this troublesome complication. I have never ventured to carry out the idea of removing the air from the pleural cavity by aspiration, after the manner of treating pleuritic exudations, even when the pressure within it is not greater than that of the outer air, because, by so doing, we run the risk of again tearing open the only partially healed perforation, and thus again allowing air to enter the pleural sac TUBERCULOSIS AXD NEW-GROWTHS. 771 from the lung. But nevertheless puncture in pneumothorax, when practised in accordance with correct indications and with proper precautions, will prove of real service in a not inconsider- able number of cases. TUBERCULOSIS OF THE PLEURA. In ordinary manuals tuberculosis of the pleura usually has a separate chapter devoted to it, and for that reason I shall here mention it briefly, although it has no claim to be considered as a distinct form of disease. In general acute miliary tuberculosis, small transparent gray nodules are developed in the tissue of the pleura, together with recent tubercle in the lungs and various other organs. In such cases the patient dies without the tuberculosis of the pleura giving rise to any distinct local symptoms. It is more common, however, for tubercle to be deposited in the recent false mem- branes produced by pleuritis, either as associated with caseous pneumonia or genuine tuberculous processes in the lungs, or in connection with tubercle of other organs; or, as sometimes happens, especially with old people, the tubercle first appears in this situation. In this case the tubercles appear as promi- nences not bigger than a millet-seed or a hemp-seed, at first of a whitish-gray, and subsequently more of a yellowish-gray color. We have already mentioned that in this form of pleuritis the exudations are often hemorrhagic, because of the abundant development of vessels which takes place in the pseudo-mem- branes. When by puncture we have ascertained that the exu- dation is of this character, or when we are justified by the general symptoms in suspecting it, we may assume, with much probability, that it is a case of tubercular pleuritis. We have already spoken fully of the symptoms of this disease. MALIGNANT NEW-GROWTHS IN THE PLEURA. Sarcoma—Cancer. Sarcomas or cancers of the pleura are never primary, but always follow the development of tumors of a like nature in 772 FRAENTZEL.—DISEASES OF THE PLEURA. neighboring organs. It is therefore impossible to give any general description of these new formations in the pleura. We are equally unable, in this place, to give an accurate anatomical account of the various kinds of tumors. We may state, however, that sarcomas are much more rarely found than cancers. In the first place, the new-growth may advance into the pleural cavity from without, attacking first the costal pleura, perforating it, and invading the pleural sac as a tumor of the most varied form. Or it may originate in the lung, and first appear in the pleura on the free surface of its pulmonary layer, growing out in the form of nodular tumors, varying in size from that of a hemp-seed to that of a child's head. The nodules themselves are sometimes flattened, but more frequently they are rounded, prominent, and often highly vascular, and usually speckled. If the pleural folds are not closely united by adhesions, fluid secretions almost invariably accumulate in the pleural sac, which, for the most part, are only transudations. In such cases genuine pleuritis, as a rule, only arises when ichorous or slough- ing tumors of external parts, as, for example, of the mamma, or of the axillary glands and the like, force their way into the pleural sac; or when pleuro-pneumonia occurs as a secondary complication of cancer of the lung, or finally, when pleuritis supervenes on the existing hydrothorax. If tumors of the pleura are very large, they may not only compress the lung to a great extent, but displace all the adjacent organs, and thrust out the chest wall. Symptoms. The smaller tumors of the pleura will often during life give rise to no distinct symptoms. The larger ones are accompanied, as we might naturally suppose, not by febrile movement, but by more or less severe attacks of dyspnoea, sometimes coming on in paroxysms, sometimes continuous. Patients often suffer from dysphagia at the same time. When there is pain which cannot be referred to coexisting pleuritis, it is of a dull character and accompanied by a feeling of weight. We are greatly aided in NEW-GROWTHS.—DIAGNOSIS. 773 our diagnosis if the patient presents an appearance of maras- mus ; if there is great emaciation ; if the skin is dry and of a dirty, yellowish-green color. At the same time, cedema of the upper extremities and of the face, and in other cases slight cedema of the joints, sometimes occurs. Enlargements of single superficial lymphatic glands are always noteworthy symptoms. The diagnosis is naturally rendered much more certain if we can also detect clearly the existence of cancerous or sarcomatous tumors in any part accessible to direct observation. It is only when the tumors are large that physical examina- tion of the organs of respiration is of much use to us. Then it is not unusual to find the wall of the chest bulged out on the affected side, the heart displaced laterally, and the diaphragm pushed downwards. The test of pectoral fremitus, in these cases, affords no certain evidence, for sometimes it is quite normal, some- times it is weakened, and sometimes it is even entirely absent, according as the substance of the tumor is capable or not of con- veying the vocal vibrations. Occasionally hydrothorax happens to be present and quite destroys the fremitus in the lower parts of the chest. If large masses of the pleural tumor lie imme- diately beneath the wall of the chest, at such spots the per- cussion sound is intensely or absolutely dull, and the feeling of resistance, especially on palpatory percussion, is remark- ably great. Respiratory murmur is entirely absent. If cough exists at the same time, it is dependent on some casual affec- tion of the bronchi. If there is any expectoration, the sputa, having no connection with the new formation in the pleura, possess no diagnostic value. Diagnosis. We should very frequently fall into error if we were to arrive at the positive diagnosis of a pleural cancer or a pleural sarcoma from the symptoms we have here set forth. Before we venture to think of the existence of a pleural tumor we must always be careful to exclude the presence of extensive caseous pneumonic infiltration of the lung, or pleuritic exudation, with either of which we may possibly confound it. 774 FRAENTZEL.—DISEASES OF THE PLEURA. Widespread and obstinate caseous pneumonic infiltrations rarely occur when malignant new-growths exist in any other place, although Rokitansky's exclusion theory with regard to cancer and caseous pneumonia, cannot be unconditionally ac- cepted ; caseous pneumonias produce no displacement of adja- cent organs, they are often double-sided, often associated with the formation of vomicae, and they seldom give so absolutely dull a percussion sound as we find over pleural tumors. In the latter case we get no nocturnal perspirations, while we often find signs of compression of the superior vena cava and the oesophagus. The differential diagnosis between a pleuritic exudation and a pleural tumor is, under certain circumstances, much more difficult, especially when the latter is combined with hydro- thorax. In the case of a tumor the area of dulness is, as a rule, not bounded by so regular an outline, and, moreover, the dulness is not always most intense at the lowest parts of the chest, nor do changes of position on the part of the patient modify the area of dulness. Striking fluctuations in the boundaries of the dulness, which we usually observe sooner or later in the course of a pleu- ritic exudation, are absent in pleural tumors. A pleural tumor can only be mistaken for an aneurism when it presses on the lung and is so situated in front of the heart or great vessels that it conveys a visible or tangible pulsation to the wall of the chest. A further careful investigation of the case will usually save us from error. We can never, however, be in a position to decide with cer- tainty whether such new formations are connected with the pleura or the lung, or with some other intra-thoracic structure. Duration, Results, Prognosis. The duration of a malignant new-growth in the pleura de- pends exclusively on the stage of growth of the primary tumor, and the rapidity of increase of the pleural nodules. The result is, as in all malignant tumors, fatal, and the prognosis, therefore, absolutely unfavorable. NEW-GROWTHS.—TREATMENT. 775 Treatment. There is no special treatment for malignant growths in the pleura. We must enforce a suitable dietetic regimen, and, in the somewhat rare event of the occurrence of violent pain, administer opiates or subcutaneous injections of morphia. INDEX. Abelin, 429. Abnormal color of mucous membrane of larynx, 193. Abscess of nasal cavity, 146. Abscess, external, in etiology of empyema, 620; of pleuritis, 596; of lung in etiology of pneumotho- rax, 748; of mediastinum in etiology of stenosis of trachea and bronchi, 477 ; retropharyngeal, a result of diseases of nose, 127. Absorption of pleuritic effusions, physical signs fol- lowing, 662. Acetate of lead in bronchial catarrh, 420 ; in chronic bronchitis, 435; in nosebleed, 168; of potash in pleuritis, 686, 690. Acetic acid in cold in the head, 129. Acid, acetic, in cold in the head, 129; benzoic, in bronchial catarrh, 417; in chronic bronchitis, 436; carbolic, in bronchial catarrh, 416, 421; in chronic nasal catarrh, 145 ; in diseases of nose, pharynx, and larynx, 82, 86, 95, 96; inhalations of, in chronic bronchitis, 435, 436; carbonic, poisoning by, in bronchial catarrh, 407; chromic, in croup, 265; in diseases of nose, pharynx, and larynx, 76 \ hydrochloric, in croup, 265; hyponi- trous, inhalation of fumes of, in etiology of bron- chial catarrh, 314; lactic, in croup, 265; in diph- theria, 95 ; in diseases of larynx, 82 ; muriatic, inhalation of fumes of, in etiology of bronchial catarrh, 314; nitric, inhalation of fumes of, in etiology of bronchial catarrh, 314; pyroligneous, in diseases of larynx, 82; sulphuric, in nosebleed, 168; inhalation of fumes of, in etiology of bron- chial catarrh, 314; tannic, in bronchial catarrh, 420 ; in chronic bronchitis, 435 ; in chronic ca- tarrh of larynx, 223 ; in diseases of nose, pharynx, and larynx, 79, 82, 86, 94; in nosebleed, 163, 168; in purulent nasal catarrh, 145. Ackerman, 311, 332. Acute catarrh of larynx, 194. Adhesions in pleuritis, 607; site of, 616 ; of the pleu- ral layers to one another, a sequel of pleuritis, 673. iEgophony in pleuritis, 659, 669. Aetius, 68b. Age, in etiology of bronchial asthma, 536; of bron- chial catarrh, 308 ; of chronic catarrh of larynx, 213 ; of coryza, 121; of croup, 235; of croupous bronchitis, 443 ; of pleuritis, 599 ; influence of, in dyspncea of acute catarrh of larynx, 198, 204; upon antiphlogistic treatment of pleuritis, 688; upon the pain of pleuritis, 631; in prognosis of bronchial asthma, 574; of capillary bronchitis, 406; of croup, 263. Aigle, a resort for the grape cure in bronchial catarrh, 424. Air, amount of, in pleural cavity in pneumothorax, 752 ; condensed, in bronchial catarrh, 424; con- densed or rarefied, in chronic bronchitis, 432; rarefied, in bronchial asthma, 580, 585 ; rarefied, in bronchial catarrh, 424. Ajaccio, climate of, in bronchial catarrh, 413. Albers, 186, 291. Albuminuria in chronic bronchitis, 389; in croup, 247 ; in pleuritis, 640. Alcohol in croup, 265; in diseases of larynx, 82; in fetid bronchitis, 435 ; in nosebleed, 163. Algiers, climate of, in bronchial catarrh, 413. Alkalies in chronic bronchitis, 423, 433. Aiken, 475. Almond water, bitter, in pleuritis, 689. Althaus, Hermann, 644. Alum in chronic catarrh of larynx, 225; in chronic nasal catarrh, 145; in cold in the head, 128; in diseases of nose, pharynx, and larynx, 76, 79, 86, 94; in hemorrhage from mucous membrane of larynx, 193 ; in nosebleed, 163. Ammon, 287, 289, 291. Ammonia in bronchial asthma, 579; carbonate of, in diseases of nose and pharynx, 86 ; muriate of, in acute catarrh of larynx, 211; in bronchial catarrh, 417, 427; in diseases of nose and pharynx, 86; water of, in acute catarrh of larynx, 211. Ammoniac in chronic bronchitis, 436. Ammonium, chloride of, in chronic nasal catarrh, 144. Ansemia of the larynx, 189. Amyl, nitrite of, in bronchial asthma, 576. Analysis, chemical, of pleuritic effusions, 609. Anatomy of the larynx, 46. Andral, 396, 481, 484, 492, 605, 630. Andriessen, 509. Aneurism of aorta in etiology of stenosis of trachea 778 INDEX. and bronchi, 476; of aorta, rupture of, in eti- ology of hasmatothorax, 739; of innominate artery in etiology of stenosis of trachea, 476. Anglada, 118. Antilles, climate of the, in pulmonary diseases, 302. Antimonials in bronchial asthma, 580; in bronchial catarrh, 417, 418 ; in croup, 267 ; in pleuritis, 688. Antiphlogistic treatment of pleuritis, 685. Antiphlogistics in bronchial catarrh, 421; in pneumo- thorax, 768. Antipyretics in bronchial catarrh, 421. Antiseptics upon supervention of diphtheria in croup, 268, Antrum of Highmore, affections of, in chronic nasal catarrh, 142; in cold in the head, 126. Aorta, aneurism of, in etiology of stenosis of trachea and bronchi, 476; rupture of, in etiology of has- matothorax, 739; ulceration of, in etiology of haematothorax, 740. Apomorphia in bronchial asthma, 580: in bronchial catarrh, 417, 418, 429; in cases of foreign bodies in trachea and bronchi, 521; in chronic bronchi- tis, 436 ; in croupous bronchitis, 467. Apoplexy, pulmonary, a complication of croup, 252; pulmonary, in etiology of pneumothorax, 748. Apparatus for aspiration in removal of pleuritic effu- sions, 698; for inhalation of atomized fluids, 88; of Bergson, 89; of Siegle, 91; of Weber Liel, 89; of Wintrich, 89; for illuminating, of Fraenkel, 28; of Krishaber, 25; of Tobold, 30; of von Ziemssen, 32. Aqua ammoniae in acute catarrh of larynx, 211. Aretaeus, (i.^5. Argenti nitras in bronchial asthma, 583; in chronic catarrh of larynx, 224 ; in croup, 265. Arsenic in bronchial asthma, 579, 581, 582; in croup, 268. Artery, carotid, compression of, in nosebleed, 163; innominate, aneurism of, in etiology of stenosis of trachea, 416. Arthritis, rheumatic, in etiology of pleuritis, 597. Artificial feeding of infants with closure of the nose, 115. Ascherson, 289. Asclepiades, 592. Aspiration in removal of pleuritic effusions, 694. Assafoetida in bronchial asthma, 583. Asthma, bronchial, 523. Asthmatic attacks in nurslings due to obstruction of the nose, 105. Astringents in bronchial catarrh, 416, 420 ; in chronic catarrh of larynx, 223, Atelectasis of lung, a complication of croup, 252; a equel of croupous bronchitis, 465; a sequel of stenosis of trachea and bronchi, 485. Atmospheric influences in etiology of acute catarrh of larynx, 196 ; of bronchial catarrh, 312; of croup- ous bronchitis, 445. Atomization of fluids for inhalation, 88. Atomized fluids, inhalation and injection of, in chronic nasal catarrh, 145. Atrophy of mucous membrane in bronchial catarrh, 324. Atropia in bronchial asthma, 577, 581. Atresia and stenosis of the nasal cavity, 103, Aubree's remedy for bronchial asthma, 583. Auscultation in acute tracheo-bronchitis, 360; in bronchial asthma, 564; in bronchial catarrh, 353; in capillary bronchitis, 370 ; in chronic bronchitis, 387, 392; in croupous bronchitis, 461; in diseases of nose, pharynx, and larynx, 71; of trachea and bronchi, 284; in malignant new-growths in the pleura, 773; in hydrothorax, 737; in pleuritis, 642, 646, 658, 664, 669, 731; in pneumothorax, 762 ; in stenosis of trachea and bronchi, 489. Aussee, a resort in pleuritis, 691. Aurelianus, Coelius, 592. Auto-laryngoscopy, 55. Avery, 12. Babington, 13,154. Baden Baden, waters of, in bronchial catarrh, 424. Badham, 292. Baerensprung, 769. Baglivi, 6S5. Ballonius, 637. Balsam of Peru in bronchial catarrh, 420; in chronic bronchitis, 435 ; of tolu in chronic bronchitis, 435. Bamberger, 343, 531, 542, 544, 546, 561, 562, 565. Barbosa, 265. Bardeleben, 290, 725, 727. Bark, cinchona, in bronchial asthma, 582. Barrier, 599. Bartels, 246, 267, 680, 693, 716. Barthez, 104,130, 147,198, 259, 265, 267, 346, 359, 368. Baths in prophylaxis of acute catarrh of larynx, 208 ; cold, in prophylaxis of croup, 264; in treatment of acute bronchitis, 427, 430; of croup, 267; of bronchial catarrh, 421. Baumes, 13. Baxt, 67. Baxt's rhinoscope, with uvula holder, 66. Bayle, 745. Beau, 300, 530, 632. Behier, 712. Belloc, 13, 74, 79, 186. Benecke, 249. Bennati. 12. Bergson, 530, 533, 541. Bcrgson's principle for inhalation of atomized fluids, 89. Bergson's hydrokonion, 90. INDEX. 779 Belladonna in bronchial asthma, 577, 582; in diseases of nose, pharynx, and larynx, 95. Belloc's tube, 98, 164. Benzoic acid in bronchial catarrh, 417; in chronic bronchitis, 436. Berkart, -125. Bert, 541, 544. Betz, 537. Bex, a resort for the grape cure in bronchial catarrh, 424. Biborate of soda in chronic nasal catarrh, 145; in cold in the head, 128. Bicarbonate of soda in diseases of nose, pharynx, and larynx, 94. Bidder, 110. Biedert, 425. Biermer, 280, 304, 309, 323, 326, 333, 369, 392, 438, 442, 443, 451, 452, 454, 455, 465, 468, 478, 480, 486, 494, 516, 530, 534. 