A TREATISE 0 N DISEASES OF THE AIR PASSAGES: COMPRISING AN INftUIEY INTO THE HISTORY, PATHOLOGY, CAUSES, AND TREATMENT, OF THOSE AFFECTIONS OF THE THROAT CALLED BRONCHITIS, CHRONIC LARYNGITIS, CLERGYMAN'S SORE THROAT, ETC., ETC. B Y \/ HORACE N, A.M , M.D. FORMERLY PRESIDENT AND PROFESSOR OF THE THEORY AND PRACTICE OF MEDlcINB, IN THE CASTLETON MEDICAL COLLEGE J VICE-PRESIDENT OF THE NEW-YORK MEDICAL AND SURGICAL SOCIETY '. AND HONORARY MEMBER OF THfl PHILADELPHIA MEDICAL SOCIETY, , (1 ETC*. ETOt* NEW-YORK AND LONDON: WILEY AND PUTNAM, 161 BROADWAY. 1 8 4 6. WVB G-796fc IS4Ł Entered, according to Act of Congress, in the year 1846, By HO 11 ACE GKEEN, [n the Clerk's Office of the District Court for the Southern District of New-York. Stereotyped by T, 13. SMITH, ai6 ti UUam-st., N. Y. Printed by R. CRAIGHEAD, 11° Fulton-si., N. Y. PREFACE. In presenting the following Treatise to the medical public, I am fully aware, that views of the pathology of disease, and of its treatment, differing, in any degree, from those generally admitted, by the profession, are received by its members, with distrust and hesitation. But, so far from complaining of this, I am, and ever have been, among those, who have condemned the disposition, manifested by a part of the profession, in America, to receive, unquestioned, the observations and conclusions of certain pathologists; and to adopt such views, as established truths in medicine. In the following pages, I have presented a series of observations and facts, with regard to the phenomena of disease, and the effect of remedies, upon that disease, which, it may be in the power of every practical man, to verify, or disprove. Let the inquiry, then, be fairly made, and if it shall be found, that the conclusions which have been adopted; as to the nature of disease, and the effect of the treatment upon it; are unphilosophical and untenable—let them be discarded. As an apology, however, for what may be deemed by some, an obtrusion upon the profession, of individual views, of the nature and treatment, of disease, I will take the liberty of stating, that I have been urged, in such a manner, by many distinguished medical gentlemen, of different parts VI PREFACE. of the Union, to publish these views, that I have not felt myself at liberty to refuse. It is in compliance with these requests, that the publication of the present work, has been undertaken. For the imperfections of the work, I have but one apology to offer. It has been prepared amid the pressure of constant, and constantly accumulating, professional engagements. 12 Clinton Place, NewYork, October, 1846. INTRODUCTION. More than six years ago, namely, in September, 1840, I brought before the New York Medical and Surgical Society, —as may be seen by a reference to the Recorded Proceedings of the Society,—the subject of the treatment of disease of the larynx, by means of the direct application of therapeutical agents to the lining membrane of that cavity. I then exhibited instruments, by means of which, topical remedies were applied to the larynx; and reported fifteen cases of laryngeal and bronchial disease, —which had come under my care during the two years preceding the above period,— in which permanent cures had been effected, by this mode of treatment. Such, however, was the degree of skepticism, on this subject, manifested, at the time, by a large proportion of the members, that, for many years, I refrained from bringing the matter, again before the Society. But, in the mean time, large numbers of patients, who were sufferers from laryngeal and bronchial disease, came under my care, and were treated, by this method, with an amount of success, that was in the highest degree, satisfactory. At length, the subject was again presented to the Society, by some of its members, who had, themselves, succeeded in applying remedial agents to the mucous membrane of the laryngeal cavity. But, as doubts still existed, in the minds of a majority of the members, on the subject, a Committee was appointed, to inquire more fully, " into the practicability of making these topical applications, to the surfaces of the larynx." This committee ; after devoting much time to the VIII INTRODUCTION. investigation of the subject, reported in favour of the entire practicability of the operation ; while, one of their number, detailed several interesting cases, of laryngeal disease, which, in his own hands, had been successfully treated, by the immediate application of remedies, below the epiglottis. But, whilst, along with this committee, large numbers of medical men, —comprising some of the most intelligent gentlemen, of this city, and of other cities, and States, have, at different times, been present, and have witnessed the introduction of a strong solution of the crystals of nitrate of silver, into the cavity of the larynx; I am not ignorant, that there are others, who, —-judging from analogy, and the experience of the past, —entertain the same opinion that was originally entertained, by the committee, as well as by almost every other member of the profession ; namely,—that it is altogether impossible to enter the glottis in this manner. The well known fact, of the great irritation, produced upon an individual, by the accidental introduction of a morsel of food, or a drop of tea, or of any other fluid, below the epiglottis, is always adduced, as an unanswerable argument, against the practicability of introducing strong medicinal agents, into the laryngeal cavity. But this plan of reasoning from analogy, is one, not applicable in this case; —for, it is a singular, but most interesting fact, —one that has been fully established by repeated experiments,—that the introduction, into the glottis, of a sponge, saturated with a solution of crystals of the nitrate of silver; of the strength of forty, fifty, or, even, of sixty grains, of the salt, to the ounce of water, does not produce, ordinarily, as much disturbance, as the accidental imbibition, into this cavity, of a few drops of tea, or, even of pure water. With all proper deference, therefore, to the opinions, in ordinary, of those medical gentlemen, who may still deny, that the operation is practicable, I beg to remark: that INTRODUCTION. IX mere opinions in medicine, however extensive the experience, on other subjects, of those, by whom they are entertained, cannot be received at the present day, in opposition to facts in medicine. Wherein, consists this impossibility of entering, intentionally, a tube, or cavity, which has been, in so many known instances, entered accidentally. The epiglottis, or valve to this opening,—except at the moment of deglutition, —is always, by virtue of its own elasticity, retained in a vertical position; what can hinder, then, I would ask those of the profession, who are so confident in their opinion, on this subject,—what can prevent an instrument, of a proper relative size, from passing the opening of the glottis ? Have the bits of coin, and other foreign bodies, which accident has introduced into the larynx, in innumerable instances, have these been hindered ? Or, has the elastic tube, which has found its way into the cavity of the larynx, a thousand recorded times, has this been prevented from passing through the rima glottidis, even into the trachea itself ? Let us inquire what others, who speak from authority, have to say, on this subject. Mr. Ryland, in a work on " Diseases and Injuries of the Larynx and Trachea," under the head of the Operation of Bronchotomy, remarks:—" The substitution of an elastic tube, passed into the trachea, for the operation of bronchotomy," to remedy suffocation arising from certain causes, was first proposed by Dessault, and by him, insisted upon, with great pertinacity. " The idea of the aperture of the glottis being closed by the abasement of the epiglottis upon it," continues Mr. Ryland, " has long been exploded, and it is now well known that a tube, passed in the manner just indicated, will, if directed by a scientific hand, readily find its way into the trachea. In these cases, there is no irritability, no convulsive spasm, caused by the contact of the tube with a highly sensitive glottis, and the insufflation of INTRODUCTION. X air can be managed as well through a pipe introduced in this manner, as through one passed into an opening in front of the air-passages." * In the Chirurgical Relations of the Oriental army, several cases are given, where soldiers, having lost the whole or a part of the epiglottis, by the passage of a bullet, were sustained by Baron Larrey, by passing an elastic tube into the oesophagus, through which, liquid nourishment was conveyed into the stomach. In one case, the entire epiglottis was cut off by a bullet, and afterwards spit out. The entrance of the larynx being thus exposed, no liquid of any kind, could be swallowed without inducing a convulsive and suffocating cough. This state continued some days, before Baron Larrey saw the patient. He immediately passed a tube into the oesophagus, and administered some nourishment. The