535, 536, 538, 541, 543, 544, 545, 550, 551, 552, 553, 554, 564, 569, 576, 701, 760. Bilin, waters of, in bronchial catarrh, 423. Billard, 104, 242. Billroth, 109. Bingen on the Rhine, a resort for the grape cure in bronchial catarrh, 424. Binz. 428, 435. Bird, 202. Bitter-almond water in pleuritis, 689. Blache, 238. Blackley, 196, 535. Blair, 234. Blanchot, 287. Blisters in acute catarrh of larynx, 211; in pleuritis, 686. Blood-vessels, injected, in pleuritis, 606. Blumberg, 278. Boerhaave, 593, 605, 676. Bogros, 192. Bohm, 418, 467. Bonn, 225, 237, 259. Boinet, 692. Boldyrew. 258. Bonnet, 4S2. Bose, 55. Bouchut, 106, 198, 267, 272, 284. 285. Bougies as dilators in 6tenosis of the nose, 114. Bouillaud, 685. Bourouillon, 25. Borax in chronic nasal catarrh, 145; in cold in the head, 128; in diseases of nose, pharynx, and larynx, 76. Borszek, waters of, in bronchial catarrh, 423. Botzen, a resort in pleuritis, 691. Bowditch, 693, 697, 703, 706. Bozzini, 12, 60. Brain, affections of, in cronp, 261; differential diag- nosis of hernia of, from nasal polypi, 171; brain symptoms following entrance of foreign bodies into trachea and bronchi, 518; symptoms in purulent nasal catarrh, 133. Brand's remedy for coryza, 96. Breath, fetid, in putrid bronchitis, 399. Bree, 540. Bresgen, 700. Bretonneau, 198, 212, 259. Breuer, 487, 570. Bricheteau, 2ii4. Bridges, J., 261. Bright's disease in etiology of bronchial catarrh, 316. Briquet, 396. Bromide of potassium in acute catarrh of larynx, 211; in bronchial asthma, 577, 583; in chronic catarrh of larynx, 224; in diseases of nose, pharynx, and larynx, 94; in diseases of larynx, 82. Bromine, inhalation of, in diphtheria, 96. Bronchi, abnormal formations of, 238; occlusion of by foreign bodies, diagnosis of, from croupous bronchitis, 404. Bronchi, larger, and trachea, acute catarrh of, 356. Bronchial asthma, 523. Bronchial catarrh, 292. Bronchial catarrh, acute, diffuse. 364. Bronchial catarrh, a complication of croup, 250; of pleuritis, 672; in etiology of pleuritis, 595; chro- nic, a sequel of bronchial asthma, 574; chronic, a sequel of croupous bronchitis, 465. Bronchial croup, 43S. Bronchial muscles, spasm of, in etiology of bronchial asthma, 541. Bronchial stenosis, 470. Bronchiectasis in bronchial catarrh, 322; a sequel of bronchial catarrh, 402; a sequel of stenosis of trachea and bronchi, 484. Bronchitis, capillary, 364. Bronchitis, chronic, 383. Bronchitis, diffuse catarrhal, diagnosis of, from croup- ous bronchitis, 463; bronchitis with the forma- tion of fibrinous casts, 438; bronchitis, putrid, a result of gangrene of the lungs, 397. Bronchocele, congenital, 289. Bronchophony in pleuritis, 659, 669. Bronchus, frequency of a foreign body falling into the right or left, 508. Bronchus, a third, 288. Brown, 175. Bruns, 15, 39, 79, 98. Brush, laryngeal, 80. Budge, 278. Buhl, 32S, 329, 366, 383, Burin, 420. Burns, Allan, 513. 780 INDEX. Burow, 30, 220. Bursa pharyngea, 63. Cabinet, pneumatic, in treatment of bronchial ca- tarrh, 424. Cairo, climate of, in bronchial catarrh, 413. Caldani, 740. Calibre of the larynx in laryngoscopy, 54. California, climate of, in pulmonary diseases, 302. Calisaya bark in bronchial asthma, 582. Callisen, 685. Calomel in bronchial catarrh, 417; in chronic nasal catarrh, 145; in croup, 267; in croupous bron- chitis, 468; in diseases of nose, pharynx, and larynx, 79; in pleuritis, 685. Calx chlorinata in chronic bronchitis, 435. Camphor in bronchial asthma, 583. Cancer in etiology of chronic catarrh of larynx, 213; of hydrothorax, 735 ; of pneumothorax, 748; can- cer of bronchial tubes in etiology of stenosis of the bronchi, 480; of lung in etiology of stenosis of trachea and bronchi, 478; of oesophagus in eti- ology of pleuritis, 596. Cancer of the pleura, 771. Cannabis Indica in bronchial asthma, 577. Cannes, climate of, in bronchial catarrh, 413. Canstatt, 174, 207, 605. Capillary bronchitis, 364. Carbolate of soda, in diseases of nose and pharynx, 87. Carbolic acid in bronchial catarrh, 416, 421; in chro- nic nasal catarrh, 145 : in diseases of nose, phar- ynx and larynx, 82, 86, 95, 96; inhalations of, in chronic bronchitis, 435, 436. Carbonate of ammonia in diseases of nose and phar- ynx, S6; of lithium in disease of nose, pharynx, and larynx (diphtheria), 95; of potassa in diseases of nose, pharynx, and larynx, 94. Carbonate of soda in chronic nasal catarrh, 144; in cold in the head, 128; in diseases of nose, pharynx, and larynx, 86, 94 ; in purulent nasal catarrh, 135. Carbonic-acid poisoning in bronchial catarrh, 407 ; in croup, 246. Carcinoma of the air-passages in etiology of stenosis of trachea and bronchi, 4S0. Carcinoma of nasal cavity, 171. Caries in the etiology of chronic nasal catarrh, 137; caries of ribs, a complication of pleuritis, 073 ; of ribs, a sequel of empyema, 620 ; of ribs, with ero- sion of intercostal artery in etiology of hfemato- thorax, 740 ; of spine, a complication of pleuritis, 673. Carlsbad, mineral waters of, in chronic catarrh of larynx, 226. Carlsbad Sprudel salts in chronic catarrh of larynx, 225. Cartilages, tracheal, absence, coalescence and exces- sive number of, 288 ; atrophy of, a result of com- pression, 482. Cartilage of Santorini, 48; of Wrisberg, 48. Carotid artery, compression of, in nosebleed, 163. Carpenter, 621. Caryophyllus in chronic nasal catarrh, 146. Castiaux, 699. Castor in bronchial asthma, 583. Casts, fibrinous, in croupous bronchitis, 451; hyaline, from kidney, in pleuritis, 640. Catania, climate of, in bronchial catarrh, 413. Catarrh, acute, of larynx, 194. Catarrh, acute, diffuse, bronchial, 364. Catarrh, acute, of the trachea and larger bronchi, 356. Catarrh, acute, of the medium-sized and minuter bronchi, 364. Catarrh, bronchial, a complication of croup, 250; bronchial, a complication of pleuritis, 672 ; bron- chial, chronic, a sequel of bronchial asthma, 574; bronchial in etiology of pleuritis, 595. Catarrh, chronic, of larynx, 212. Catarrh, chronic, bronchial, a sequel of croupous bronchitis, 465. Catarrh, nasal, chronic, 136. Catarrh, nasal, purulent, 129. Catarrh of the tracheal and bronchial mucous mem- brane, 292. Catarrhal pneumonia, a complication of bronchial catarrh, 402. " Catching cold" in etiology of acute catarrh of larynx, 194; of bronchial asthma, 538; of bronchial catarrh, 310; of hydrothorax, 733 ; of pleuritis, 594. Catheterism of larynx in croup, 272. Catheters of Nelaton in after-treatment of opening pleural cavity for discharge of purulent effusions, 718. Caustic darts in diseases of pharynx, 80. Caustics in diseases of nose, pharynx, and larynx, 76. Cazenave, 145. Celsus, 687. Chamomile, infusion of, in diseases of nose, pharynx, and larynx, 95. Charcoal in chronic nasal catarrh, 146; in chronic bronchitis, 435. Charnal, 483. Chassaignac, 725. Chemical analysis of pleuritic effusions, 609. Cherry-laurel water in diseases of nose, pharynx, and larynx, 95. Cheyne, 186. Chills in acute tracheo-bronchitis, 357; in bronchial catarrh, 345; in croupous bronchitis, 460; in pleuritis, 624. INDEX. 781 Chloral hydrate in bronchial asthma, 576. Chlorate of potassa in chronic nasal catarrh, 144; in croup, 265; in diseases of larynx, 82 ; in diseases of nose, pharynx, and larynx, 94. Chloride of ammonium in chronic nasal catarrh, 144; of iron in croup, 265; in diseases of larynx, 82; in nosebleed, 163, 168; of sodium in acute catarrh of larynx, 211; in chronic catarrh of larynx, 224 ; in chronic nasal catarrh, 144 ; in cold in the head, 128 ; in diseases of nose and pharynx, 86; in purulent nasal catarrh, 135. Chlorinated lime in chronic bronchitis, 435; in chronic nasal catarrh, 146; chlorinated soda in chronic nasal catarrh, 146; in diseases of nose and pharynx, 86. Chlorine gas, inhalation of, in etiology of bronchial catarrh, 314. Chlorine water in diseases of nose, pharynx, and larynx, 95. Chloroform in bronchial asthma, 577; in diseases of larynx, 82. Cholera in etiology of croup, 238. Choleraic gastro-enteritis, a complication of croup, 248. Cholesteatomata in antrum of Highmore in chronic nasal catarrh, 142. Chomel, 685. Chondroma of nasal cavity, 171. Chromic acid in croup, 265; in diseases of nose, pharynx, and larynx, 76. Chronic bronchial catarrh, a sequel of bronchial asth- ma, 574. Chronic bronchitis. 383. Chronic catarrh of larynx, 212. Chronic nasal catarrh, 136. Chronic pharyngitis in etiology of chronic catarrh of larynx, 213. Chronic rhinitis, 136. Cicatrices in etiology of stenosis of trachea and bronchi, 479. Cigarettes of Espic in bronchial asthma, 578. Cinchona in chronic nasal catarrh, 146; in pleuritis, 690. Clarens, a resort for the grape cure in bronchial catarrh, 424. Clavicle, diseases of, in etiology of stenosis of trachea, 478. Clemens, 268. Climate in etiology of bronchial asthma, 537, 538; of croupous bronchitis, 444 ; in prophylaxis of bron- chial catarrh, 410, 413, 433; climate of Ajaccio in prophylaxis of bronchial catarrh, 413; of Algiers, 413; of Cairo, 413; of Cannes, 413; of Catania, 413; of Davos, 413; of Geneva, 413; of Hyeres, 413; of Madeira, 413; of Mentone, 413; of Meran, 413; of Nice, 413; of Pau, 413; of Pisa, 413; of Venice, 413; climate of the Antilles, of California, of Egypt, of plains of India, of prai- ries of North America in pulmonary diseases, 302. Cloquet, 173. Cloves in chronic nasal catarrh, 146. Cold in the head, 115. Cold in treatment of acute catarrh of larynx, 211; application of, in croup, 266; in haematothorax, 743; in hemorrhage of mucous membrane of larynx, 193; in nosebleed, 163; in diseases of pharynx and larynx, 96; in pleuritis, 688; to point of puncture after aspiration in pleuritis, 712; cold baths in acute bronchitis, 427, 430 : in bronchial catarrh, 421 ; in prophylaxis of croup, 264; in treatment of, 267, Cold weather in etiology of coryza, 121. Cohnheim, 612, 711. Color of mucous membrane in bronchial catarrh, 320; abnormal, of mucous membrane of larynx, 193 ; of the parts in laryngoscopy, 53; of pleura in pleuritis, 606. Collapse of the lung, a complication of bronchial catarrh, 402; a sequel of bronchial cntarrh, 329. Complications of bronchial catarrh, 409; of chronic nasal catarrh, 141; of cold in the head, 125 ; of croupous bronchitis, 464 ; of haematothorax, 741; of pleuritis, 669; of pneumothorax, 762; of puru- lent nasal catarrh, 1S2. Compression of the thorax in chronic bronchitis, 436. Conchoscope of Wertheim, 58. Coniantron of Weber-Liel, 89. Conjunctiva, affection of, a complication of purulent nasal catarrh, 132. Contagion of coryza, 117; transient, in etiology of bronchial catarrh, 315. Cook, 234. Copaiba in bronchial catarrh, 420 ; in chronic bron- chitis, 4Z5. Copland, 307, 632. Copper, sulphate of, in croup, 267; in diseases of nose, pharynx, and larynx, 76. Cords, vocal, alterations in, in chronic catarrh of larynx. 217; vocal, false, 48; true, 49. Corrigan, 402. Corrosive chloride of mercury in diseases of nose, pharynx, and larynx, 82, 95; in chronic nasal catarrh, 145. Corvisart, 676. Coryza, 115. Cough in acute catarrh of larynx, 204; in acute bron- chitis, 127 ; in acute tracheo-bronchitis, 358; in bronchial asthma, 505 ; in bronchial catarrh, 335; in capillary bronchitis, 372 ; in chronic bronchitis, 385, 391; in croup, 239 ; in hydrothorax, 737 ; in pleuritis, 632; in pneumothorax, 756; in stenosis 782 INDEX. of trachea and bronchi, 492; in tracheal and bronchial affections, its causes and results of experiments, 277. Countenance, aspect of, in pleuritis, 635. Court-in, 583. Courty, 577. Cousin, 144. Cramer's forehead headband for laryngeal mirrors, 21. Crawford, 237. Croup, 231; bibliography, 231; general considera- tions and etiology, 234 ; definition of the disease, 234; origin of the word croup, 234; difference between the membrane of croup and diphtheria, 234 ; relations of the two diseases, 234 ; primary or true croup, 2'-5 ; influence of age, 235 ; of sex, 235; hereditary influences, 236 ; rarity of recur- rence of the disease, 236; influence of seasons of the year, the weather, and nature of the soil, 236; sporadic and epidemic forms, 237 ; primary croup not a contagious disease, 237; secondary or symp- tomatic croup, 237 ; diseases in which it occurs, 237 ; symptomatology and course, 238 ; catarrhal symptoms, 238; appearances in the throat, 238; duration of the first stage. 239; the second stage, 239; dyspncea and hoarseness, 239; the respira- tion, 239; suffocative attacks, 240; different ex- planations of these attacks, 241 ; explanation of change in the voice, 244; of cough, 244 ; remis- sions during the second stage, 244: discharge of false membranes during this stage, 245 ; the third or stage of asphyxia, 245 ; carbonic-acid poisoning, 246; its causes, 246; the fever, 247; the pulse, 247; enlargement of the submaxillary and lateral cervical glands, 247 ; albuminuria, 247 ; digestive derangements, 247 ; croup of the stomach, 248 ; choleraic gastro enteritis, 248; paralysis of vagus nerve, 248 ; pain in larynx, 248; results of laryn- goscopical examination, 248; limits of the exuda- tion, 249; implication of trachea and bronchi, 249; bronchial catarrh, 250 ; pneumonia, 251; atelectases, 252; pulmonary apoplexy and gan- grene, 252; symptoms of secondary croup, 252; the ascending and descending forms, 253 ; dura- tion of croup, 253 ; sequelae, 254; pathology, 255; hyperaemia, 255 ; the exudation, 255; its mode of formation, 257; its extent, 258; condition of the lungs, 260 ; the bronchial and pulmonary glands, 260; pleural disorders, 260; affections of the heart, 260; the spleen and kidneys, 261; the liver, 261; enlargement of intestinal solitary glands, 261 ; affections of the brain, 261: diag- nosis, 261; differential diagnosis. 202 ; prognosis, 263 ; influence of age, 263 ; sporadic or epidemic forms, 203; influence of site of the false mem- brane, 263 ; mortality, 204 ; trratment, 264 ; pro- phylaxis, 264 ; cold baths and cold water gargles, 264; avoidance of cold dry winds, 265 ; inspection of throat during prevalence of diphtheria, 265; treatment after the exudation has appeared, 265 ; gargles, 265; applications by attendant where gargling is impossible, 205; special treatment, 265; antiphlogistic method, 266; leeching, 260 ; application of cold, 266; calomel, 267; emetics, 267; antiseptics upon supervention of diphtheria, 268 ; treatment by narcotics, quinine, and arsenic, 268; tracheotomy, 268 ; object of its employment, 269; time for its performance, 209; the operation itself, 209; the after- treatment, 270; dietetics, 270; the after medical treatment, 270 ; the sur- gical treatment, 271; choice of tracheotomy tube, 271; management of the wound, 271; time for removal of canula, 271; results of the operation, 272; catheterism of the larynx, 272 ; treatment if tracheotomy be not permitted, 272 ; croup a com- plication of cholera, 238; of diphtheria, 238; of epithelioma of larynx, 238; of measles, 237; of pneumonia, 238 ; of scarlatina, 238 ; of small-pox, 238; of typhoid fever, 238; of whooping-cough, 238. Croupous bronchitis, 438. Croup, laryngeal, diagnosis of, from croupous bron- chitis, 464. Cruveilhier, 186, 278. 2S8, 605, 632. Crystals in expectoration in bronchial asthma, 548, 565. Cube, 425. Cullen, 530, 534. Curtin, 165. Cupping in pleuritis, 6S6; in pneumothorax, 768; dry, in bronchial catarrh, 419; in nosebleed, 164. Cupri sulphas in croup, 267. Cyanosis in bronchial asthma, 561; in bronchial catarrh, 338; in capillary bronchitis, 373; in croupous bronchitis, 460; in pleuritis, 635; in pneumothorax, 751, 757; of mucous membrane of larynx, 193. Cyr, 479, 481. Czermak, 12, 59, 65, 68, 186, 218. Damoiseau, 657. Darts, caustic, in diseases of pharynx, 80. Davies, 597. Davos, climate of, in bronchial catarrh, 413. Davy, 753. Daylight, diffused, use of, in laryngoscopy, 33. Deafness, a complication of cold in the head, 125; due to diseases of nose, 111. Demarquay, 175, 470, 481. Demme, 474, 475, 478, 481, 482. 488. 516. Demonstration of a laryngoscopic image, 54. Depressors, tongue, 6. INDEX. 783 Derivatives in bronchial catarrh, 418, 429; in nose- bleed, 163. Diagnosis of abscess of nasal cavity, 148; of acute catarrh of larynx, 206; of bronchial asthma, 568; of bronchitis, 403; of capillary bronchitis, 3S2 ; of chronic nasal catarrh, 142; of congenital tracheal fistula, 291; of croup, 261; of croupous bronchitis, 463; of foreign bodies in nasal cavity, 176; of foreign bodies in trachea and bronchi, 519; of haematothorax, 742; of hydrothorax, 738; of malignant new-growths in the pleura, 773 ; of nasal polypi, 170 ; of nosebleed, 158; of parasites of the nasal cavity, 180; of pleuritis, 674; of pneumothorax, 763; of purulent nasal catarrh, 133; of stenosis and atresia of the nasal cavity, 111; of stenosis of trachea and bronchi, 495 ; of tracheitis, 403; of ulcerations of the nasal cavity, 149; differential, of putrid bronchitis, 400. Diaphoretics in bronchial catarrh, 418, 426; in pleu- ritis, 691. Diaphragm, spasm of, in etiology of bronchial asthma, 54G. Diet in haematothorax, 743 ; in hydrothorax, 739; in pleuritis, 690, 691; in pneumothorax, 768. Dieulafoy, 694, 698, 700, 703. Digestion, symptoms of organs of, in acute tracheo- bronchitis, 363; in bronchial catarrh, 346; in croup, 247; in pleuritis, 639. Digitaline a cause of coryza, 121. Ligitalis in pleuritis, 085, 690. Diodes, 592. Diphtheria, application of lime-water in, 87; diph- theria in etiology of croup, 238; diphtheria of the nasal cavity, 136; purulent nasal catarrh during course of, 131. Disinfectants in fetid bronchitis, 435. Diuretics in bronchial catarrh, 419 ; in pleuritis, 690. Dixon, 455. Diillinger, 537. Donders, 122, 381. Douche, nasal, in chronic nasal catarrh, 144. Douche, nasal, of Th. Weber, 84 Dover, 085. Dropsy in bronchial catarrh, 331, 339; in croupous bronchitis, 460 Dubuisson, 420. Duchck, A., 102, 126, 174, 198, 217. 272. Duchenne, 572. Duclos, 583. Ducros, 579. Duct and sac, lachrymal, affection of, in cold in the head, 126; duct, thoracic, compression of, in eti- ology of hydrothorax, 734. Duration of acute catarrh of larynx, 207; of bronchial asthma, 574; of cases of foreign bodies in trachea and bronchi, 519; of cold in the head, 125; of croup, 253: of croupous bronchitis, 464, 406; of haematothorax, 742; of hydrothorax, 738; of malignant new-growths in the pleura, 774; of pleuritis, 680 ; of pneumothorax, 765 ; of stenosis of trachea and bronchi, 498. Dust, inhalation of, in etiology of bronchial catarrh, 312. Dysentery in etiology of hydrothorax, 735. Dysphagia in acute catarrh of larynx, 205; in malig- nant new-growths in the pleura, 772. Dyspnoea in acute catarrh of larynx, 198, 204; in acute tracheo-bronchitis, 362 ; in bronchial asthma, 501; difference between inspiratory and expiratory, in bronchial asthma, 551; in bronchial catarrh, 331; in capillary bronchitis, 36S; in croup, 239; in diminished calibre of trachea, 276 ; in hydro- thorax, 737; in malignant new-growths in the pleura, 772 ; in pleuritis, 62S ; in pneumothorax, 751, 754; in stenosis of trachea and bronchi, 492. Dzondi, 2S9. Ear, caries of internal, in etiology of pneumothorax, 749; diseases of ear, following the use of nasal douche, 85. Echinococci of nasal cavity, 171. Eck, 5S2. Edwards, 134, 476. Egypt, climate of, in pulmonary diseases, 302. Eichhorst, 352. Eilsen, mineral waters of, in chronic catarrh of lar- ynx, 226. Electricity in diseases of the larynx, 96, 225. Electrode, intra-laryngeal, of Mackenzie, 97. Elder, infusion of, in diseases of nose, pharynx, and larynx, 95. Elopatak, waters of, in bronchial catarrh, 423. Emaciation in malignant new-growths in the pleura, 773; in pleuritis, 635. Emboli, infective, of lung, in etiology of pneumo- thorax, 749. Emetics in acute catarrh of larynx, 212; in acute bronchitis, 428, 429; in bronchial asthma, 5S0; in bronchial catarrh, 416; in cases of foreign bodies in trachea and bronchi, 521; in chronic bronchitis, 433, 436; in croup, 267; in croupous bronchitis, 467; in pleuritis, 688. Emmert, 113. Emollients in bronchial catarrh, 416, 426. Emphysema, cutaneous, in pneumothorax, 757; cu- taneous, following puncture of pleural cavity in pneumothorax, 770 ; of lung, in chronic bron- chitis, 391; of lung, a sequel of bronchial asthma, 573; of bronchial catarrh, 329, 402; of croupous bronchitis, 465; of stenosis of trachea and bron- chi, 4S5. 784 INDEX. Emphysematous tumors in etiology of stenosis of tra- chea, 478. Empyema in etiology of caries of ribs, 620 ; of pneu- mothorax, 748; a result of an external abscess, 620. Ems, waters of, in bronchial catarrh, 423, 424; in chronic catarrh of larynx, 227; in diseases of nose, pharynx, and larynx, 94. Endocarditis, a complication of pleuritis, 670; in etiology of pneumothorax, 750. Engel, 213. Engelberg, a resort in pleuritis, 691. Epiglottis in laryngoscopy, 43, 46. Epithelioma of air-passages in etiology of stenosis of trachea and bronchi, 480; of larynx in etiology of croup, 238. Epithelioma of nasal cavity, 171. Epistaxis, 150. Erasistratus, 592. Ergot in bronchial asthma, 580; in haematothorax, 743 ; in nosebleed, 167. Erosions in chronic catarrh of larynx, 216. Erysipelas, laryngitis a complication of, 201; erysipe- las, facial, a complication of cold in the head, 125; erysipelas of nose, 136. Espic's cigarettes in bronchial asthma, 578. Ether, sulphuric, in bronchial asthma, 577. Ethmoid bone, cavities of, affections of, in cold in the head, 126. Etiology of acute catarrh of larynx, 194; of anaemia of larynx, 189 ; of atresia of nasal cavity, 112; of bronchial asthma, 533; of bronchial catarrh, 301; of chronic catarrh of larynx, 212 ; of cold in the head, 117; of croup, 234; of croupous bronchitis, 442; of the fetor in putrid bronchitis, 401; of foreign bodies in trachea and bronchi, 506; of haematothorax, 739; of hemorrhage of mucous membrane of larynx, 191; of hydrotho- rax, 733 ; of hyperaemia of larynx, 190; of nose- bleed, 150; of pleuritis, 593; of pneumothorax, 745; of purulent nasal catarrh, 129; of putrid chronic bronchitis, 397; of rhinitis chronica, 136; of stenosis of nasal cavity, 112 ; of stenosis of the trachea and bronchi, 474; of ulcerations of the nasal cavity, 148. Eulenburg, 533. Euriphon, 592. Eustachian tubes, affections of, as complications of purulent nasal catarrh, 132 ; catarrh of, as com- plication of cold in the head, 125, Eustachian tubes, pharyngeal orifices of, 63. Evenor, 592. Ewald, 609, 745. Examination, physical, in acute tracheo-bronchitis, 360 ; in bronchial catarrh, 350 ; in capillary bron- chitis, 370 ; in cases of foreign bodies in trachea and bronchi, 519; in chronic bronchitis, 387, 392, 399; in haematothorax, 741 ; in hydrothorax, 737; in malignant new-growths in the pleura, 773; in pleuritis, 641; in pneumothorax, 759. Expectant treatment of pleuritis, 684. Expectorants in acute catarrh of larynx, 211; in acute bronchitis, 428, 430; in bronchial catarrh, 416; in chronic bronchitis, 432, 433, 434, 435, 436. Expectoration in acute catarrh'of larynx, 205; in acute tracheo-bronchitis, 360 ; in bronchial asthma, 548, 565; in bronchial catarrh, 340 ; in capillary bron- chitis, 374 ; in chronic catarrh of larynx, 215 ; in chronic bronchitis, 385, 391, 397; in croupous bronchitis, 451 ; in diagnosis of croupous bronchi- tis, 463; in pleuritis, 6^2; in pneumothorax, 756 ; in stenosis of trachea and bronchi, 492. Exploration, physical, in diseases of trachea and bronchi, 281. Exudation in croup, 255 ; in pleuritis, its source, 607. Fachingen, waters of, in bronchial catarrh, 423. False glottis, 49. False vocal cord, 48. Feeding, artificial, of infants, with closure of the nose, 115. Fever in acute tracheo-bronchitis, 357; in bronchial catarrh, 332, 347; in croupous bronchitis, 460; following foreign bodies in trachea and larynx, 519; in pneumothorax, 754; in pleuritis, 624; in stenosis of trachea and bronchi, 492. Ferri chloridum in diseases of nose, pharynx, and larynx, 94; in nosebleed, 163. Ferri perchloridi, liquor, in hemorrhage of mucous membrane of larynx, 193. Fibrinous bronchitis, 438. Fibrinous casts in croupous bronchitis, 451. Fibroma of the air-passages in etiology of stenosis of trachea and bronchi, 480 ; of nasal cavity, 170. Fick, 332, 494. Filtrum laryngis, 49. Fischer, 291. Fistula, cesophageo-tracheal, 287; hepatic, communi- cating with lung, in etiology of pneumothorax, 748; tracheal, 289. Fleischmann, 288. Fleury, 692, 733, 753. Fluids, atomized, various principles for inhalation of, 88. Forehead-band of Cramer for laryngeal mirrors, 21. Foreign bodies in nasal cavity, 172; in trachea and bronchi, 501; in etiology of bronchial catarrh, 315; of chronic nasal catarrh, 137. Form of the parts in laryngoscopy, 53. Fornix pharyngis, 62. Forster, 289, 480, 548. INDEX. 785 Forster, B., 249. Fossa of Rosenmuller, 63. Fourcroy, 213. Fowler's solution in bronchial asthma, 581. Fraenkel, 191. Fraenkel on diseases of nose, 101; on general diag- nosis and therapeutics of diseases of nose, pha- rynx, and larynx, 3. Fraenkel's illuminating apparatus, 28; nares specu- lum, 57; rhinoscope, 60. Fraentzel on diseases of the pleura, 589. Fraenum linguae, shortness of, an obstacle to laryngo- scopy, 41. Frame, spectacle of Semeleder for laryngeal mirrors, 21. Frank, J., 732. Frank, J. P., 105, 155; 156, 164, 165. Frank, J. P., method of, tamponing the posterior nares, 164. Frank, P., 292. Franque, 264. von Frantzius, A., 178, 179, 180. Frazer, 476. Fremitus, pectoral, diminution of, in cases of foreign bodies in bronchi, 516; in pleuritis, 661, 669; in pneumothorax, 758; in stenosis of trachea and bronchi, 490. Frerichs, 609. Fricker, 152. Friction sounds in pleuritis, 642, 659, 664. Friedel's method of treating ozaena, 86. Friedliinder, 366. Friedreich, 102, 118, 198, 478, 490, 509, 516, 548, 613. Friedrichshall bitter water in vicarious nosebleed, 168. Frontal sinus, affections of, in cold in the head, 126. Fungi in expectoration of putrid bronchitis, 398. Galen, 115, 592, 685. Galvano-cautery in chronic nasal catarrh, 145. Gangrene in etiology of pneumothorax, 748; of lung, a complication of croup, 252 ; of pleura in pleuri- tis, 618 ; pulmonary, following putrid bronchitis, 397. Garcia, 13, 34, 55. Gargles in diseases of pharynx, 87; of cold water in prophylaxis of croup, 264. Gases, inhalation of, in diseases of nose, pharynx, and larynx, 96; inhalation of, in etiology of bronchial catarrh, 314; acrid, inhalation of, in etiology of coryza, 121. Gastro-enteritis, choleraic, a complication of croup, 248. Gazeol in bronchial catarrh, 420. Geigel, 308, 312, 408. Gendrin, 605. VOL. IV.—50 Geneva, climate about the lake of, in bronchial ca- tarrh, 413. Geographical distribution of bronchial catarrh, 301. Gerhardt, 15, 193, 203, 219, 242, 261, 282. 2S3, 333, E55, 379, 425, 436, 482, 483, 486, 489, 493, 495, 516, 569, 630. Gibb, 202, 218, 484. Gibson, 202. Gieshubel, waters of, in bronchial catarrh, 423, Gilibert, 287. Gilruth, 105. Gintrac, 481. Girandet, 462. Glands, bronchial, affections of, in croup, 260 ; cer- vical, lateral, enlargement of, in croup, 247; in- testinal, solitary, enlargement of, in croup, 261; of larynx, affections of, in chronic catarrh of larynx, 217; lymphatic, affections of, in cold in the head, 126 ; in malignant new-growths in the pleura, 773 ; swelling and suppuration of, a cause of stenosis of the trachea and bronchi, 475; of bronchi and lungs, affections of, in bronchial catarrh, 329; mucous, degeneration of, in bron chial catarrh, 384; pulmonary affections of, in croup, 280; submaxillary, enlargement of, in croup, 247; thymus, diseases of, in etiology of stenosis of trachea and bronchi, 478; thyroid, congenital enlargement of, in etiology of bron- chial asthma, 537. Glandulae aggregatae laterales, 49; posteriores, 51. Gleichenberg, waters of, in bronchial catarrh, 423. Gleisweiler, a resort for the grape cure in bronchial catarrh, 424. Glottis, false, 49. Glottis, scarification of, in acute catarrh of larynx, 212 ; spasm of, in bronchial catarrh, 403. Glycerine in chronic nasal catarrh, 144; in diseases of nose, pharynx, and larynx, 95; iodized, in dis- eases of pharynx and larynx, 98. Gohl, 289. Goitre in etiology of stenosis of the trachea and bron- chi, 474. Gonorrhoeal matter a cause of purulent nasal catarrh, 131. Gooch, 482. Gorup-Besanez, 609. Gosselin, 725. Gout in etiology of bronchial asthma, 537 ; of pleuri- tis, 597. Grape cure in bronchial catarrh, 424. Graphic method of investigation in bronchial catarrh, 352. Graves, 676. Gray ointment in croupous bronchitis, 468. Green, 415. Gregory, 344. 786 IXDEX. Greve, 264. Growths, abnormal, in etiology of chronic nasal ca- tarrh, 137. Guaiac, solution of, in diseases of nose, pharynx, and larynx, 95. Guerin, 605, 694. Guersant, 198, 236, 237. Guinier, 599. Gurlt, 474. Gut, filled with water or air, a means of tamponing the nares, 164. Gutbrod, 639. Guttman, 355. Haen, de 593. Haematothorax, 739. Haematothorax in etiology of pneumothorax, 748. Haemoptysis in etiology of croupous bronchitis, 445 ; during croupous bronchitis, 458. Haemorrhoids in etiology of bronchial asthma, 537. Haenisch, 108, 425, 534, 581 Haidenhain, A., 123. Haller, 305, 541, 593, 605. Hallier, 258. Halmar, 509. Hamburger, 497, 518. Hasse, 605. Hauke, 422, 585. Hauner, 106, 130. Hawkins, 478. Hay-fever, application of solution of quinine in, 87. Headache, in bronchial catarrh, 345 ; in pleuritis, 639. Hearing, impairment of, in diseases of nose, 111. Heart, affections of, in chronic bronchitis, 390, 401; in croup, 260 ; diseases of, in etiology of bronchial catarrh, 315 ; of hydrothorax, 734 ; displacement of, in pleuritis, 651, 660 ; affections of, following bronchial catarrh, 330. Heat, application of, in diseases of pharynx and larynx, 96. Hedenus, 139, 146. Heiberg-Hjalmar, 126. Helfft, 423. Heliostat, use of, in laryngoscopy, 35. Helmholtz, 7. Hemorrhages in etiology of stenosis of trachea and bronchi, 477 ; from lungs following aspiration in pleuritis, 711; of mucous membrane of larynx, 191. Hemorrhagic diathesis in etiology of hemorrhagic pleuritis, 614; infarctions of lung in etiology of pleuritis, 595. Henbane in pleuritis, 690. Henle, 186. Henoch, 106, 147, 639, 756. Hernia of the brain, differential diagnosis of, from nasal polypi, 171, | Hertel, 297, 301. Heyfelder, 509. Hiard, 161. Highmore, antrum of, affections of, in chronic nasal catarrh, 142 ; in cold in the head, 126. Hiller, 118. Hinckes, 202. Hippocrates, 115, 502, 595, 619, C34, 642, 647, 607, 655, 695, 761. Hirsch, 179, 237, 302, 304. Hirschberg, J., 16, 27. Hirt, 213, 312, 314, 408. Hirtz, 253, 577. History of cold in the head, 115; of diseases of larynx, 185 ; of laryngoscopy, 12; of hydrothorax, 732 ; of pleuritis, 592; of pneumothorax, 745. Hoffmann, 267. Hoffman, Franz, 728. Holder for sponge, 80. Homburg, waters of, in bronchial catarrh, 414, 424. Honerkopf, 236, 267. Honsell, 105. Hoppe, 114. Hoppe-Seyler, 609, 725. Houssenot, 260. Hueter, 124, 522. Hufeland, 267. Huhnerwolff, 120. Humidity of the air, its influence upon prevalence of bronchitis, 302. Huss, 630. Huxham, 6S5. Hydatids in etiology of pneumothorax, 748. Hydrarg. chlor. corrosivum in chronic nasal catarrh, 145; in diseases of nose, pharynx, and larynx, 95. Hydrarg. chlor. mitis in bronchial catarrh, 417; in chronic nasal catarrh, 145; in croup, 267 ; in crou- pous bronchitis, 46S; in pleuritis, 6S5. Hydrarg. oxid. rubrum in chronic nasal catarrh, 145. Hydrarg. unguentum in croupous bronchitis, 468 ; in pleuritis, 686. Hydrate of choral in bronchial asthma, 576. Hydrochloric acid in croup, 265. Hydrokonion of Bergson, 90 ; of Wintrich, 90. Hydrops antri Highmori in chronic nasal catarrh, 142. Hydrothorax, 732. HySres, climate of, in bronchial catarrh, 413. Hyoscyamus in diseases of nose, pharynx, and larynx, 95: in pleuritis, 690. Hyperaemia of the larynx, 190. Hyperaemia in bronchial catarrh, 318 ; of the lungs, due to forced inspiration, 106; of mucous mem- brane of larynx in croup, 255. Hypertrophy of connective tissue of under surface of vocal cords in chronic catarrh of larynx, 218; of INDEX. 787 the walls of the air-passages in etiology of stenosis of trachea and bronchi, 480. Hyponitrous acid, inhalation of fumes of, in etiology of bronchial catarrh, 314. Ice wrappings in bronchial catarrh, 421. Icterus of mucous membrane of larynx, 193. India, plains of, climate of, in pulmonary diseases, 302. Indian hemp in bronchial asthma, 577. Infarctions, hemorrhagic, of lung in etiology of pleu- ritis, 595. Infective diseases in etiology of acute catarrh of larynx, 196. Inflammation, submucous, and abscess of the nasal cavity, 146. Inflammation, relapsing, of pleura in etiology of hemorrhagic pleuritis, 613. Influenza, epidemic, in etiology of bronchial catarrh, 315. Infusion of belladonna, of chamomile, of elder, of linden in diseases of nose, pharynx, and larynx, 95 ; compound, of senna in pleuritis, 688. Inhalation of atomized fluids, various principles, 88; of atomized fluids in chronic nasal catarrh, 145; inhalations in acute bronchitis, 426, 428, 429; in bronchial catarrh, 415 ; in chronic bron- chitis, 431, 433, 434; in croup, 265; in croupous bronchitis, 468 ; of dust in etiology of bronchial catarrh, 312; of gases and vapors in etiology of bronchial catarrh, 314; of gases in diseases of nose, pharynx, and larynx, 96; of oxygen in bronchial catarrh, 580. Inheritability in bronchial asthma, 530; in croup, 236; in nosebleed, 154. Injections of atomized fluids in chronic nasal catarrh, 145; submucous, in diseases of pharynx and larynx, 96. Injuries in etiology of pleuritis, 594. Illuminating apparatus of Fraenkel, 28; of Krishaber, 25 ; of Toboid, 30 ; of von Ziemssen, 32. Illumination in inspection of the pharynx, 6; in laryngoscopy, 16. Innominate artery, aneurism of, in stenosis of trachea, 476. Inspection of thorax in acute tracheo-bronchitis, 362 ; in bronchial catarrh, 350 ; in croupous bronchitis, 462 ; in pleuritis, 641, 643, 646, 663, 668 ; in pneu- mothorax, 751, 75S. Inspiration in relation to entrance of foreign bodies into trachea and bronchi from without, 508. Insufflation of powders in diseases of nose, pharynx, and larynx, 7S. Insufflator, laryngeal, 7S: of Rauchfuss, 78. Interlaken, a resort for the milk-and-whey cures in bronchial catarrh, 424. Inunction of oil in acute bronchitis, 426. Iodide of potassium in bronchial catarrh, 420; in croupous bronchitis, 468; in diseases of nose, pharynx, and larynx, 80, 95, 96; in pleuritis, 691. Iodine in chronic catarrh of larynx, 225, 226; in croup, 265; in diseases of pharynx and larynx, 80, 82, 96; inhalation of fumes of, in etiology of bronchial catarrh, 314; of coryza, 120; tincture of, painting with, in pleuritis, 687. Iodinii, liq. comp., in chronic nasal catarrh, 145. Iodized glycerine in diseases of pharynx and larynx, 96. Ipecac in bronchial asthma, 580; in bronchial catarrh, 418, 427 ; in croup, 268; inhalation of, in etiology of coryza, 120. Iron, chloride of, in croup, 265 ; in diseases of larynx, 82; in nosebleed, 163; compound mixture of, in bronchial catarrh, 420 ; liquor of perchloride of, in hemorrhage of mucous membrane of larynx, 193. Ischl, a resort for the milk-and-whey cure in bronchial catarrh, 424; mineral waters of, in chronic catarrh of larynx, 227. Itard, 745. Itzigson, 534. Jabobandi in bronchial catarrh, 419. Jaden, 258. Jaffe, 397. 