passage of the tube was not always executed with the same facility; as, in some instances, it is stated, it went into the larynx, instead of the oesophagus; and when this happened, the mistake was not discovered, by any particular sensation about the glottis.t Dr. A. H. Stevens, of this city, has also assured me, that in attemping to introduce the tube of the stomach pump, it has frequently passed, accidentally, into the larynx, without exciting any marked irritation. And yet there are those, who having neither made the attempt, themselves, nor having seen it attempted by others; assert, in the face of all these facts, that the introduction into the larynx, of an instrument, formed for the purpose, and guided by a hand, endeavouring to effect the passage, "is altogether impossible!" But. I can assure the profession that it is an operation, which, in the treatment of laryngeal diseases, I have been in the practice of performing every day, for several years ; and it * Treatise on the Diseases and Injuries of the Larynx and Trachea, p. 317. t Relation Chirnrg. de l'Armee d'Orient. INTRODUCTION. XI has been witnessed, and admitted, by a large number of well-informed medical gentlemen, who, from time to time, have been present, and who have, themselves, many of them, adopted, successfully, the practice of treating chronic inflammation of the larynx, with topical medication. Before closing these introductory remarks, I wish to correct one wrong impression, in order to give credit where it is due. It has been frequently stated, by members of the profession, and in some of the medical journals, that, in applying topical remedies to the laryngeal cavity, I have done so, after the manner of MM. Trousseau and Belloc. While I claim no credit for having originated the practice, myself; I, on the other hand, give these authors none, for having, so far as I am concerned, suggested it; for, I had been in the practice of cauterizing the larynx, nearly two years, before I had even heard of Trousseau and Belloc. Their work was translated and published in this country, in 1841. In 1838, when in London, I had a conversation with Dr. Johnson, the late editor of the Medico-Chirurgical Review, on the subject of the treatment of chronic laryngeal disease. He spoke of the frequent occurrence of the affection, among the members of Parliament, the clergy, and other public speakers, and alluded to the difficulty of treating the disease successfully, after the ordinary method ;—from the fact, that the affection, after having extended into the laryngeal cavity, was beyond the reach of gargles, and other topical remedies, as ordinarily employed; and the suggestion was made, that if proper applications could be applied below the . epiglottis, no difficulty would occur in treating, successfully, the disease. Acting upon this suggestion, after my return home, I made the attempt, and was sue cessful, in entering the larynx ; and thereby, succeeded in XII INTRODUCTION. curing a well marked, and severe case of laryngeal disease. With the like success, other cases were treated, in the same year; and the appearance of the work of Trousseau and Belloc, soon after, confirmed my confidence in a method of treatment, which I have since pursued, and which I intend to follow, until a more excellent way shall have been discovered. H. G. CONTENTS. CHAPTER I. CHAPTER III. Structural changes consequent on plastic inflammation of the lining membrane of the air-passages ... 27 Of the Throat ib. Structural changes consequent on superficial inflammation of the mucous membrane of the throat ... 26 Pathology of the Throat, Larynx, and Bronchi ... 24 CHAPTER III. Follicles of the Larynx ib. Follicles of the Trachea 22 Different forms of Glands - ib. Follicles of the Pharynx 21 Physiology of the Mucous Follicles 15 CHAPTER II. Bifurcation of the Trachea ...... 12 Of the Trachea 11 Chorda? Vocales 9 Arytenoid Cartilages - 8 Cricoid Cartilage ....... ib. Thyroid Cartilage 7 Of the Larynx ......... 6 Anatomy of the Larynx, Trachea, and Bronchi - . - 1 CHAPTER I. Introduction - - ix Preface - vii PA OB. XIV CONTENTS. CHAPTER IV. CHAPTER VII. Influence of age - -- -- -- - 164 Influence of sex - -- -- -- - 163 Debility 162 Climate - -- -- 161 Hereditary tendency ------- ib. Causes of the Follicular Disease of the Air-Passages - - 158 CHAPTER VII. Ulceration of the Follicular Glands .... 154 Morbid Secretion of the Follicular Glands ... 