401. Jaksch, 249. Jurgensen, 366, 422, 467. Jurine, 1S6. 253. Kabsten, 258. Kermes mineral in bronchial catarrh, 417. Kidd, 540. Kidneys, affections of, in croup, 261; disease of, in etiology of bronchial catarrh, 316; of hydro- thorax, 735 ; of pleuritis, 597; a sequel of bronchial catarrh, 331, 401. King, 478. Kissengen, waters of, in bronchial catarrh, 414, 424. Klebs, 258. Klein, 287. Klemm, 206. Kochel, waters of, in bronchial catarrh, 423. Kohlrausch, 123. Kohts, 279, 336, 358, 633. KOlliker, 63, 176. Koppe, 159. Kostlin, 176. Kratschmer, F., 109. Krause, 621, 693. Kretschy, 452, 455, 457, 460. Kreuth, a resort for the milk-and-whey cure in bron- chial catarrh, 424; in pleuritis, 691. 788 INDEX. Krimer, 277. Krishaber, illuminating apparatus of, 25. Kiichenmeister, 256. Kussmaul, 105, 115, 152, 343, 693, 716. Labory, 179. Laboulbene, 609. Lachrymal duct and sac, affection of, in cold in the head, 126. Lactic acid in croup, 265; in diseases of larynx, 82 ; in diphtheria, 95. Laennec, 300, 326, 336, 371, 391, 395, 396, 431, 593. 630, 657, 660, 666, 676, 686, 688, 692, 705, 745, 746. Lamp, rack-movement, of Mackenzie, 25. von Langenbeck, 728. Langenbriicken, waters, of, in bronchial catarrh,424. Langhans, 480. Larrey, 743. Laryngeal brush, 80. Laryngeal croup, diagnosis of, from croupous bron- chitis, 464. Laryngeal electrode (internal), of Mackenzie, 97. Laryngeal insufflators, 78; of Rauchfuss, 78. Laryngeal mirror, 16, 19, 44. Laryngeal sounds, 44. Laryngeal sponge, 80. Laryngeal syringes, 83. Laryngitis catarrhalis acuta, 194. Laryngitis catarrhalis chronica, 212. Laryngitis crouposa et diphtheritica, 231, Laryngitis, a complication of cold in the head, 126 ; a result of foreign body in the air-passages, 514. Laryngoscopic appearances in chronic catarrh of larynx, 215. Laryngoscopy, 11. Laryngoscopy in acute catarrh of larynx, 197, 206; in croup, 248; in foreign bodies in the air-passages, 514, 519. Larynx, acu\j catarrh of, 194. Larynx, affections of, following bronchial catarrh, 401. Larynx, anatomy of, 46. Larynx, chronic catarrh of, 212. Larynx, catheterism of, in croup, 272. Larynx, Diseases of Mucous Membrane of, 185; introduction, 185; general literature, 185; history, 185. An2emia, 189; etiology and symptomatology, 189. Hypee.3emia, 190; etiology, 190; anatomical changes, 190; symptomatology, 190. Hemorrhage of the Mucous Membrane, 191; etiology, 191; symptoms and course, 191; prog- nosis and treatment, 193. Abnormal Color or the Mucous Membbane, 193; cyanosis, 193; icterus, 193. Laeyngitis catarrhalis acuta ; Acute Catarrh of the Larynx, 194; bibliography, 194; etiology, 194; catching cold, 194; various other causes, 195; atmospheric influences, 196; influence of in- fective diseases, 196; local treatment of net. plasms, etc., 196; pathology, 196; general de scription of the disease and symptomatology, 196; the mildest cases, 197; irritation of larynx and impairment of voice, 197; appearances of the larynx, 197; the moderately severe cases, 197; the general increase in severity of symptoms, 197; laryngoscopic appearances, 197; dyspnoea, 198; the so-called pseudo-croup, 198; its symptoms, 198; the severest forms, 199; terminating in cedema of the larynx, 199; in laryngitis hemor- rhagica, 200; laryngitis exanthematica, 201; dif- ferent diseases causing it, 201; analysis of individ- ual symptoms, 202 ; derangement of vocalization, 202; dyspncea, 204 ; cough, 204 ; secretion, 205; dysphagia and pain, 205; the general malaise, 205; diagnosis, 206 ; importance of laryngoscopy, 206; course, duration, results, and prognosis, 207; treatment, 208; prophylaxis, 208; cold frictions, 208; sea-bathing, 209: sparing the voice, 209; treatment during the attack, 209 ; prohibition of talking, 210 ; the fever, 210 ; the irritable throat, 210; antiphlogistic treatment, 211 ; local treat- ment, 211; internal remedies, 211; electricity, 212 ; scarification of the glottis and tracheotomy, 212. Laryngitis cataeehalis cheonica ; cheonic cA- xabbh of the Labynx, 212 ; etiology, 212; over- use of voice, 212; chronic pharyngitis, 213 ; an elongated uvula, 213; dusty atmosphere, 213; age and sex, 213; processes due to various dis- eases, 213 ; pathology, 214 ; symptomatology and terminations, 214; commencement of the disease, 214; subjective symptoms, 214; objective symp- toms, 214 ; voice, 214 ; expectoration, 215; laryn- goscopical appearances, 215; motor derange- ments, 216 ; erosions and ulcerations, 216 ; thick- enings, 216; development of veins, 217 ; alter- ations in vocal cords, 217; hypertrophy of the glands, 217; papillary proliferations and polypi, 218; site of erosions, 218 ; corditis vocalis inferior \ hypertrophica, 218; ulcerations, perichondritis, and oedema as results, 220; the chronic second- ary laryngitis, 220 ; course and prognosis, 221 ; treatment, 223 ; prophylaxis, 223 ; the local treat- ment, 223; spray inhalations, 223 ; application of nitrate of silver, 224 ; other remedies, 225; saline cathartics and diet. 225 ; electricity, 225; exter- nal counter-irritation, 226 ; mineral waters, 226. Larynx, general diagnosis and therapeutics of, 3. Larynx, movements of, in stenosis of trachea and bronchi, 489. Larynx, stenosis of, its diagnosis from croupous bron- chitis, 464. INDEX. 789 Lasegue, 137. Lassar, 352. Laycock, 258, 344, 396. Lead, acetate of, in bronchial catarrh, 420 ; in chronic bronchitis, 435; in nosebleed, 168. Lead ointment in chronic nasal catarrh, 145. Lead poisoning in etiology of bronchial asthma, 538. Lead water in chronic nasal catarrh, 145. Lebert, 304, 305, 308, 309, 348, 349. 307, 396, 401, 438, 442, 443, 534, 536, 538, 546, 576, 5S0, 581, 583, 700. Leeching in croup, 266. Lefevre, 541. Lehmann, 288, 531, 5-15. Leisring, 147. Lenses, illumination of larynx by means of, 24. Le Roy, 637, 617. Leudet, 288. Leukaemia in etiology of hydrothorax, 735. Levret, 13. Lewin, 11, 15, 26, 78, 88, 217, 224, 205. Lewy, 53S. Leyden, 397, 398, 401, 435, 531, 541, 547, 5S4. Lichtheim, 695, 700. von Liebig, 432. Liebreich, 576. Lieutaud, 482. Ligamentum vocale spurium, 4S. Ligamenta vooalia vera sive inf eriora, 49. Lime, chlorinated, in chronic bronchitis, 435; in chro- nic nasal catarrh, 146. Lime-water in diseases of nose, pharynx, and larynx, 82, 86; in diphtheria, 95 ; inhalation of, in croup- ous bronchitis, 468 ; gargles of, in croup, 265. Linden, infusion of, in diseases of nose, pharynx, and larynx, 95. Liniments, irritating, in bronchial catarrh, 419. Liquor ferri chloridi in diseases of nose, pharynx, and larynx, 94. Liquor ferri perchloridi in hemorrhage of mucous membrane of larynx, 193. Liquor iodinii comp. in chronic nasal catarrh, 145. Liquor potassae arsenitis in bronchial asthma, 581. Liquor soda? chlorinatae in diseases of nose, pharynx, and larynx, 95. Lister's apparatus for inhalation of atomized fluids, 88. Lister's treatment in opening the pleural cavity in cases of purulent effusion, 718. Listen, 13, 39. Lithium, carbonate of, in disease of nose, pharynx, and larynx (diphtheria), 95. Liver, abscess of, in etiology of pleuritis. 596; affec- tions of, in bronchial catarrh, 401; in croup, 261; affections of, following bronchial catarrh, 331; fistula of. communicating with lung, in etiology of pneumothorax. 74S. Lobelia in bronchial asthma, 582. Locality in etiology of bronchial asthma, 538. Loiseau, 272 Longet, 278, 541. Lori, 53. Louis, 530, 756. Loven, 550. Lowndes, 173. Lowenberg, 65. Lucae, 111. Lucerne, vicinity of lake of, a resort in pleuritis, 691. Lugol's solution in chronic nasal catarrh, 145. Luhatschowitz, waters of, in bronchial catarrh, 423. Lungs, affections of, in bronchial catarrh, 328; in croup, 260; in croupous bronchitis, 456; in hy- drothorax, 736; in pneumothorax, 753; apoplexy of, a complication of croup, 252; collapse of, a complication of bronchial catarrh, 402; gan- grene of, a complication of croup, 252; abscess of, in etiology of pneumothorax, 748; affections of, in etiology of bronchial catarrh, 316 ; of haema- tothorax, 740 ; apoplexy of, in etiology of pneumo- thorax, 748 ; cancer of, in etiology of stenosis of trachea and bronchi, 478; chronic disease of, in etiology of hydrothorax, 734; emphysema of, in etiology of pneumothorax, 748; hemor- rhagic infarctions of, in etiology of pleuritis, 595; tuberculosis of, in etiology of pneumo- thorax, 740 ; affections of, as sequelae of foreign bodies in bronchi, 511 ; as sequelae of pleuritis, 670, 674; atelectasis and collapse of, as sequelae of bronchial catarrh, 329; atelectasis of, a sequel of croupous bronchitis, 465 ; of stenosis of trachea and bronchi, 485; emphysema of, a sequel of bronchial asthma, 573; of bronchial catarrh, 329; of croupous bronchitis, 465: of stenosis of trachea and bronchi, 485 ; hyperaemia of, due to forced inspiration, 106 ; infiltration of parenchyma of, a sequel of croupous bronchitis, 405. Lupus, in etiology of chronic catarrh of larynx, 213. Luschka, 38, 46, 113, 621. Lymphatic glands, affections of, in cold in the head, 126; in pleuritis, 606; in etiology of stenosis of trachea and bronchi, 475. MacDonnell, 637. Mackenzie, 197, 217. Mackenzie's intra-laryngeal electrode, 97; rack-move- ment lamp, 25. Macnamara, 163. Madeira, climate of, in bronchial catarrh, 143. Magatus, Caesar, 180. Maier, R., 261. Malaria in etiology of hydrothorax, 735. Malformations of trachea and bronchi. 286. Malignant new-growths in the pleura, 771. Mandl, 191. 790 INDEX. Mankiewicz, 178, 181. Marienbad, waters of, in bronchial catarrh, 414; in chronic catarrh of larynx, 226. Marrotte, 692, 693. Marsh-mallow, infusion of, in acute catarrh of larynx, 210. Martin,- 753. Martineau, 155. Matthieu's principle for inhalation of atomized fluids, 88. Mayne, 488, 694. Measles in etiology of bronchial catarrh, 315; of croup, 237. Measurement of chest in diseases of trachea and bron- chi, 284. Mediastinum, diseases of, in etiology of stenosis of trachea and bronchi, 477; inflammation of, a complication of pleuritis, 672. Mehu, 609. Membrana laryngis elastica, 50. Membrana quadrangularis, 48. Membrane discharged in croup, its characteristics, 245. Membrane, mucous, of larynx, diseases of, 185. Membrane, mucous, of pharynx, its characteristics, 8. Membrane, mucous, atrophy of, in bronchial catarrh, 324; color of, in bronchial catarrh, 320; hyper- aemia of, in bronchial catarrh, 318; softening of, in bronchial catarrh, 324 ; ulcers of, in bronchial catarrh, 324; appearances of, in croupous bron- chitis, 455; swelling of, in abscess of nasal cavity, 147; swelling of, in bronchial catarrh, 318, 321; swelling, in cold in the head, 122; in purulent nasal catarrh, 132. Mensuration in pneumothorax, 758. Mentone, climate of, in bronchial catarrh, 413. Meran, climate of, in bronchial catarrh, 413; a resort for the grape cure in bronchial catarrh, 424; a resort in pleuritis, 691. Mercurial ointment in pleuritis, 6S6. Mercury, corrosive chloride of, in diseases of nose, pharynx, and larynx, 82, 95 ; mild chloride of, in bronchial catarrh, 417; in pleuritis, 685; red oxide of, in chronic nasal catarrh, 145. Merkel, 49, 111, 213, 313, 745. Mettenheimer, 474. Meyer, 69. Michel, 98. Micrococci in secretion, in cold in the head, 124. Milk and whey cure in bronchial catarrh, 424. Millar, 198. Mineral waters in croupous bronchitis, 469; in diseases of nose, pharynx, and larynx, 94; mineral waters of Carlsbad in chronic catarrh of larynx, 226: of Eilsen in chronic catarrh of larynx, 226; of Ems in chronic catarrh of larynx, 227 ; of Ischl in chronic catarrh of larynx, 227; of the Kreuz- brunnen in Marienbad in chronic catarrh of larynx, 226; of Neundorf in chronic catarrh of larynx, 226 ; of Reichenhall in chronic catarrh of larynx, 227 ; of Weilbach in chronic catarrh of larynx, 226. Mirror, laryngeal, 16, 19, 44. Mistura ferri composita in bronchial catarrh, 420. Mohr, 615. Montreux, a resort for the grape cure in bronchial catarrh, 424. Monneret, 318, 692, 733, 753. Morgagni, 154, 161, 18C, 186, 200, 593, 688, 740, 745. Morgagni, ventricle of, 49. Morphia in acute catarrh of larynx, 210 ; in bronchial asthma, 575; in cold in the head, 128; in croup, 208; in diseases of nose, pharynx, and larynx, 95; in haematothorax, 742; in pleuritis, 689; in pneumothorax, 768. Mortality in acute croupous bronchitis, 448; in coryza, 125; in croup, 204 ; in croupous bronchitis, 466; in purulent nasal catarrh, 133. Mosler, 151, 152, 167. Moura, 25. Moutard-Martin, 672, 723. Movements of the parts in laryngoscopy, 54. Mucous membrane of larynx, diseases of, 185. Mucous membrane, swelling of, in abscess of the nasal cavity, 147; swelling of, in cold in the head, 122; in purulent nasal catarrh, 132. Muller, Johannes, 186. Munch, 248. Munk, 242. Muriate of ammonia in acute catarrh of larynx, 211; in bronchial catarrh, 417 ; in diseases of nose and pharynx, 86. Muriatic acid, inhalation of fumes of, in etiology of bronchial catarrh, 314. Muscles, bronchial, spasm of, in etiology of bronchial asthma, 541; hypertrophy of muscles, in chronic bronchitis, 390. Musculus arytaenoideus transversus, 48. Musculus thyreo-arytaenoideus internus, 50. Mustard foot-baths in nosebleed, 164. Mustard plasters in acute catarrh of larynx, 211. Myrrh in chronic bronchitis, 435; in chronic nasal catarrh, 146. Myxoma of nasal cavity, 171. Narcotics in acute bronchitis, 426. 428, 430 : in bron- chial asthma, 575; in bronchial catarrh, 416, 419; in chronic bronchitis, 433; in croup, 268, Nares speculum of Fraenkel, 57. Narrowing of the trachea and bronchi, 470. Nasal catarrh, chronic, 137. Nasal catarrh, purulent, 129. IXDEX. 791 Nasal douche in chronic nasal catarrh, 144. Nasal douche of Th. Weber, 84. Nasal polypi, 16S. Nauseants in bronchial catarrh, 416, 420. Naunyn, 609. Navratil, 191. Neck, fistula of, 289. Negrier, 164. Nelaton's catheters in after-treatment of opening pleural cavity for discharge of purulent effusions, 718. Neundorf, waters of, in bronchial catarrh, 424; in chronic catarrh of larynx, 226. Neumann, E., 568. Neustadt, a resort for the grape cure in bronchial catarrh, 424. Nerve influences in etiology of bronchial asthma, 550. Nerve, vagus, paralysis of, in croup, 248. Nervous symptoms in acute tracheo-bronchitis, 363 ; in bronchial asthma, 566; in bronchial catarrh, 345, 402; in capillary bronchitis, 374: in pleu- ritis, 639; following entrance of foreign bodies into trachea and bronchi, 518. New-growths, malignant, in the pleura, 771. Nice, climate of, in bronchial catarrh, 413. Niemeyer, 241, 243, 246, 250, 267, 268, 317, 345, 355, 357, 375, 412, 655. 691, 735, 747. Nitrate of potash in bronchial asthma, 579, 583; in pleuritis, 686; of silver in bronchial asthma, 583 ; in chronic catarrh of larynx, 224 ; in cold in the head, 128, 129; in croup, 265; in diseases of nose, pharynx, and larynx, 76, 79, 82, 86, 94; in nosebleed, 163; in purulent nasal catarrh, 135, 145; of soda in pleuritis, 686. Nitric acid, inhalation of, in etiology of bronchial catarrh, 314. Nitrite of amyl in bronchial asthma, 576. Nocturnal asthma due to tumors of the nose, 107. Nonet, 253. Noose, thread, of Tiirck in rhinoscopy, 67. North America, western prairies of, climate of, in pulmonary diseases, 302. Nose, Diseases of, 101; introduction, 101. Stenosis and Atresia of the Nasal Cavity, 103 ; symptomatology, 103; normal respiratory movements, 103; effects of closure of the nose in nursing infants, 104; asthmatic attacks, 105; hyperaemia of the lungs, 106; asthma clue to tumors, 107; nocturnal asthma, 107; emphysema of the lungs, 108; influence of reflex action, 109; impairment of the sense of smell, 109 ; imperfect removal of secretions, 110 ; changes in the voice, 110; impairment of hearing, 111; diagnosis, 111; mode of occurrence and causes, 112; posi tion of the stricture, 112; congenital errors of development, 112; other causes, 112; congenital bony closure, 113; treatment. 114. L' Cold in the Head," Rhinitis, Coryza, 115; history, 115; etiology, 117; question of con- tagion, 117; occurrence of epidemic forms, 117; susceptibility to influence of gonorrhoeal matter, 118 ; coryza of new-born children, 119; predispo- sition to coryza, 120; atmospheric influences, 120; irritants, 120; coryza a symptom of first stage of various diseases, 121; influence of age, 121; symptomatology, 121; swelling of the mu- cous membrane, 122 ; the secretion, 123 ; course of the disease, 124; mortality, 125; chronic form following the acute, 125; duration, 125; com- plications, 125; invasion of neighboring organs, 125: the skin of the nose, 125; facial erysipelas, 125; pharyngitis and disease of the Eustachian tubes, 125 ; tinnitus and deafness, 125 ; laryngitis and tracheitis, 126; inflammation of the lachry- mal duct, sac, and the conjunctiva, 126; affections of the frontal sinus, cavities of the ethmoid and sphenoid bones, and the antrum of Highmore, 126; swelling of the lymphatic glands, 126; retro- pharyngeal abscess, 127; pathological anatomy, 127; treatment, 127 ; general measures, 127; drugs employed, 128; prophylaxis, 129. Purulent Nasal Cataerh, Rhinitis Blennor- rhoica, 129; definition, 129; etiology, 129; infec- tion during birth, 129 ; from gonorrhoeal matter, 131; during scarlet fever, small-pox. and diph- theria, 131; after burns and cauterizations, 131; by extension from the conjunctiva or pharynx, 131; the circumscribed inflammations, 131; symptomatology, 131; the secretion, 132; com- plications, 132; course and terminations, 132; diagnosis. 133; diagnosis from diphtheria, 133 from laryngeal diseases, 134; from abscess, 134 ; gonorrhoeal infection, 134 ; treatment, 135 ; pro- phylaxis, 135. Diphtheria of the Nasal Cavity, 136. Eeysipelas of the Nose, 136. Rhinitis Chronica, Oz.ena, Stockschnupff.n, Stincknase, 136 ; etiology, 136; tendency of the acute and subacute forms to pass into the chronic form, 136; influence of scrofula and syphilis, 136 ; effects of deep lesions of the cavity, 137; symptomatology and course, 137; the hyperplastic and atrophic forms, 138; the secre- tion, 138; its stench, 139 ; influence of some dys- crasia, 140 ; complications, 141; acute exacerba- tions, 141; ulcerations, 141; affections of the pharynx and skin, 141; of the antrum of High- more, 142 ; of the periosteum and perichondrium, 142; of the sense of smell, 142; diagnosis, 142; prognosis, 143; treatment, 143; various local treatments, 144. 792 INDEX. Submucous Inflammation and Absckss of the Nasal Cavity, 146; symptomatology, 147; diag- nosis, 148; course, termination, and prognosis, 148; treatment, 148. Ulcerations of the Nasal Cavity, 143; etiology, 143; diagnosis, 149; treatment, 150. Nosebleed, Epistaxis, 150; etiology, 150; spon- taneous nosebleed, 151; its local causes, 151; dis- eases giving rise to a hemorrhagic diathesis, 151; effects of disturbance of lateral pressure within the blood-vessels, 151; influence of state of the barometer, 151; infectious diseases, 151; diseases of the spleen, 152; habitual epistaxis, 152; the vicarious form, 152; frequency of habitual nose- bleed, 154; inheritability, 154; an epidemic form, 154; symptomatologg, 155; its site, amount, and duration, 155; color, 155 ; premonitory signs, 156; course, 157; evidences of anaemia, 157; syncope, 157; prognosis, 158; diagnosis, 158; differential diagnosis, 159; treatment, 160; the question of arrest of the hemorrhage in cases evidencing hyperaemia of the head, 160; the same in regard to vicarious epistaxis, 161; external pressure, 161; internal pressure by the finger, 161; internal pressure by a pledget of lint, the anterior tampon, 162; compression of the carotid artery, 163; application of cold, 163; various astringent drugs. 163 ; use of reflex action to produce spasm of the vessels, 163; deriva- tives, 163, plugging the posterior nares, 164; instruments employed, 164; time for removing the tampons, 166; method of their removal, 166; treatment of syncope, 167; transfusion, 167; internal use of haemostatics, 167; prophylaxis, 168. Tumors of the Nasal Cavity, 168; characteristics of mucous polypi, 169; diagnosis, 170 ; sarcoma- tous and fibromatous tumors, 170; their site of origin and mode of growth, 171; other varieties, 171; differential diagnosis from hernia of the brain, 171; symptomatology,Yl\ ; treatment, 172. Foreign Bodies and Concretions, 172; general considerations, 172; rhinoliths, 175; calcareous degeneration of the mucous membrane, 175 ; di- agnosis, 176; treatment, 176. Parasites of the Nasal Cavity, 177; vegetable parasites, 177; the infusoria, 177; living creatures, 177; symptomatology, 178 ; prognosis, 180 ; diag- nosis, 180; treatment, 180. Nose, Pharynx, and Larynx, General Diagnosis and Tlierapeutics of, 3 ; inspection of the pharynx, 3 ; mode of procedure, 3; management of the tongue, 3; instruments, 5; method of illumination, 6; the use of reflec- tors, 7; appearances of the velum palati, 7; i of the mucous membrane, 9; mobility of the i velum, 9; difficulties in the examination, 9; laryngoscopy, 11; bibliography, 11; history, 12 ; means requisite for laryngoscopy, 15 ; the mirror, 16; illumination, 16 ; artificial illumination, 18; concave mirrors, 19; Semeleder's spectacle-frame, 21; Cramer's forehead-band, 21; position of the mirror, 21; position of the light, 24; illumination by means of lenses, 24 ; method of employment, 24; Krishaber's apparatus, 25; Mackenzie's lamp, 25; combination of concave mirrors and lenses, 26; Fraenkel's illuminating apparatus, 28 ; Tobold's apparatus, 30 ; the choice of a flame, 31; von Ziemssen's apparatus, 32; the use of day- light, 33; diffused daylight, 33 ; sunlight, 34; the performance of laryngoscopy, 36; method of in- struction, 36; position of the patient, 37; man- agement of the tongue, 38; of the laryngeal mirror, 38 ; obstacles to laryngoscopy, 41; short- ness of the fraenum linguae, 41; irritability of the pharynx, 42 ; enlarged tonsils, velum, and uvula, 43; obstacles presented by the epiglottis, 43; Voltolini's uvula-holder, 43; obstacles presented in refractory patients, 44; the appearances as seen in the mirror, 46 ; general anatomy of the larynx, 46; the complete examination, 52; the color, 53 ; form, 53; calibre, 54; movements, 54 ; demonstration of a laryngoscopic image, 54 ; auto- laryngoscopy, 55; examination through a trache- otomy wound, 57; inspection of the nose from the front, 57; the nares speculum, 57; Wer- theim's conchoscope, 58 ; Voltolini's method, 58 ; parts that can be seen in the examination, 59; rhinoscopy, 59; instruments, 60; method of examination, 61; the appearances as seen in the mirror, 62; pathological changes, 64 ; difficulties encountered in the examination, 64; transillu- mination, 68; palpation, 68; external and inter- nal palpation, 69; palpation of the larynx, 69; examination by auscultation and the sense of smell, 70 ; general therapeutics, 73 ; introduction of instiuments, 74; purposes of treatment by medical agents, 76; the application of solids, 76 ; the simple direct method, 76 ; the principal drugs used, 76 ; instruments employed, 76 ; insufflation of powders, 78; instruments and mode of appli- cation, 78 ; caustic darts, 80 ; ointments, 80 ; the application of fluids, 80; pencilling, 80; instru- ments, 80; drugs employed, 82; syringing, 82 ; nasal douches, 84 ; objections to their use, 85; other methods, 85 ; drugs employed, 86 ; gargles, 87; inhalation of atomized fluids, 88 ; principle of Matthieu, 88; principle of Bergson, 89; prin- ciple of Siegle, 91; mode of using the apparatus, 93; duration and frequency of the inhalations, 93; drugs employed and their doses, 94 ; inhala- tion of gases, 90; submucous injections, 96; IXDEX. 793 application of cold and heat, 96 ; electricity, 96; different points of application, 97; galvano- caustic treatment of chronic pharyngeal catarrh, 98; tamponing the posterior nares, 98; Belloc's tube, the rhineurynter and rhinobyon, 98. Nothnagel, 278, 336, 358, 633, 761. Nutrition, conditions of, and changes in, in capillary bronchitis, 374; in bronchial catarrh, 339, 349, 402 ; in croupous bronchitis, 460. Obermeier, Otto, 152. Oberselters, waters of, in bronchial catarrh, 423. Occupation in etiology of bronchial catarrh, 539 ; of chronic catarrh of larynx, 212, 213. (Edema, acute, in etiology of stenosis of trachea and bronchi, 481 ; in pleuritis, 635 ; in pneumothorax, 757 ; result of chronic catarrh of larynx, 220. Oertel, 258. CEsophageo-tracheal fistula, 287. Oesophagus, cancer of, in etiology of pleuritis, 596, perforation of, in etiology of pneumothorax, 750 ; tumors of, in etiology of stenosis of trachea, 478. Ofen bitter-water in chronic catarrh of larynx, 225. Oidium albicans in expectoration of putrid bronchitis, 398. Oil of turpentine in bronchial asthma, 577, 583; in bronchial catarrh, 420, 434, 435. Ointments in diseases of nose, 80 ; gray, in croupous bronchitis, 4U8. Operation of opening pleural cavity in haematothorax, 743; for removal of fluid in pleuritis, 692; operation of opening pleural cavity in pyopneu- mothorax, 767 ; operation, radical, for removal of purulent effusions into the pleura, 716. Opium in acute catarrh of larynx, 211: in bronchial asthma, 575 ; in cold in the head, 12S : in diseases of nose, pharynx, and larynx, 95 : in haematotho- ax, 742; in pleuritis, 689; in pneumothorax, 768. Oppenheimer, 126, 448. Oppolzer, 267. Orthopncea in pleuritis, 628 ; in pneumothorax, 755. Osteoma of nasal cavity, 171. Ostium pharyngeum laryngis, 4S. Otto, 287. Oxide of mercury, red, in chronic nasal catarrh, 145 ; of zinc in bronchial asthma, 583 ; in diseases of nose, pharynx, and larynx, 79. Oxygen, inhalations of, in bronchial asthma, 580. Ozaena, 136. Paget, 4S2. Pain in acute catarrh of larynx, 205 ; in bronchial ca- tarrh, 344; in chronic bronchitis, 388; in dis- eases of trachea and bronchi, 2M ; in larynx in croup, 248; in malignant new-growths in the pleura, 772; pleuritic, in diagnosis of tubercular and purulent exudations from the sero-fibrinous in pleuritis, 032 ; in pleuritis, 029 ; treatment of, 689; in pneumothorax, 751, 750. Palermo, climate of, in bronchial catarrh, 413. Palpation in acute tracheo bronchitis, 361; in dis- eases of trachea and bronchi, 2S4; in examination of larynx, 69; of nasal cavil y, 68 ; of pharynx, 69; in pleuritis, 636, 643, 646, 661, 666, 669; in pneu- mothorax, 759. Paoli, 605. Papillary proliferations in chronic catarrh of larynx, 218. Paraeus, 728. Parasites of the nasal cavity, 177. Pastau, 477. Pasteur, 397, 398. Pathogenesis of bronchial asthma, 533; of foreign bodies iu trachea and bronchi, 506. Pathology of acute catarrh of larynx, 196 ; of bron- chial asthma, 555; of bronchial catarrh, 317; of catarrhal pneumonia, following capillary bron- chitis, 366; of chronic catarrh of larynx. 214; of cold in the head, 127: of croup, 255; of croupous bronchitis, 451; of foreign bodies in trachea and bronchi, 510; of haematothorax, 740 ; of hydrothorax, 735 ; of hyperaemia of larynx, 190 ; of pleuritis, 600 ; of pneumothorax, 751; of stenosis of trachea and bronchi, 481. Pau, climate of, in bronchial catarrh, 413. Pauli, 237, 262, 269. Pectoral fremitus, diminution of, in cases of foreign bodies in bronchi, 516 ; in pleuritis, 661, 669. Pencilling, a means of applying remedies in diseases of nose, pharynx, and larynx, 80. Pentzold, 493. Pepsine in diseases of larynx, 82. Percussion in acute tracheo-bronchitis, 360 ; in bron- chial asthma, 563 ; in bronchial catarrh, 353 ; in capillary bronchitis, 370; in chronic bronchitis, 387; in croupous bronchitis, 461; in diseases of trachea and bronchi, 284 ; in hydrothorax, 737; in malignant new-growths in the pleura, 773; in pleuritis. 641, 643, 648, 662, 668, 731 ; in pneumo- thorax, 759. Pericarditis a complication of pleuritis, 669; in etio- logy of pleuritis, 596. Pericardium, diseases of, in etiology of stenosis of trachea and bronchi, 477. Perichondritis laryngea in etiology of chronic catarrh of larynx, 213; perichondritis a sequel of chronic catarrh of larynx, 220. Perichondrium, affections of, in chronic nasal catarrh, 142. Perier, 288. 794 INDEX. Periosteum, affections of, in chronic nasal catarrh, 142. Peritonitis, a complication of pleuritis, 672; in etiology of pleuritis, 596. Permanganate of potassa in chronic nasal catarrh, 145; in croup, 208; in diseases of nose, pharynx, and larynx, 82, S6, 95. Peru, balsam of, in bronchial catarrh, 420 ; in chronic bronchitis, 435. Peruvian bark in bronchial asthma, 582. Peter, 249, 251, 259, 625, 657, 660, 704, 712, 733. Petrunti, 477. Petters, 344. Pfeiffer, 432. Pfeufer, 192. Pharyngeal, retro-, abscess, a sequel of diseases of nose, 127. Pharyngitis, a complication of cold in the head, 125 ; chronic, in etiology of chronic catarrh of larynx, 213. Pharynx, affections of, in chronic nasal catarrh, 141; in purulent nasal catarrh, 132. Pharynx, diseases of, 3. Pharynx, fornix or vault of, 62. Pharynx, general diagnosis and therapeutics of, 3. Pharynx, inspection of, 3. Pharynx, irritability of, an obstacle to laryngoscopy, 42. Philotimns, 592. Phthisis in etiology of chronic catarrh of larynx, 213. Physical examination in acute tracheo-bronchitis, 360; in bronchial catarrh, 350 ; in capillary bron- chitis, 370 ; in cases of foreign bodies in trachea and bronchi, 519; in chronic bronchitis, 387, 392, 399; in croupous bronchitis, 461; in diseases of trachea and bronchi, 281; in haematothorax, 741; in hydrothorax, 737; in malignant new-growths in the pleura, 773; in pleuritis, 641; in pneumo- thorax, 759. Pick, 576. Pimser, 691. Pinel, 593. Piorry, 657, 764. Pisa, climate of, in bronchial catarrh, 413. Pleura, affections of, in bronchial catarrh, 329, 402; in croup, 260 ; in hydrothorax, 736. Pleura, Diseases of, 589. Pleuritis, 589; bibliography, 589; history, 592; etiology, 593; catching cold, 594; external in- juries, 594 ; pneumonia, 595 ; bronchial catarrh, 595; hemorrhagic infarctions and gangrene of the lung, 595; circumscribed inflammation of pleura leading to secondary pleuritis, 596; pneu- mothorax and its results, 596 ; pleuritis produced by an extension of disease from neighboring organs, and vice versa, 596; pleurisy a complica- tion of other diseases not directly connected with the pleura, 597; age and sex, 599; pathology, 600; various forms, and general course of pleu- ritis, 600; anatomical changes, 605; injected blood-vessels, 606; extravasations of blood, 606; color of the pleura, 606; the neighboring lym- phatics, 606; the exudation on surface of the pleura, 606; its source, 607; fatty degeneration of the fibrine, 607; formation of adhesions, 607 ; their conversion into fully organized and vascu- lar connective tissue, 607 ; the process of organi- zation, 608; the fluid effusions, 609; chemical analyses, 609; division of various forms of effu- sion, 610 ; the fibrino-serous effusion, 610 ; its frequency, 610 ; deposition of fibrinous portion of exudation, 610 ; other elements of the exudation, 610; changes in the pleura, 610; proportion between the fibrine and the albuminous serum, 611; the purulent effusion, 611; its characteris- tics, 611; rarity of primary purulent pleuritis, 611; question of origin of purulent exudations, 612; the hemorrhagic effusion, 613; characteris- tics and causes, 613; relapsing inflammation of the serous membrane, 613 ; influence of tubercu- losis, 614; the hemorrhagic diathesis, 614; amount of effusion influencing the displacement of organs, 615 ; site of adhesions, 616; multilocular form of exudation, 616 ; influence of rapidity of formation of exudation, 617; changes induced by the quality of the exudation, 618 ; necrosis of pulmonary or costal pleura, 618; shape of the opening, 619; pyopneumothorax, 619; the empyema necessita- tis, 620 ; empyema a result of an external abscess, 620 ; perforation through the diaphragm, 620 ; other courses, 620; recovery in fibrino-serous effusions, 621; changes where the exudative deposits become organized into connective tissue, 622; symptomatology; general aspects of the dis- ease, 624; fever, 624; initial chills, 624; the pulse, 625 ; respiration, 626 ; dyspnoea, 627 ; posi- tion of the patient, 628; orthopnoea, 628; pleu- ritic pain, 629; its site, 629; intensity and dura- tion, 630 ; reappearance of pain, 631; influence of age and other conditions upon the pain, 631 ; pain in diagnosis of tubercular and purulent exu- dations from the sero-fibrinous, 632; relation between the pain and the local disease, 632; cough and expectoration, 632; cause of cough, 633; its character, 634; character of expectora- tion, 634; perforation of the pulmonary pleura, 634; aspect of the countenance, emaciation, loss of strength, 635; cyanosis, 635; oedema, 635; palpation, 636; tension of, and pulsation in in- tercostal spaces, 637; special features of the disease, 639; the nervous system, 639; the di- gestive organs, 639; the urine, 640; physical signs, 641; in the commencement of pleurU INDEX. 