145 Induration of the Follicular Glands ... - 143 Hypertrophy of the Follicular Glands ... - 141 Pathology of Follicular Disease of the Air-Passages - - 139 CHAPTER VI. Ulcerations 137 Disease of the Follicles of the QEsophagus . - - 133 Stricture of the Oesophagus ------ ib. Ideopathic disease of the Oesophageal Tube - - 129 Malignant Follicular Disease of the Oesophageal Tube - - 128 CHAPTER V. Follicular Disease of the Air-Passages complicated with Phthisis Pulmonalis - 118 Follicular Disease complicated with Chronic Bronchitis 108 Follicular Disease complicated with elongation of the Uvula 9S Follicular Disease complicated with Laryngitis - - 106 Follicular Disease terminating in ulceration of the mucous glandulae - -- -- -- - 70 History of Follicular Disease of the Air-Passages - - 44 Follicular Inflammation of the Throat and Air-Passages - 42 CHAPTER IV. Organic lesions consequent on inflammation of the bronchial mucous membrane ------ 37 Organic lesions consequent upon sub-acute inflammation of the superior portion of the respiratory tube - - 36 PAOB, C ONT E NT S. XV CHAPTER VIII. PAGE. Explanation of Plates - 269 Appendix 257 Influence of Climate - 245 Sanguinaria ib. Muriate of Ammonia 244 Prussic Acid - - 242 Mercury 240 General Remedies - ib. Nitrate of Silver ib. Iodine 237 Of the Treatment of Follicular Disease .... 236 CHAPTER X. Treatment of Follicular Disease, when complicated with Pulmonary Phthisis 231 Treatment of Follicular Disease, when complicated with Chronic Laryngitis - 214 Excision of the Tonsils 214 Excision of the Uvula - 208 Method of applying remedies ..... 199 Topical Medication - - - - - - - 195 Of the Treatment of Follicular Disease .... 193 CHAPTER IX. Aspect of the Epiglottis 188 Mental Depression ....... 184 Cough 183 Ulceration of the Follicles ..... 180 Hoarseness ......... 179 Increased mucous secretion ..... t 7j. Symptoms of Follicular Disease of the Air-Passages - - 178 CHAPTER VIII. Tobacco 174 Exercise of the Voice - - - - - - - 170 Eruptive Fevers 169 Influenza - - - 165 Exciting Causes. A TREATISE ON THE DISEASES OF THE AIE PASSAGES. CHAPTER I. Anatomy of the Larynx; Trachea, and Bronchi. Before we enter upon the inquiry respecting those diseases which affect the organs of voice and respiration, it will be expedient to take a brief view of the anatomy and pathology of the parts which enter into the structure of these organs. Familiar as their organization may be to the special anatomist, a definite knowledge of their structure, and of the organic changes to which they are liable, is not, always, clearly possessed by the general practitioner. Commencing at the isthmus of the fauces, or the posterior boundary of the mouth, this description will include all those parts which, ordinarily, are involved in the diseases that are to be considered. The isthmus faucium, or that opening by which the mouth communicates with the throat, or pharynx, is bounded above, by the palatine arch, from 2 2 ANATOMY OF THE LARYNX. which depends the velum pendulum palati, or the soft palate. The velum palati is a floating, membranous septum, which is attached to the margin of the palate bones, and which descends from thence, at the posterior border of the mouth, obliquely downwards and backwards, towards the base of the tongue. It is composed of a dense, cellular membrane, in which are numerous small glands ; and of several muscles whose office is to stretch, or relax, this moveable septum. One of these muscles, the azygus, descending vertically from the posterior nasal process to the inferior border of the septum, on the median line, helps to form that conical prolongation, which is called the uvula. The whole is covered by a mucous membrane, which is a prolongation of the palatine membrane, and beneath which, numerous sub-cutaneous, mucous follicles are placed. These follicles are especially large, and numerous, towards the inferior extremity of the uvula. Not unfrequently they become diseased, in affections of the throat, causing a chronic enlargement and elongation of the uvula, with a thickening of its mucous membrane, until, in some instances, this organ reaches the opening of the glottis, producing constant irritation, on the base of the tongue, and at the top of the wind-pipe. The use of the uvula and velum, it is supposed, is, by operating as a valve, to prevent the food, in the act of deglutition, from ascending into the posterior nares. Continuous with the velum palati, 3 ANATOMY OP THE LARYNX. at the lateral parts of the throat, there is, on each side of the posterior part of the roof of the mouth, a fleshy