795 tis, when there is little or no fluid effusion, 641'- inspection, 641; percussion, 641; auscultation, 642; the respiratory murmur, 642; friction sounds, 642; palpation, 643 ; when there is fluid effusion, without displacement of adjacent or- gans or expansion of the thorax, 643; level of the effusion, 643; inspection, 643; percussion, l 643; influence of change of position, 644 ; per- cussion note in subclavicular region, 644 ; auscul- tation, 646; palpation, 640; in fluid effusions leading to displacement of adjacent organs and dilatation of the thorax, 646; inspection, 646; percussion, 648; displacement of organs, 651; the half-moon-shaped region, 653; influence of change of position of patient upon percussion sounds, 655; auscultation, 658; bronchial breath- ing, 658; metallic bronchial breathing, 659; rales, 659; friction sounds, 6591 bronchophony and aegophony, 659; displacement of the heart, 660; palpation, 661 ; pectoral fremitus, 661' when the effusion becomes absorbed, without leaving any deformity of the chest, 662; percus- sion, 662; inspection, 663; auscultation, 664; friction sounds, 664; rales, 665 ; palpation, 666; in diminution of the effusion, with consequent more or less circumscribed retraction and defor- mity of the chest, 666 ; various deformities, 667 ; their causes, 668; inspection, 668; percussion, 668; auscultation, 669: bronchophony and aego- phony, 669; rales, 669; vocal fremitus, 669; pal- pation, 669 ; complications and sequelce, 669; pericarditis, 669; endocarditis, 670 ; influence of tuberculosis in double pleurisy, 670 ; affections of the lungs, 670; bronchial catarrh, 672; inflam- mations of the mediastinum and peritoneum, 672 ; pleuritis a complication and sequel of other diseases, 673 ; caries of ribs ahd spine, 673 ; adhe- sion of the pleural walls to one another, 673; caseous pneumonia, 674 ; other sequelae, 674; diagnosis, 674; quality of the effusion, 675; differential diagnosis, 675; duration, results, and prognosis, 680 ; treatment, 684 ; the expectant method, 684; the antiphlogistic method ; vene- section, 6S5 ; digitalis and calomel, 685; nitrate of potash or soda, 686; acetate of potash, 686, inunc- tion with mercurial ointment, 686; cupping and blistering, 686 ; sinapisms, 687 ; flying blisters 687, painting with tincture of iodine, 687 ; application of cold, 688 ; quinine and aperients, 688 ; the com- pound infusion of senna, 688 ; emetics, 688; in- fluence of age upon the antiphlogistic treatment, 088; the relief of pain, 689 ; warm applications, 689; opiates, 689; the bitter almond water, 689; extract of henbane, 690 ; diet, 690 ; diuretics, 690 ; their combination with tonics, 690 ; diaphoretics, 691' Schroth's method, 691; residence in an ele- vated region, 691; removal of the fluid by opera- tion, 092 ; choice of operation in relation to char- acter of effusions, 692; aspiration, 694; indications or operative interference, 695 ; difference between operative treatment of purulent and other effu- sions, 696; choice of apparatus, 698 ; avoidance of admission of air into pleural cavity, 699; choice between the hollow needle or trocar, 700 ; descrip- tion of the author's trocar, 704; time for operation, 705; place for the puncture to be made, 715; the operation itself, 706; precautions to be taken before operating, 708; fits of coughing upon the removal of the effusion, 710; quantity of fluid to be withdrawn, 710; accidents following the operation, 711 ; hemorrhage, 711; applica- tion of cold to point of puncture, 712 ; objec- tions by authors to the operation, 712; the author's results, 713; after-sensations at point of puncture, 714; constitutional effects, 714 ; changes in the residual fluid, 714; prognosis in cases of hemorrhagic effusion, 714; prognosis in cases of purulent effusions, 715; encapsulation of puru- lent effusions, 715; discharge of purulent effusions into the bronchi, 715 ; the radical operation, 716 ; preliminary puncture, 716 ; the operation itself, 717; after-treatment of wound, 718; introduc- tion of a canula, 718; after-treatment of the cavity, 720 ; percussion and auscultation sounds after healing of the wound, 722; results of the author's operations, 722 ; other methods of treat- ment, 724 ; necessity of a large opening into the pleural sac, 726; danger of wounding an inter- costal artery, 726 ; resection of a portion of rib to facilitate the after-treatment, 727 ; insertion of a metallic canula in the wound, 727 ; trephining a rib, 728 ; advantages of use of a canula, 728 ; in- fluence of temperature of patient upon the after-treatment, 729 ; healing processes of the pleural surfaces and how the compressed lung becomes permeable to air, 730; retraction of thorax after the operation, 731; results of auscul- tation and percussion, 731. Hydrothorax, 732; bibliography, 732; introductory observations, 732; history, 732, etiology, 733; catching cold, 733; scarlatina. 734; decided anatomical changes within the body 734; com- pression of the thoracic duct, 734 ; high pressure in the venous system, 734; diseases in which there is loss of albumen of the blood, 735; other conditions, 735; pathology, 735 ; form and gen- eral course of the disease, 735; anatomical changes, 735 ; nature of the fluid, 736 ; its quan- tity, 736; conditions of the pleura and subpleural connective tissue, 736; of the lung, 736; symp- tomatology, 737; cough, 737; absence of inter- costal pain, 737; results of auscultation and per- 796 INDEX. cussion, 737; dyspnoea, 737; complications, se- quela;, and diagnosis, 738; duration, results, and prognosis, 738; treatment, 738; puncture of pleural cavity, 738; incisions into subcutaneous tissue, 738; diet, 739. H.ematothobax, 739; bibliography, 739 ; definition, 739; etiology, 739; pathology, 740 ; course and mode of attack, 740; anatomical changes, 741; symptomatology, 741; physical signs, 741; com- plications and sequela;, 741; diagnosis, duration. results, and prognosis, 742; treatment, 742; rest and morphine, 742 ; application of cold and anti- phlogistic diet, 743; hypodermic injection of ergotine, 743; opening the pleural cavity by in- cision, 743. Pneumothorax, 744; bibliography, 744; introductory remarks, 744; history, 745 ; etiology, 745 ; ques- tion of development of gas in closed pleural sac, 745; external injuries, 746; pulmonary tuber- culosis, 746; other diseases, 748; form and gen- eral course of the disease, 750; pain and dys- pnoea, 751; cyanosis, 751; death from collapse, 751; pathology and anatomical changes, 751; appearance of chest, 751; escape of air on punc- ture of pleural cavity, 751; amount of air in the cavity, 752; composition of the gas, 753 ; ques- tion of air producing purulent inflammation, 753; condition of the lung, 753; the opening, 753; displacements of organs, 754 ; the circum- scribed pneumothorax, 754; symptomatology, 754; body temperature, 754; pulse, 754 ; respira- tion, 754 ; dyspnoea, 754 ; orthopncea, 755 ; vari- ous positions of patients, 756 ; pain, 756 ; voice, 756; cyanosis, 757 ; oedema of face and extremi- ties, 757; subcutaneous emphysema, 757; condi- tion of the urine, 757; displacement of organs, 758; the pectoral fremitus, 758 ; appearance of thorax, 759; palpation and percussion, 759 ; suc- cussion, 761; auscultation, 762; complications and sequelae, 762, diagnosis, 763; duration, re- sults, and prognosis, 765; treatment, 767; the radical operation by incision, 767; morphine and cupping, 768; antiphlogistics, 768; question of venesection, 768; diet, 768; puncturing the pleural cavity in cases of threatened suffocation, 768; cutaneous emphysema, 770. Tuberculosis of the Pleura, 771; general charac- teristics, 771. Malignant New-growths in the Pleura, 771; sarcoma, cancer, 771; their origin and progress, 772 ; symptomatology, 772; dyspncea and dyspha- gia, 772; pain. 772; emaciation and condition of the skin, 773; enlargement of lymphatic glands, 773; physical signs, 773 ; diagnosis, 773 ; duration, results, prognosis, 774; treatment, 775. Pleuritis, 589. Pleuritis a complication of chronic renal disease, 597 ; of gout, 597; of rheumatic polyarthritis, 597; of scarlet fever, 597; of various diseases, 673; a sequel of pneumothorax, 762. Plica ary-epiglottica, 48; glosso-epiglottica lateralis, 47 ; glosso-epiglottica media, 47; pharyngo-epi- glottica, 47; salpingo-palatina, 64; salpingo- pharyngea, 04. Plumbi, acetas, in bronchial catarrh, 420; in chronic bronchitis, 4S5; in nosebleed, 168. Pneumatic cabinet in treatment of bronchial catarrh, 424. Pneumatometry in diseases of trachea and bronchi, 284. Pneumonia, a complication of croup, 251; in etiology of croup, 238; of pleuritis, 595 ; caseous, a sequel of pleuritis, 674; catarrhal, a complication of bronchial catarrh, 402; catarrhal, secondary to capillary bronchitis, £65 ; croupous, its diagnosis from pluritic effusion, 677; serosa, a sequel of pleuritis, 671. Pneumothorax, 744. Pneumothorax, diagnosis of, from croupous bronchitis, 464; in etiology of pleuritis, 596, Podagra in etiology of pleuritis, 597. Polypi, nasal, 168. Polypi in chronic catarrh of larynx, 218 ; in etiology of chronic catarrh of larynx, 213 ; of the air-pas- sages in etiology of stenosis of trachea and bronchi, 480; nasal and naso-pharyngeal in etiology of bronchial catarrh 581. Ponfick, 597 Portal, 740. Porte-caustiques for pharynx and larynx, 77 : guarded, of Tobold, 77. Porter, 200. Position of patient in pleuritis, 628. Potain, 699, 704, 725. Potassa, acetate of, in pleuritis, 686, 690 ; carbonate of, in diseases of nose, pharynx, and larynx, 94; chlorate of, in chronic nasal catarrh, 144 ; in croup, 265; in diseases of larynx, 82 ; in diseases of nose, pharynx, and larynx, 94; nitrate of, in bronchial asthma, 579, 583 ; in pleuritis, 686 ; per- manganate of, in chronic nasal catarrh, 145; in croup, 268; in diseases of nose, pharynx, and larynx, 82, 86, 95. Potassium, bromide of, in acute catarrh of larynx, 211; in bronchial asthma, 577, 583; in chronic catarrh of larynx, 224; in diseases of larynx, 82 ; in diseases of nose, pharynx, and larynx, 94; iodide of, in bronchial catarrh, 420 ; in croupous bronchitis, 408 ; in diseases of nose, pharynx, and larynx, 80, 95, 96; in pleuritis, 691. Praxagoras, 592. Precipitate, red, in chronic nasal catarrh, 145. INDEX. 797 Pregnancy in etiology of bronchial asthma, 581. Pressure, external, in nosebleed, 161. Processus vocalis, 50. Prochaska, 541. Prognosis of abscess of nasal cavity, 148; of acute bronchitis, 406; of acute catarrh of larynx, 207; of bronchial asthma, 573; of capillary bronchitis, 400; in cases of foreign bodies in trachea and bronchi, 520 ; of chronic catarrh of larynx, 221; of chronic bronchitis, 406; of chronic nasal catarrh, 143; of croup, 263; of croupous bron- chitis, 464, 400 ; of haematothorax, 742; of hydro- thorax, 738; in malignant new-growths in the pleura, 774; of nosebleed, 158; of parasites of the nasal cavity, 180 ; of pleuritis, 680 ; of pneu- mothorax, 765; of putrid bronchitis, 400; of stenosis of trachea and bronchi, 498; of tracheitis, 405; of tracheotomy in croup, 272. Proliferations, papillary, in chronic catarrh of larynx, 218. Prophylaxis of acute catarrh of larynx, 208; of bron- chial catarrh, 407; of chronic bronchitis, 431; of chronic catarrh of larynx, 223; of cold in the head, 129; of croup, 264 ; of croupous bron- chitis, 469; of nosebleed, 168; of purulent nasal catarrh, 135. Pseudo-croup, 198. Pseudo-membranous bronchitis, 438. Puech, 153. Pulmonary apoplexy, a complication of croup, 252; in etiology of pneumothorax, 748; emphysema in etiology of pneumothorax, 748 ; gangrene, a com- plication of croup, 252. Pulse in bronchial catarrh, 349; in capillary bron- chitis, 373 ; in croup, 247; in pleuritis, 625; in pneumothorax, 754; in stenosis of trachea and bronchi, 491. Pulverisateur des liquides of Sales-Girons, 88. Purgatives in bronchial catarrh, 419. Purulent nasal catarrh, 129. Pus in secretion in cold in the head, 124. Pyophlebitis in etiology of pneumothorax, 750. Pyroligneous acid in diseases of larynx, 82. Quetil, 467. Quincke, 432, 693, 694, 698, 725. Quinine in bronchial asthma, 581, 583; in bronchial catarrh, 421, 427, 430, 435 ; in croup. 26S; in hay-fever, 87; in pleuritis, 688, 690; in whooping- cough, 95. Rachitis in etiology of croupous bronchitis, 446. Rack-movement lamp of Mackenzie, 25. Rales in acute tracheo-bronchitis, 360; in bronchial catarrh, 353; in capillary bronchitis, 371 ; in chronic bronchitis, 387, 392; in croupous bron- chitis, 462; in pleuritis, 659, 665, 669. Ramadge, 541. Ramazzini, 213. Rarefied air in bronchial asthma, 580, 5S5. Rasmussen, 694. Rauchfuss, 15. Rauchfuss's laryngeal insufflator, 78. Rayer, 104, 579. Recessus pharyngei, 63: pharyngo-laryngeus, 4S. von Recklinghausen, 596. Red oxide of mercury in chronic nasal catarrh, 145. Reflectors of light in inspection of the pharynx, 7. Reflex action, its employment in nosebleed, 163. Reichenhall, a resort for the milk and whey cure in bronchial catarrh, 424; mineral waters of, in chronic catarrh of larynx, 227. Reinerz, a resort for the milk-and-whey cures in bronchial catarrhs, 424. Reisseissen, 532, 541, Remak, 451. Residence, influence of nature of, in etiology of bron- chial asthma, 539. Resolvents in bronchial catarrh, 416, 426. Respiration in acute tracheo-bronchitis, 362; in bron- chial asthma, 561, 562 ; in bronchial catarrh, 331, 350; in capillary bronchitis, 368; in cases of for- eign bodies in bronchi, 516 ; in chronic bronchi- tis, 391 ; in croup, 239, 249; in croupous bronchi- tis, 461; in pleuritis, 626, 642, 646 ; in pneumo- thorax, 754; in stenosis of trachea and bronchi, 276, 486. Respiratory apparatus, complete absence of, 2S7. Retching in inspection of the pharynx, 4. Retro-pharyngeal abscess, a result of diseases of nose, 127. Revulsives in bronchial catarrh, 418. Reybard, 692, 701, 728. Rhatany in bronchial catarrh, 420. Rheiner, 1S6. Rheumatic arthritis in etiology of pleuritis, 597. Rheumatism in etiology of bronchial asthma, 537. Rhineurynter, 98, 164. Rhinitis, 115. Rhinitis blennorrhoica, 129. Rhinitis chronica, 136. Rhinobyon, 98. Rhinoliths, 175. Rhinoscope of Fraenkel, 60. Rhinoscope and uvula-holder of Baxt, 66. Rhinoscopy, 59. Ribs, caries of, a complication of pleuritis, 673 : caries of, with erosion of intercostal artery in etiology of haematothorax. 740; caries of, a sequel of em- pyema, 020; resection of, in radical operation for removal of pleuritic effusions, 727 ; trephining of, in radical operation for removal of pleuritic effu- sions, 728. 798 INDEX. Richardson, 597. Riecke, 693. Riegel on diseases of trachea and bronchi, 275. Riegel's stethograph, 426. Rima glottidis, 50. Rimula sive incisura interarytaenoidea, 48. Rindfleisch, 322, 608. Rilliet, 104, 130, 147, 198, 259, 265, 267, 346, 359, Riverius, 688. Rodolfi, 173. Roisdorf, waters of, in bronchial catarrh, 423. Rokitansky, 186, 218, 323, 476, 480, 607, 774. RoUet, 126. Romberg, 278, 530, 541. Ronda, waters of, in bronchial catarrh, 423. Rose, 167. Rosenmuller, fossa of, 63. Rosenstein, 398, 539. Rosenthal, 278, 311, 332. Roser, 269, 693, 725, 727. Roses, inhalation of perfume of, a cause of coryza, 120. Rossi, 287. Rostan, 530. Roth, 584. Rudnicky, 242, 268. Ruehle, 74, 192, 198, 200, 211, 213, 235, 267. Riigenberg, 544. Rupprecht, 114. Ryland, 186, 202. Sao and duct, lachrymal, affection of, in cold in the head, 126. Sachs, 10. Sal ammoniac in bronchial catarrh, 417, 427, Sales-Girons, 88. Salkowski, 548. Salomon, 253. Salt in acute catarrh of larynx, 211; in chronic ca- tarrh of larynx, 224; in chronic nasal catarrh, 144; in cold in the head, 128; in diseases of nose and pharynx, 86; in purulent nasal catarrh, 135. Salter, 5.33, 536, 539, 541, 574. Saltpetre, fumes of, in bronchial asthma, 579, 583. Salzbrunn, mineral waters of, in diseases of nose, pharynx, and larynx, 94. Sanderson, 540. Santorini, cartilage of, 48. Sarcomata of nasal cavity, 170 ; of pleura, 771. Sarcone, 605. Saussier, 748. Sauvages, 530. Scarification of glottis in acute catarrh of larynx, 212. Scarlatina, laryngitis, a complication of, 201; puru- lent nasal catarrh, a complication of, 131; scarla- tina in etiology of croup, 238; of hydrothorax, 734; of pleuritis, 597. Scharlau, 267. Scheff, 219. Schindler, 254, 271. Schlautmann, 241. Schneider, 115. Schnitzler, 15, 444. Schnitzler's syringe, 88. Scholer, 287. Schonbein, 122. Schroth's treatment of pleuritis, 691. Schrotter, 15, 68, 283, 299. Schrotter's laryngeal sound, 44 Schuh, 693. Schuller, 136. Scilla in pleuritis, 690. Scoda, 355, 435. Scrofula in etiology of chronic nasal catarrh, 137 ; of croupous bronchitis, 446. Scultet, 694. Sea-bathing in prophylaxis of acute catarrh of larynx, 209. Seasons in etiology of bronchial asthma, 538; of bronchial catarrh, 305 ; of croup, 236 ; of croupous bronchitis, 444 Secretion of mucous membrane in bronchial catarrh, 318, 324; in chronic nasal catarrh, 138 ; in cold in the head, its characteristics, 123; in purulent nasal catarrh, 132. Sedillot, 692, 728. Seidel, 404, 412. 482. Seitz, 194, 317, 355, 375, 380, 420, 580, 583, 655, 691, 735, 747. Selters, waters of, in bronchial catarrh, 423. Selligue, 12. Semeleder, 59, 112, 149, 191, 249. Semeleder's spectacle-frame for laryngeal mirrors, 21. Senega in bronchial catarrh, 417 ; in chronic bronchi- tis, 436. Senn, 13. Senna, compound infusion of, in pleuritis, 688. Sequelae of bronchial catarrh, 401; of croup, 254 : of haematothorax, 741; of pleuritis, 669; of pneumo- thorax, 762. Severinus, 728. Sex, influence of, in etiology of bronchial asthma, 536; of bronchial catarrh, 307; of chronic ca- tarrh of larynx, 213; of croup, 235 ; of croupous bronchitis, 443; of pleuritis, 599. Siebert, 467. Siegle, 55, 88, 144. Siegle's principle for inhalation of atomized fluids, 91. Siegle's steam-atomizer, 91. Siegmund, 119. Signs, physical, In croupous bronchitis, 461; in hae- matothorax, 741; in hydrothorax, 737; in malig- INDEX. 799 nant new-growths in the pleura, 773 ; in pleuritis, 641; in pneumothorax, 759. Sigaud, 213. Silver, nitrate of, in bronchial asthma, 583 ; in chronic catarrh of larynx, 224 ; in cold in the head, 12S, 129 ; in croup, 205 ; in diseases of nose, pharynx, and larynx, 70, 79, 82, 86, 94; in nosebleed, 163; in purulent nasal catarrh, 135, 145. Simon, Edmund, 126. Sims, 578. Sinapisms in bronchial catarrh, 419; in pleuritis, 687. Sinus pyriformis, 48. Sinus of frontal bone, affections of, in cold in the head, 120. Sion, a resort for the grape cure in bronchial catarrh, 424. Skin, condition of, in abscess of nasal cavity, 147; in bronchial catarrh, 338, 349; in capillary bron- chitis, 373; in chronic nasal catarrh, 141; in cold in the head, 125; in malignant new-growths in the pleura, 773 ; in purulent nasal catarrh, 132; diseases of, in etiology of bronchial esthma, 537. Sklarek, 468. Skoda, 639, 600, 693. Small-pox, laryngitis a complication of, 201; Emall- pox in etiology of bronchial catarrh, 315 ; in eti- ology of croup, 238; purulent nasal catarrh dur- ing the course of, 131. Smell, sense of, in examination of diseases of the nose, pharynx, and larynx, 70 ; impairment of, in diseases of the nose, 109, 142. Smith, Th., 174. Smyly, Josiah, 165. Soda, biborate of, in chronic nasal catarrh, 145 : in cold in the head, 128; carbolate of, in diseases of nose and pharynx, 87; carbonate of, in chronic nasal catarrh, 144; in cold in the head, 128; in diseases of nose, pharynx, and larynx, 86, 94; in purulent nasal catarrh, 135 ; chlorinated, in chro- nic nasal catarrh, 146; in diseases of nose and pharynx, 86; liquor of, in diseases of nose, phar- ynx, and larynx, 95 ; nitrate of, in pleuritis, 686. Soden, waters of, in bronchial catarrh, 424. Sodium, chloride of, in acute catarrh of larynx, 211; in chronic catarrh of larynx, 224; in chronic nasal catarrh, 144; in cold in the head, 128; in diseases of nose and pharynx, 86; in purulent nasal catarrh, 135. Softening of mucous membrane in bronchial catarrh, 324. Soil, nature of, in etiology of croup, 236. Bolon, 753. Solution of chloride of iron in nosebleed, 163; of Lugol in chronic nasal catarrh, 145. Sommer, 152. Sommerbrodt, 222, 425. Soporific manifestations in bronchial catarrh, 346. Sounds, friction, in pleuritis, 642, 659, 664. Sounds, laryngeal, 44. Spatulas, tongue, 6. Spath, 454. Spectacle-frame of Semeleder for laryngeal mirrors, 21. Speculum narium of Fraenkel, 57. Speech in bronchial asthma, 565. Sphenoid bone, cavities of, affections of, in cold in the head, 126. Spine, caries of, a complication of pleuritis, 073. Spirometry in bronchial catarrh, 351 ; in diseases of trachea and bronchi, 284; in pleuritis, 063. Spleen, abscess of, in etiology of pleuritis, 597; affec- tions of, in croup, 261. Sponge-holder, 80. Sponge, laryngeal, 80. Squill in pleuritis, 690. Stachelberg, a resort in pleuritis, 691. Stadion, 121. Stammer, 106. Stansky, 694. Steam atomizer, of Siegle, 91. Steiner on croup, 231. Stenosis, larnygeal, its diagnosis from croupous bron- chitis, 464; tracheal, its diagnosis from croupous bronchitis, 464; stenosis and atresia of nasal cavity, 103. Sternum, diseases of, in etiology of stenosis of trachea, 478 Stethograph, use of, in bronchial catarrh, 352. Stethograph of Riegel, 426. Stethography in diseases of trachea and bronchi, 284. I Steudener, F., 257. Stimulants in acute bronchitis, 429; in chronic bronchitis, 433; in croup, 272. Stinknase, 136. Stockschnupfen, 136. Stofella, 201. Stokes, 213, 676, 756. Stoll, 6S5, 688. Stomach, croup of, 248. Storck, 26, 59, 67, 425, 426, 531, 550, 552, 553, 556, 580. Stramonium in bronchial asthma, 578; in diseases of nose, pharynx, and larynx, 95. Strength, loss of, in pleuritis, 635. Strychnine in bronchial asthma, 580. Styptics in hemorrhage of mucous membrane of larynx, 193. Sublimate, corrosive, in chronic nasal catarrh, 145. Submucous inflammation and abscess of the nasal cavity, 140. Succussion in pneumothorax, 761. Sulphate of copper in croup, 267; in diseases of nose, 800 INDEX. pharynx, and larynx, 76; of zinc in nosebleed, 163. Sulpho-carbolate of zinc in diseases of nose and pharynx, 87. Sulphur in bronchial asthma, 583; in diseases of nose, pharynx, and larynx, 79; sublimed, in croup, 265. Sulphuric acid, inhalation of fumes of, in etiology of bronchial catarrh, 314; in treatment of nosebleed, 168. Sulphuric ether in bronchial asthma, 577. Sunlight, use of, in laryngoscopy, 34. Sweating in bronchial catarrh, 339, 349; in croupous bronchitis, 460. Swelling of mucous membrane in bronchial catarrh, 318, 321. Swieten, van 593, 605, 647. Sydenham, 593, 085. Symptomatology of acute catarrh of larynx, 197; of anaemia of the larynx, 189; of bronchial asthma, 557; of bronchial catarrh, 331; of cases of foreign bodies in trachea and bionchi, 511; of chronic catarrh of larynx, 214; of chronic bronchitis, 385; of chronic nasal catarrh, 137; of croupous bronchitis, 456; of cold in the head, 121; of croup, 238; of haematothorax, 741; of hemorrhage of mucous membrane of larynx, 191; of hydro- thorax, 737; of malignant new-growths in the pleura, 772 ; of nosebleed, 155; of parasites of the nasal cavity, 178; of pleuritis, 624; of pneumo- thorax, 754; of purulent nasal catarrh, 131; of stenosis of trachea and bronchi, 485 ; of stenosis and atresia of the nasal cavity, 103; of submu- cous inflammation and abscess of the nasal cavity, 147; of tumors of nasal cavity, 171. Syphilis in etiology of chronic catarrh of larynx, 213; of chronic nasal catarrh, 137; of croupous bron- chitis, 446; of stenosis of trachea and bronchi, 479. Syphiloma of trachea and bronchi, 482. Tamponing the anterior nares, 162; the posterior nares, 98, 164. Tannin in bronchial catarrh, 420 ; in chronic catarrh of larynx, 223; in chronic bronchitis, 435 ; in cold in the head, 128 ; in diseases of nose, phar- ynx, and larynx, 79, 82, 86, 94; in nosebleed, 163, 168 ; in purulent nasal catarrh, 145. Tarasp, a resort in pleuritis, 691. Tartar emetic in bronchial asthma, 580; in bronchial catarrh, 417, 418; in croup, 267. Temperature of air, its influence upon prevalence of bronchitis, 302. Temperature of body in acute tracheo-bronchitis, 357; in bronchial asthma, 506; in bronchial catarrh, 332, 348 ; in capillary bronchitis, 372; in cases of foreign bodies in trachea and bronchi, 519 ; in chronic bronchitis, 388; in croup, 247 ; in croupous bronchitis, 460 ; in pleuritis, 624 ; in pneumothorax, 754 ; in putrid bronchitis, 399 ; in stenosis of trachea and bronchi, 492 ; its influ- ence upon treatment following the radical opera- tion for removal of pleuritic effusions, 729. Temperature of nasal douche, 87. Terrillon, 672. Thery, 538, 541. Thickenings of mucous membrane and submucosa in chronic catarrh of larynx, 216. Thiedemann, Fr., 172, 177. Thierfelder, 468. Thiersch, 115. Thilenius, 423. Thompson, 165. Thompson, Charles, 704. Thoracic duct, compression of, in etiology of hydro- thorax, 734. Thorax, contractions of, following pleuritis, 666. Thread noose of Tiirck in rhinoscopy, 67. Thymus gland, diseases of, in etiology of stenosis of trachea and bronchi, 478. Thyroid gland, congenital enlargement of, in etiology of bronchial asthma, 537. Tice, Graham, 476. Tincture of belladonna in diseases of nose, pharynx, and larynx, 95 ; of iodine in croup, 265 ; in dis- eases of pharynx and larynx, 96 ; painting with, in pleuritis, 687; of opium in diseases of no?e, pharynx, and larynx, 95. Tinnitus aurium, a complication of cold in the head, 125. Tissot, 688. Tobacco in bronchial asthma, 578, 579. Tobold, 189, 191, 200, 205, 222, 225, 249. Tobold's illuminating apparatus, 30. Tobold's porte-caustique, 77. Tolu, balsam of, in chronic bronchitis, 435. Tongue, base of, in laryngoscopy, 46 ; management of in inspection of the pharynx, 4 ; of the larynx, 38; position of, during sleep, 105. Tonnissteiner, waters of, in bronchial catarrh, 423. Tonsilla pharyngea, 63. Trachea, absence of, 287; affections of, following bronchial catarrh, 401; atresia of, 287; blind termination of, 2S7; cartilages of, atrophy of, a result of compression, 482; closure of both branches of, 287; congenital dilatation of. 289: doubling of, 289 ; fistula of, 289; shortness, nar- rowness, lack of division, and unusual curvature of, 288; stenosis of, its diagnosis from croupous bronchitis, 464. Trachea and Bronchi, Diseases of, 275; prefatory remarks, 275; results of variations in INDEX. 801 calibre of the trachea, 276 ; dyspncea, 276 ; respi- ration, 276 ; cough, 277 ; its causes and results of experiments, 277; pain, 281; the sputa, 2S1; physical exploration, 281; inspection, 281; tra- cheoscopy, 281; palpation, 2S4; percussion and auscultation, 2S4 ; the spirometer and tape-meas- ure, 2S4; stethography and pneumatometry, 284. Malformations, 286; bibliography, 2S6; absence of the trachea, 287 ; atresia, blind termination of and closure of both branches of trachea, 287: oesophageal fistula, 287 ; absence, coalescence, and excessive number of tracheal cartilages, 288; ab- normal shortness, narrowness, lack of division, and unusual curvature, 288; abnormal formations of the bronchi, 28S; the third bronchus, 288 ; dou- bling of the trachea, 289; fistulae of the neck, 289; diagnosis of tracheal fistula, 291; treatment, 291. Catarrh of the Tracheal ANr Bronchial Mucous Membrane ; Tracheitis, Bronchitis, Catarrh- alis ; bronchial catarrh, 292; bibliogra- phy, 292 ; prefatory remarks, 297 ; etiology, 301; geographical distribution, 301; influence of tem- perature and humidity of atmosphere, 302 ; influ- ence of condition of the earth's surface. 303; influ- ence of individual months of the year, 305; individ- ual predisposition to catarrhal inflammations, 306; influence of sex, 307 ; of age, 308; special exciting causes, 310 ; " catching cold," 310 ; its physiologi- cal action, 311; injurious admixtures in the at- mosphere, 312 ; inhalation of dust, 312; effects of different kinds of dust, 313; inhalation of gases and vapors, 314 ; influence of various gases, 314 ; foreign bodies, 315; transient contagions, 315; diseases of the heart, 315 ; diseases of the lungs, 316; bronchitic affections as secondary conditions of other diseases, 316 ; pathological anatomy, 317; origin of the term catarrh, 317: the prominent lesions, hyperaemia, swelling of the mucous mem- brane, and alterations in the secretion, 318; ab- sence of anatomical demonstration of lesions after death, 319; color of the mucous membrane, 320 ; degree of injection, 320 : extent of the hypevaemia, 320; the swelling, 321; bronchiectasis, 322; mi- croscopic appearances, 322 ; ulcers, softening, and atrophy, 324; the secretion, 324 ; its microscopic appearance, 326 ; conditions of the parenchyma of the lung, 32S ; emphysema, collapse and atelecta- sis, 329 , affections of the pleura, 329; affections of lymphatic glands, 329 ; affections of the heart, 330; dropsical symptoms, 331 ; changes in the liver and kidneys, 331; symptomatology, 331; alterations of breathing, 331; fever, 332 ; cough, 335; influence of consistence of secretions upon the cough, 337; condition of the skin, 338; cya- nosis, 338; dropsy, 339; secretion of sweat, 339; VOL. IV.—51 condition of nutrition, 339; the expectoration, 340; thoracic pains, 344; nervous symptoms, 344 ; chilliness, 345; headache, 345; soporific manifes- tations, 346; disturbances of the digestive organs, 346; condition of the urine, 347 ; febrile symptoms, 347; sweating, 349; nutritive changes, 349; con- dition of activity of the heart and the pulse, 349 ; symptoms furnished by physical exploration, 350; inspection, 350 ; deviations from normal breath- ing, 350 ; spirometry, 351; pneumatometry, 852 ; the graphic method, use of the stethograph, 352; percussion, 353; auscultation, 353 ; varieties of rales, 353; alteration in the respiratory murmur, 353. Acute Tracheobronchitis ; Acute Catarrh of the Trachea and Largee Bbonchi, 356; its mode of commencement, 357; chills, 357; fever, 357 ; cough, 358 ; the expectoration, 360 ; physical examination, 360 ; percussion, 360 ; auscultation, 300 ; various rales, 360 ; palpation, 361; inspec- tion, 362; respiration, 362; dyspnoea, 362; general appearance of the patient, 363 ; gastric symptoms, £63 ; nervous symptoms, 363 ; terminations, 364. Acute Catarrh of the Medium-sized and Minuter Bronchi, Bronchitis Capillabis, Acute Dif- fuse Bronchial Cataebh, 364 ; its origin, 365; secondary catarrhal pneumonia, 365; its pathol- ogy, 365; severity of capillary bronchitis, 367; the respiration, 367; dyspnoea, 368 ; the type of breathing, 369; results obtained by percussion, 370 ; by auscultation, 370 ; the respiratory mur- mur, 371; various rales, 371; cough, 372 ; febrile sj'mptoms, 372: action of the heart and pulse, 373; the skin, 373; general appearance of the patient, 374 ; the urine, 374; cerebral symptoms, 374; gastric symptoms, 374; the subjective symptoms, 374; the expectoration, 374; course of the various forms, 375; the acute diffuse form, 375; capillary bronchitis proper, 378; chronic forms of bronchitis, 383 ; origin of the chronic form, 383; its site, 384; glandular degen- erations, 384; symptomatology, 385 ; the cough and expectoration, 3S5; results of physical exa- mination, 3S7; percussion, 387; auscultation, 387; the various rales, 387; remissions and inter- missions, 388; fever, 388; pain in right hypochon- drium and epigastrium, 388; albuminuria, 389; prospects of recovery, 389; affections of the heart, 390; hypertrophy of various muscles, 390 ; varieties of chronic bronchitis, 391; the dry catarrh, 391; the form with moderate expectora- tion, 393 ; forms with excessive amount of expec- toration, 393; fetid or putrid form, 396; its etio- logy, 397; the expectoration, 397; the breath, 399; physical examination, 399; fever, 399 ; ex- tension of the process upon the parenchyma of 802 INDEX. the lung, 399; diagnosis from empyema perforat- ing the lung, 400; from bronchiectatic cavities, 400; prognosis and course, 400; cause of the fetor, 401; complications and sequela of the various forms of bronchitis, 401; diagnosis oj tracheitis and bronofntis, 403; termination and prognosis, 405; treatment, 407; prophylaxis, 407 ; special treatment, 411 ; removal of exciting causes, 411; effects of different climates, 412; removal of injurious existing influences in the patient, 413; local treatment, 415 ; inhalations, 415 ; internal remedies, 416; venesection, 421; various mineral waters, 423; milk-and-whey cures, 424; the grape cure, 424 ; the use of condens- ed and rarefied air, 424 ; treatment of acute bron- chitis, 426; general measures, 426; treatment of the chronic forms of bronchitis, 430; prophylaxis, 431; special therapeutics, 431; the dry variety of bronchitis, 431; winter cough, 433; the bronchitis associated with various dyscrasiae, 334 ; the fetid form, 434; broncho - blennorrhcea and serous bronchorrhcea, 435. Pseudo-membranous, Croupous, ob Fibrinous Bronchitis; Bronchial Cboup; Beonchitis with the Formation of Fibeinous Casts, 438 ; prefatory remarks, 438 ; bibliography, 439; various names for the disease, 442 ; etiology, 442; its frequency, 443; influence of sex, 443 ; of age, 443; previous health and vigor, 443; position in life, 444; locality and nationality, 444; relation to frequency of bronchitis, 444; climate and sea- son of the year, 444; atmospheric influences and taking cold, 445; tuberculosis and haemoptysis, 445; syphilis, rachitis, and scrofulosis, 446; forms and course of croupous bronchitis in general, 446; the acute form, 446; its general course, 446; duration, 448; mortality, 448; the chronic form, 448; its general course, 448; transition forms, 449; duration of the chronic form, 450; duration of individual attacks, 550; interval between them, 450; irregularity of recurrence of attacks, 451; pathological anatomy, 451; the fibrinous cast, 451; its general appearance, 451; its length and thickness, 452; its structure, 453; its consistence and color, 454; microscopic ap- pearances, 454; chemical reactions, 455; the mucous membrane of the affected bronchi, 455; mode of formation of the croup membrane, 456; condition of parenchyma of lungs, 456; symp- tomatology, analysis of individual symptoms, 456; quantity of the casts, 457; rapidity with which they appear, 457 ; mode of expulsion, 458; haemoptysis, 458; the voice, 459; febrile move- ments, 460; sweating, 460 ; venous hyperaemia and cyanosis, 460; dropsy, 460 ; the nutrition, 460 ; the subjective symptoms, 460 ; pleurodynia, 461; sensations Of pressure and feelings of anx- iety, 461; physical signs, 461 ; percussion, 461; auscultation, 461; the respiratory murmur, 461 ; rales, 462; inspection, 462; diagnosis, 463; expectoration of casts, 463; differential diag- nosis, 463; complications, duration, termina- tion, and prognosis, 464; the acute form, 464; the chronic form, 465; emphysema, chronic bronchial catarrh, and infiltration of parenchyma of the lung as sequelae, 465; atelectasis of lung and obliteration of individual peripheric bron- chial ramifications, 465; treatment, 467; eme- tics, 467; inhalations, 468 ; mercurial treatment, 468; iodide of potassium, 468; mineral waters, 469; prophylaxis, 469. Naeeowing of the Trachea and Bronchi ; Tra- cheostenosis ; Bronchial Stenosis, 470; bib- liography, 470; preliminary remarks, 473 ; eti- ology, 474; stenosis from goitre, 474; seat of tracheal stenosis when muscular pressure pre- dominates, 475; swelling of lymphatic glands, 475 ; suppuration of the glands, with perforation into the trachea, or a bronchus, 476; aneurism of the aorta, 476; of the innominate artery, 476 ; pressure upon left recurrent nerve, 476 ; diseases of the mediastinum, 477; of the pericardium, 478; of the thymus gland, 478; of the sternum, clavicle, and vertebral column, 478; emphysea- tous tumors, and tumors of the oesophagus, 478; cancer of the lung, 478; alterations in the tra- cheal and bronchial walls, 479 ; cicatrices, 479 ; their syphilitic and other origins, [479; tumors of the air-passages, 480 ; thickening of the walls of the air-passages, 4S0; acute cedema, 481; pathological anatomy, 481; stenoses from com- pression, 481; form of the stenosis, 482 ; intratra- cheal and intrabronchial stenoses, 482; syphiloma, 482 ; seat of syphiloma, 483 ; morbid growths, 483; inflammatory thickening of the tracheal and bron- chial walls, 484; anatomical consequences of such stenosis, 484; bronchiectasis, 484; emphysema and atelectasis, 485; symptomatology, 485 ; alter- ations in respiration, 486; influence of site of obstruction, 486; prolongation of respiration, 487; movements of larynx, 489; auscultation, 489; exploration with the sound, 490 ; with mir- ror, 490 ; the vocal fremitus, 490 ; appearance of the chest walls, 491; general aspect of patient, 491; pulse, 491; temperature, 492; cough and expectoration, 492 ; dyspncea, 492 ; experiments in artificial constriction of the trachea in animals, 494; diagnosis, 495; from laryngeal stenosis, 495; foreign bodies, 497 ; duration, terminations, and prognosis, 498 ; treatment, 499. Fobeign Bodies in the Trachea and Bronchi' 501; bibliography, 501; etiology and pat/io. INDEX. 