prominence, which, extending towards the base of the tongue, becomes bifurcated in its descent, and forms two vertical eminences, which are composed of folds of the mucous membrane, containing muscular fasciculi. These are called the pillars of the fauces. Occupying the angular space, formed by the intercolumniation of these pillars, are found the amygdala, or tonsillary glands. These bodies are of an oval form, corresponding, in size and shape, to an almond, from which they receive their name. They are composed, almost entirely, of a great number of mucous follicles, loosely bound together, or aggregated into a mass, and are surrounded by, or deposited in, cellular tissue. They are of a spongy nature, and are exceedingly vascular, being largely supplied with blood from the pharyngeal, the palatine, and the labial arteries. Internally, they present several small sulci, or openings, which lead into follicles or cells, that are filled, generally, with mucous, and a viscid humor. The tonsils are bounded, laterally, by the pillars of the soft palate; externally, they adhere to the surface of the superior constrictor, a thin muscle, by which they are separated from the internal carotids. When the tonsils are enlarged, they pass backwards far enough to touch these vessels ; consequently, in the removal of the glands, which frequently becomes necessary, from their diseased and 4 ANATOMY OF THE LARYNX. enlarged condition, reference must be had to the anatomical relation of the parts, or the internal carotid may be wounded in the operation. In affections of the throat the tonsils are, often, the seat of morbid action. Infiltration, the formation of abscesses internally, and indolent enlargement of these glands, are of frequent occurrence. When the inflammation is severe, large abscesses may be formed in the centre of the glands, increasing their size, so as to render respiration difficult, and requiring a prompt operation to allow the pus to escape. Ordinarily, however, when the inflammation is concomitant with, or is the result of that peculiar affection of the throat which we are to consider, it is sub-acute in its character, progressing slowly, and involving, successively, one follicle after another, in the suppuration which follows. The matter thus formed, is discharged through the openings of the mucous follicles, into the sulci, which are on the internal surface of the glands. As there is but little pain attendant upon this kind of inflammation, the disease may be going on for months, perhaps, without the individual being at all aware of the extent of the morbid action ; whilst the acrid matter, which oozes slowly, and, perhaps, unobserved, from the affected glands, is irritating the surrounding parts, or it may be, is communicating disease to the adjacent follicles of the mucous membrane. In other instances the glands become indurated, and permanently enlarged; requiring, fre- ANATOMY OF THE LARYNX. 5 quently, in both the above morbid conditions, the application of the caustic, or the knife, for their removal. Situated between the palatal arch, or the posterior boundary of the mouth, and the oesophagus, and lying immediately before the upper part of the vertebral column, is the pharynx. More properly speaking, the pharynx extends from the centre of the base of the cranium as far as the level of the fifth cervical vertebra, when it unites, or becomes continuous with the oesophagus. The pharynx is a musculo-membranous canal; irregular in its diameter, being narrow at its superior portion, enlarging at its middle, and contracting again where it communicates with the oesophagus. At the upper and anterior portion of the pharynx we have the nasal fossae, opening from above, downwards, into this canal; and at its external and superior part are the mouths of the Eustachian tubes; the latter forming a communication between the posterior fauces and the cavity of the tympanum. The mucous membrane which lines these canals, and the nasal fossae, is continuous with that which covers the pharynx. That portion which covers the latter is highly vascular ; its follicles are large and abundant, particularly at its superior portion. Beneath this membrane is placed the muscular layer of the pharynx. It is composed of the fibres of five or six small muscles, by which it is connected to the vertebral column posteriorly, and lat- 6 ANATOMY OF THE LARYNX. erally to the internal carotids. In long-continued disease of the throat, these muscles become atrophied, or are wasted away, thereby greatly enlarging the posterior fauces and the superior portion of the pharynx. This change in the dimensions ol the cavity of the upper part of the throat, tends greatly to weaken the voice, which, in some instances, where the disease has involved the vocal cords in its progress, becomes quite extinguished. The oesophagus is a continuation of the pharyngeal tube; being extended from the latter downwards, between the vertebral column and the trachea, to the stomach. Like the pharynx, it consists of a muscular or external coat, and a mucous lining. The mucous membrane is continuous, superiorly, with that of the pharynx and mouth, inferiorly, with that of the stomach; it is separated from the muscular by a cellular structure, and is marked by several longitudinal folds, which disappear when the tube is distended. This membrane of the oesophagus is thick and firm, and its internal surface is perforated by the ducts of the mucous glands, which are situated, at intervals, beneath it. The Larnyx. —We now come to the consideration of those parts which more properly belong to the respiratory apparatus, and which are, therefore, in a pathological point of view, eminently important. Highly complicated in its structure, and differing, essentially, from most other organs of the body—in ANATOMY OF THE LARYNX. 7 that it performs two of the most important functions of the animal economy —the larynx becomes to the anatomist and physiologist, whether viewed in its healthy or morbid condition, an object of the highest interest. The larynx is a cartilaginous tube, which is placed at the top of the wind-pipe. Through it is transmitted the air, in its passage to and from the lungs; and within its cavity is placed that delicate and intricate structure, which forms and modulates the vocal sounds. It commences at the base of the tongue, where it is attached to the os-hyoides, and passing down, directly in front of the pharynx, it is connected, by a membranous union, to the first ring of the trachea. To afford protection to the delicate, vocal organs, the larynx has a frame-work composed of several strong cartilages. Of these, the most prominent, is the thyroid cartilage, which forms the upper and anterior part of the larynx. It is composed of two lateral plates, which, uniting on the median line, at the upper part of the neck, form that prominent angle, to which the name of Pomum Adami has been given. Below the thyroid, and forming the inferior boundary of the larynx, is the cricoid cartilage. It is of an annular form, irregular in its shape, being much broader behind than it is in front; and it is so connected with the thyroid cartilage, that a triangular space is formed, in front, between the two cartilages, which space is occupied by the 8 ANATOMY OF THE LARYNX. crico-thyroid membrane. It is at this point, that the operation for laryngotomy is commonly performed. The arytenoid cartilages are two small bodies, of a triangular shape. They are situated above the cricoid cartilage, at the upper and back part of the larynx. They are narrow above, and broad at their lower extremities ; and when connected together, the two cartilages present the form of the mouth of a pitcher, whence they are named. The opening between the lips of these two cartilages, is called the superior orifice of the larynx, or the aperture of the glottis. Over it is placed a fibrocartilaginous valve, to which the name of epiglottis is given. This cartilage is of an ovoid form, and of a tissue very elastic. It is placed immediately below the base of the tongue, and above the entrance of the larynx j whose aperture it closes, completely; guarding it, like a valve, against the ingress of food, during the act of deglutition, and directing the morsel, at the same time, towards the oesophagus. The upper, and larger, extremity of this oval body, is free; the smaller, or inferior one, is somewhat elongated, and is attached, by ligamentous fibres, to a notch, in the anterior face of the thyroid cartilage. By its natural elasticity, it preserves, ordinarily, nearly a vertical position; and its broad margin may often be seen, elevated above, and overlooking the base of the tongue. Within the larynx are parts essential to the 9 ANATOMY OF THE LARYNX. formation of the voice, which are, frequently, seriously affected, in diseases of the air passages. Extending from the arytenoid, to the angle of the thyroid cartilage, are two remarkable ligamentous cords, placed one beneath the other; which are called the chorda vocales, or vocal