803 genesis, 506; the modes of entrance, 507; deep inspiration in relation to entrance of foreign bodies from without, 508: impaction of the body in the larynx, 508; frequency of foreign body falling into right or left bronchus, 508; change of position of foreign body, 509; natural methods of expulsion, 509; results of its retention, 509 ; time of retention, 509; pathologicdl anatomy, 510; alterations produced in the lungs, 511; symptomatology, 511; symptoms immediately following the entrance of a foreign body into the air-passages, 512; where the foreign body has entered the trachea, 513; change of its location, 513; tracheitis and laryngitis, 514; dyspnoea, 514; laryngoscopy, 514; inspection through the wound after tracheotomy, 515; bronchial stenosis, 515; wheezing respiration, 516 ; diminution of pectoral fremitus, 516 ; thrilling of chest wall on inspiration and expiration, 516; secondary symp- toms, 517; course, 517; causes of sudden death, 518; cerebral symptoms, 518; other symptoms, 519; fever, 519 ; duration, 519; diagnosis, 519 ; prognosis, 520 ; treatment, 520; emetics, 521; inversion of the body, 521: tracheotomy, 522. Bronchial Asthma, 523; bibliography, 523 ; intro- duction, 530 ; etiology and pathogenesis, 533; inheritance, 536; sex, 536; age, 536 ; connection of asthma with other diseases, 537 ; influence of climate, 538; of locality, 538; of seasons, 538; of taking cold, 53S; of different winds, 538; of time of day, 539 ; influence of occupation, 539; of resi- dence, 539; nature and causes of the disease, 540; different theories, 541; spasm of the bron- chial muscles, 541; spasm of the diaphragm, 546 ; spasm of bronchial muscles and diaphragm combined, 546 ; theory of crystals in the expector- ation being the cause of attacks, 548; of tume- faction of bronchial mucous membrane in conse- quence of dilatation of its blood-vessels through vaso-motor nervous influence, 549; choice of theories, 551; pathological anatomy, 555; con- gestion of bronchial mucous membrane, 556; symptomatology and course, 557; mode of occur- rence of an attack and its general features, 557 ; differences from the above, 558; prodromata, 5J8; time of day for the paroxysm, 559; the catarrhal form, 559 ; analysis of individual symp- toms, 561; dyspncea, 561; position of the patient during the paroxysm, 561; number of respirations during the paroxysm, 562; character of the respiration during the paroxysm, 562 ; results ob- tained by percussion, 563; auscultation, 564; speech and cough, 565; the sputum, 565; tem- perature of the body, 566; the subjective symp- toms and disorders on the part of the nervous system, 566 ; number and modes of occurrence of attacks, 566; spontaneous stoppage of the disease, 566; differences between the essential or idio- pathic form, and a symptomatic form, 567; diagnosis, 568; difference between inspiratory and expiratory dyspnoea, 569; diagnosis from spasm of the glottis, 570 ; from spasm of the dia- phragm, 572; from dyspnoea the result of para- lysis of posterior crico-arytenoid muscles, 572; prognosis and terminations, 573; emphysema, 573 ; chronic bronchial catarrh, 574; influence of age, 574 ; duration of the disease, 574; discovery of the exciting cause, 575; treatment, 575; dur- ing the paroxysm, 675; fresh air, 575; narcotics, 575 ; chloral hydrate, 576 ; nitrite of amyl, 576 ; belladonna and atropia and cannabis Indica, 577; inhalations of chloroform, sulphuric ether, and oil of turpentine, 677; bromide of potassium, 577 ; stramonium, 578; tobacco, 578; Espic's cigarettes, 578; the fumes of arsenic, 579; of saltpetre paper, 579; the use of ammonia, 579; emetics, 580; ipecac, 580; tartar emetic, 5S0; muriate of apomorphia, 5S0; inhalations of oxygen, 5S0; use of strychnia, 580: ergotine, 580 ; rarefaction of the air, 580 ; treatment betioeen the paroxysms, 581; removal of exciting causes, 581; various medicines, 581; constitutional treatment, 5S4; employment of rarefied air, 585 ; change of resi- dence, 586. Tracheal cartilages, absence, coalescence, and exces- sive number of, 288. Tracheal catarrh, 292. Tracheitis, a complication of cold in the head, 126; a sequel of foreign bodies in the air-passages, 514. Tracheo-bronchitis, acute, 356. Tracheo-bronchitis crouposa, a complication of croup, 249. Tracheo-cesophageal fistula, 287. Tracheoscopy, 281; in diagnosis of diseases of trachea, 403; in stenosis of trachea and bronchi, 490. Tracheostenosis, 470. Tracheotomy in acute catarrh of larynx, 212 ; in cases of chorditis vocalis inferior hypertrophica, 218; in cases of foreign bodies in trachea and bronchi, 522; in croup, 268; in hemorrhagic infiltration of submucous tissue of larynx, 193. Trallianus, Alex., 685. Transfusion in nosebleed, 167. Transillumination in examination of the nasal cavity, 68. Traube, 15, 57, 85, 87, 106, 114, 297, 332, 342, 347, 359, 361, 371, 376, 390, 397, 398, 399, 401, 435, 476, 595, 597, 603, 618, 619, 627, 628, 634, 636, 638, 639, 649, 644, 645, 650, 653, 661, 665, 671, 679, 693, 705, 712, 722, 728, 760. Treatment of abscess of the nasal cavity, 148; of 804 INDEX. acute bronchitis, 426 ; of acute catarrh of larynx, 208; of bronchial asthma, 575; of bronchial ca- tarrh, 407; of cases of foreign bodies in nasal cavity, 176; of cases of foreign bodies in trachea and bronchi, 518; of chronic bronchitis, 430 ; of chronic catarrh of larynx, 223 ; of chronic nasal catarrh, 143; of cold in the head, 127; of croup, 264; of croupous bronchitis, 467 ; general considerations of, in diseases of nose, pharynx, and larynx, 73 ; of haematothorax, 742 ; of hydro- thorax, 738; of malignant new-growths in the pleura, 775; of nosebleed, 160 ; of parasites of the nasal cavity, 180; of pleuritis, 684; of pneumo- thorax, 767 ; of stenosis of trachea and bronchi, 499; of stenosis and atresia of the nasal cavity, 114; of tracheal fistula, 291; of ulcerations of the nasal cavity, 150. Trousseau, 534, 538, 541, 552, 559, 578, 579, 580, 582, 583, 680, 692, 693, 695, 706, 709. True vocal cord, 49. Tuberculosis, effect of bronchial catarrh upon, 402 ; tuberculosis in etiology of croupous bronchitis, 445; of double pleuritis, 670; of hemorrhagic pleuritis, 614; of pneumothorax, 746. Tuberculosis of the pleura, 771. Tuberculum epiglottidis, 47. Tumors of the air-passages in etiology of stenosis of trachea and bronchi, 480; emphysematous, in etiology of stenosis of trachea, 478; mediastinal, in etiology of stenosis of trachea and bronchi, 477; of nasal cavity, 163; of nasal cavity in etiology of asthmatic attacks, 107; of oesophagus in etiology of stenosis of trachea, 478. Turck, 6, 14, 34, 39, 56, 65, 186, 192, 198, 201, 202, 217, 218, 249, 282, 478, 480, 482, 490. Turck's thread-noose in rhinoscopy, 67. Turpentine, oil of, in bronchial asthma, 577, 582. 583 ; in bronchial catarrh, 420, 434; in chronic bron- chitis, 435; syrup of, in bronchial asthma, 482. Tutschek, 700, 703. Typhoid fever, laryngitis a complication of, 201. Typhoid fever in etiology of bronchial catarrh, 316; of chronic catarrh of larynx, 213 ; of croup, 238; of pleuritis, 598. Typhus fever, laryngitis a complication of, 201. Uhlenbeck, 111. Ulcerations in etiology of chronic nasal catanh, 137; of aorta in etiology of haematothorax, 740; ul- cerations in chronic catarrh of larynx, 216; re- sults of, 220; ulcerations in chronic nasal ca- tarrh, 141; of the mucous membrane in bronchial catarrh, 324; ulcerations of the nasal cavity, 148. Unguent, hydrargyri in croupous bronchitis, 468; in pleuritis, 686. Urine in bronchial catarrh, 345, 402; in capillary bronchitis, 374; in pleuritis, 640; in pneumo- thorax, 757. Uvula, elongated, in etiology of chronic catarrh of larynx, 213. Uvula-holder of Voltolini, 43; uvula-holder with rhinoscope of Baxt, 66. Valerian in bronchial asthma, 583. Valleculae of the larynx, 47. Valleix, 629. Valsalva, 161. Vapors and gases, inhalation of, in etiology of bron- chial catarrh, 314. Vault of the pharynx, 62. Vauthier, 238. Veins, development of, in chronic catarrh of larynx, 217; ulceration of, in etiology of haematothorax, 740. Venesection in bronchial catarrh, 421; in nosebleed, 164; in pleuritis, 685 ; in pneumothorax, 768. Venice, climate of, in bronchial catarrh, 413. Ventricle of Morgagni, 49. Verneuil, 175. Vernex, a resort for the grape cure in bronchial catarrh, 424. Vertebral column, diseases of, in stenosis of trachea, 478. Vesicants in bronchial catarrh, 419. Verson, 242. Vevey, a resort for the grape cure in bronchial catarrh, 424. Vienna paste in diseases of nose, pharynx, and larynx, 76. Vinegar in nosebleed, 163. Virchow, 151, 170, 171, 176, 398, 480, 613. von Vivenot, 432. Vocal cords, false, 48; true, 49. Vocal cords, alterations in, in chronic catarrh of larynx, 217. Vocal fremitus in pleuritis, 661, 669; in stenosis of trachea and bronchi, 490. Vogel, 725. Voice in acute catarrh of larynx, 197, 199, 202; in chronic catarrh of larynx, 212, 214, 215; in croup, 239, 244 ; in croupous bronchitis, 459; in diseases of nose, 110 ; in pneumothorax, 756. Voigtel, 289. Volkmann, 541. Voltolini, 4, 58, 68, 107, 108, 510, 515, 534, 581. Voltolini's uvula-holder, 43. Vomiting in bronchial catarrh, 346. Wade, 258. Wagner, 257, 259, 315, 483, 606. Waldenburg, 15, 88, 94, 284, 333, 352, 415, 425, 426, 432, 454, 468, 537, 568, 5S2, 583, 585. INDEX. 805 Wallman, 483. Walshe, 450,-540, 637, 667, 676, 685. Warden, 13. Warmth, application of, in pleuritis, 689. Water of bitter almonds in pleuritis, 689; water, bitter, of Friedrichshall, in vicarious nosebleed, 168; bitter, of Ofen, in chronic catarrh of larynx, 225 ; lead, in chronic nasal catarrh, 145; lime, gargles of, in croup, 265; pure, objections to its use in the nasal douche, 87; inhalation of warm vapor of, in chronic bronchitis, 431, 433; waters, min- eral, in chronic bronchitis, 432; in croupous bron- chitis, 463; in diseases of nose, pharynx, and larynx, 94; of Baden-Baden in bronchial catarrh, 424; of Bilin in bronchial catarrh, 423 ; of Borszek, in bronchial catarrh, 423 ; of Carlsbad in chronic catarrh of larynx, 226; of Eilsen in chronic catarrh of larynx, 226 ; of Elopatak in bronchial catarrh, 423 ; of Ems in bronchial catarrh, 423 ; in chronic catarrh of larynx, 227 ; of Fachingen in bronchial catarrh, 423; of Geishubel in bron- chial catarrh, 423; of Gleichenberg in bronchial ! catarrh, 423; of Ischl in chronic catarrh of larynx, 227 ; of Homburg in bronchial catarrh, 414, 424; of Kissengen in bronchial catarrh, 414, 421; of Kochel in bronchial catarrh, 42); of the Kreuz- brunnen in Marienbad, in chronic catarrh of larynx, 220; of Langenbriicken in bronchial ca- tarrh, 424; of Luhatschowitz in bronchial ca- tarrh, 423; of Marienbad in bronchial catarrh, 414; of Neundorf in bronchial catarrh, 424; in chronic catarrh of larynx, 226 ; of Oberbrunnen in bronchial catarrh, 424 ; of Oberselters in bron- chial catarrh, 423 ; of Reichenhall in chronic ca- tarrh of larynx, 227; of Roisdorf in bronchial ca- tarrh. 423; of Ronda in bronchial catarrh, 423 ; of Selters in bronchial catarrh, 423 ; of Soden in bronchial catarrh, 424 ; of Tonnissteiner in bron- chial catarrh, 423; of Waldquelle in bronchial catarrh, 424; of Weilbach in bronchial catarrh, 424 ; in chronic catarrh of larynx, 226 ; of Weis- senburg in bronchial catarrh, 423 ; of Wiesbaden in bronchial catarrh, 424; of Wipfeld in bronchial catarrh, 424. Weber, 119, 122, 133, 178, 179, 180, 265, 531, 536, 539, 54S, 549, 552, 553, 725. Weber, Th., nasal douche of, 84. Weber-Liel, 84. Weber-Liel's coniantron, 89. Wedl, 217. Wiel, 16, 30, 56, 476, 490, 491, 515, 516. Weilbach, waters of, in bronchial catarrh, 423; in chronic catarrh of larynx, 226 ; in diseases of nose, pharynx, and larynx, 94. Weinlechner, 272. Weissbad, a resort for the milk-and-whey cures bronchial catarrh, 424. Weissenburg, waters of, in bronchial catarrh, 423. Wells, Spencer, 704. Wertheim, 56 Wertheim's conchoscope, 58. West, 238, 309. Wetzlar, 146. Whooping-cough in etiology of bronchial catarrh, 315; of croup, 238. Wichmann, 198. Wicks, capable of absorbing fluids, fo- tamponing the nares in nosebleed, 165. Wiesbaden, waters of, in bronchial catarrh, 424. Wilks, 484. Williams, 534, 541, 544. Willigk, 149. Wilms, 650, 722. Winter, 530. Wintrich, &3, 89, 111, 355, 531, 545, 546, 600. 605, 617, 630, 636, 641, 642, 643. 6-14, 651, 655, 659, 660, 662, 667, 678, 692, 693, 694, 736, 740, 741, 743, 748, 752, 765. Wintrich's hydrokonion, 90. Wipfeld. waters of, in bronchial catarrh, 424. Wistinghausen, 582. Woillez, 724. Wolff, J., 113. Wrisberg, cartilage of, 48. Widzer, 478. Wunderlich, 348, 468. von Ziemssen, 15, 39, 97, 249. 302, 372, 373, 405, 599, 738. von Ziemssen on diseases of the larynx, 185. von Ziemssen's illuminating apparatus, 32. Zimmermann, 267. Zinc, oxide of, in bronchial asthma, 583; in diseases of nose, pharynx, and larynx, 79; sulphate of, in nosebleed, 163; sulpho-carbolate of, in diseases of ' nose and pharynx, 87. j > 3 X/ ? ^ 3 Xv£_£""^ X/'A | /£*% I . r -- ian tvnouvn 3Nnia3w do Aavaan tvnouvn dNiDiasw do Aavaan IVNOIIVN I i^\> I < ^"^ SNiDiasw do Aavaan t OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE /vf* An.. i£zr~^ '. « <' ~~-r\&}y ian tvnouvn snidiosw do Aavaan tvnouvn snidiosw do Aavaan tvnouvn 1 '! V NATIONAL LIBRARY OF M S ^*xf -_ yzp \ _//^?SrOW ^ aNiDiaaw do Aavaan t X-Jpp _ ^fi,^ - X-S<^ <° O^ i, OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE 2 o" "2 X- ^O NATIONAL LIBRARY OF N aan ivnoiivn 3nidici3w do Aavaan tvnouvn 3Ni_ia3w do Aavaan tvnouvn NATIONAL LIBRARY OF MEDICINE dNiDiadw do Aavaan i NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF /v OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF M ; £- ?WX f "7 X__, »• ^i&V » y aNiDiasw do Aavaan tvnouvn 3Ni_ia3w do Aavaan tvnouvn snoiosw do Aavaan ivnoiivn r I x '.. x x , l , x. f ..- ■ i -x « -I - : -. i :/ 1 / • ^ I -A, > § ■'- i ..- \,,- ^ g* -fcf- i --^ ST -*■-' . '^ NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE i /-", \ X -&f > si /B V o f 8 ^ ~ ^ i SNiDiasvy do Aavaan tvnouvn 3nidio3w do Aavaan tvnouvn 3nioiq3w do Aavaan tvnouvn ! \ jX | X]{ J ,< x _ .>" / 1 E NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE A _.- . ,_ X _ /■'V.--..^-3' '^ _w ^■&y ^ _ h ^ x ^ J 3NIDIQ3W do Aavaan tvnouvn snidiqsw do Aavaan tvnouvn 3nioi_3w do Aavaan tvnouvn >v ? x ■ •' "J ^ 5> v x. _ ts iv I JP-"-x. ■ I ' -; x ^ I -' vx ? x^< _, ' ,> -= \ x / _ ; I v XI E NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE ,(C s- v,,. ,-- l-^-X * 'k-^'-' / „,.-•; \ jj ./ vX -.i ■" 'y-% >' - -^' * "X- 4 g 3NiDia3w do Aavaan tvnouvn 3ni_i_3w do Aavaan tvnouvn snidiosw do Aavaan tvnouvn rX. ^ I .i^-X, ' 1 ' ,,'"; ?x ! '- x: r X- *'\_kv i ' -^^X §- ^Xr> s. Xl & P- '• ■ ^ -:h & "< -;. -X _ s X ^^ ° A-~ / 5 --v " -4-- / E NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE C - -/ P /K ^ P /■■ ^ '^ . X XN xl' 3NIDIQ3W do Aavaan tvnouvn 3ni_i_3w do Aavaan tvnouvn 3nidiq3w do Aavaan tvnouvn X "'^X m >"--£■ > -X " _: ^ -. \ » ^ -■ *' _ , ■! -*, .. ^- Q_ -^ f- "t "i _ C . -■-! -t * ■ / NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE o Q- I 'WN3 f^l ,-s ■uwvon 1WNJ/-Hiwu ^Nnin^w do Aavaan tvnouvn tnitki^w -in ovimn ivkk-invm NLM001023172