ligaments. The superior cords are semilunar in shape, and consist merely of a duplicature of the lining membrane. The inferior pair are more strongly marked than the others. They are formed of highly elastic and parallel fibres, enveloped in a fold of the lining membrane of the larynx. They are about two lines in breadth, and from half to three quarters of an inch in length; and they are rendered more or less tense, by the action of the small muscles, with which they are connected. These ligaments bound a triangular interval, called the rima glottidis ; and from their connection with the special function of the larynx, are called the proper chordae vocales. Just above the vocal ligaments, on either side, a cavity of an oval shape is formed, which is called the sinus, or ventricle of the larynx. These cavities, with the vocal ligaments, perform an important part in the formation of the voice. The mucous membrane which lines the interior of the larynx, is continuous with that which has been described as covering the pharynx above, and with the lining membrane of the trachea below. There are some peculiarities in the arrangement of the mucous membrane of the larynx, worthy of 2 * 10 ANATOMY OF THE LARYNX. remark. It is known that, to the mucous membranes, belong but a limited degree of extensibility; and, yet, they are often found lining cavities; as the stomach and the intestines, for example, whose ordinary dimensions are subject to frequent enlargement. This difficulty; namely, a want of elasticity in the mucous membrane, is obviated by this tissue being laid in innumerable folds, or wrinkles, in these cavities. But in the larynx, whose calibre is likewise undergoing constant change in its dimensions, this disposition of the lining membrane would doubtless interfere, seriously, with the smoothness of the voice. Here the difficulty is met by another arrangement. As the mucous membrane is reflected from the base of the tongue, to the anterior or lingual surface of the epiglottis, it forms, upon its front and outer part, three distinct folds, by which a free motion to the epiglottis is allowed; such as a perfect exercise of its functions requires. The membrane then passes downwards, adhering closely to, and lining smoothly, the interior, or laryngeal face of the epiglottis, and the cricoid cartilage. When it reaches the ventricles of the larynx, it adheres loosely to these cavities, but over the vocal ligaments it is thin and adherent; thus presenting a smooth surface, whilst it allows freedom of motion, in the expansion and contraction of these important parts of the vocal apparatus. The larynx is supplied, abundantly, with mu- 11 ANATOMY OF THE TRACHEA. cous follicles. They are most numerous at the root of the epiglottis, where their ducts are seen opening upon its laryngeal surface. They abound, likewise, in the mucous membrane, which passes from the arytenoid cartilages to the sides of the epiglottis, and in that part, also, which covers the cricoid cartilage. The nerves of the larynx are the inferior and superior laryngeal nerves—branches of the eighth pair, or par vagum. A branch, also, from the cervical ganglia of the sympathetic nerve is sent to the larynx. The inferior laryngeal is the motor nerve of the larynx, whilst the superior laryngeal is the excitor, or nerve of sensation. Nearly all the muscles of the larynx —both those which open and those which close its apertures —receive filaments from these nerves. The inferior laryngeal awakens the muscles into action ; whilst the office of the superior is to convey sensation to the medulla oblongata. At the inferior margin of the cricoid cartilage, immediately below the larynx, commences the trachea. It is a fibro-cartilaginous tube, about five inches in length, situated before the oesophagus, and, like the larynx, is placed exactly over the median line of the neck. The trachea is composed of several incomplete cartilaginous rings, arranged one above the other, and connected together by a highly elastic fibrous tissue. These rings form about two thirds of a circle; surrounding only the 12 ANATOMY OP THE TRACHEA. anterior and lateral parts of the tube, whilst the open space in the rings, posteriorly, is occupied by a membrane, composed of thin bands of muscular fibres. As the trachea descends into the thorax, it bifurcates just opposite the third dorsal vertebra, sending one of the two branches, which here take the name of bronchi, into each of the lungs. The bronchi, as they penetrate the lungs, divide and sub-divide, very minutely, and transmit their ramifications into every part of the pulmonary tissue. Thus formed, the wind-pipe has been compared, not inaptly, to an inverted hollow tree.* The larynx and trachea, representing the trunk and the bronchi, and their innumerable sub-divisions, the branches and twigs of the pulmonary tree. The mucous membrane of the trachea is a continuation of the lining membrane of the larynx. It is thin and vascular in the trachea, adhering closely to the sub-mucous tissue of this tube, and lining not only the minute branches of the bronchi, but extending into the air cells of the lungs. The mucous follicles of the trachea are still more abundant than those of the larynx. They pour their secretion upon the mucous membrane of this tube. Near the bifurcation of the trachea, and around the roots of the bronchi, are found a great number of dark-coloured, lymphatic glands. They are larger in size than the mucous follicles, and * Meckel. 13 OF THE EPITHELIUM. they are called the bronchial glands. Their functions are unknown. The striking analogy which exists between the mucous membranes and the skin, has long been known. They are continuous with each other, and, although differing in their functions, the same structural elements enter into the formation of both. Instead of the dry epidermis of the skin, the surface of the mucous membranes is covered with a soft and moist kind of cuticle, to which the name of epithelium has been given. There are various forms in which this covering of the mucous membranes is presented. The two principal and most common forms, however, are the tesselate, or pavement-epithelium, and the cylinifcr-epithelium. The tesselated epithelia are composed of flattened cells of a peculiar form, arranged in layers, one above the other; in many instances, however, the mucous membrane will be found to be covered by a single stratum only. The cells of cylinder epithelia, as the name indicates, have the form of conoid cylinders, resting side by side upon the mucous membrane. Their free extremities are sometimes fringed with minute hair-like filaments, to which the name of cilia has been given. It is this latter form—the ciliated epithelium—which is found lining the fauces, the posterior surface of the pendulous velum of the palate, the larynx, the trachea, and extending through the bronchi and all their sub-divisions. 14 OF THE EPITHELIUM. During life, and for some time after death, the cilia which are attached to the edges of the epithelial cells, are in a state of continual vibration, and, as their motions are directed towards the outlets of the cavities which they line, their function, it is supposed, is to propel the accumulated secretions towards the exterior orifices, from which they may be removed.* In diseases of the mucous membrane, the epithelia are easily removed, but they possess the power of reproduction to an unlimited extent, and when detached from the mucous surfaces by disease, or any other cause, they are most readily renewed. * See Prin. of Human Phys. by Dr. Carpenter, p. 504. CHAPTER II. Physiology of the Mucous Follicles. Allusion has been made already to a part of the glandular follicles which are found scattered along that portion of the mucous membrane which lines the fauces, pharynx, and air passages. The important influence which they exert in the diseases of these passages, renders necessary a farther inquiry into their history and the phenomena which they present. In order more fully to understand the nature and functions of the follicles occupying the mucous surface of the above passages, it may be well, first, briefly to trace the history of those which occupy the lining membrane of other parts. Nearly all the membranes lining the internal cavities, are supplied with numerous glandular, which secrete the mucus that covers their surfaces. They differ, however, essentially in their structure, and, in some instances, in the secretions which they elaborate. In some cases, the secreting glands consist merely of numerous slight depressions of the mucous membrane, or small sacs, with narrow necks; in others, again, they are composed of minute tubes arranged perpendicularly to the surface, with their closed extremities resting upon the sub-mucous 16 PHYSIOLOGY OF THE MUCOUS FOLLICLES. tissue, and their opposite ends opening upon the face of the mucous membrane. These are the most simple, and, indeed, are the elementary forms of all glandular follicles. Of the former kind, are the follicules of Lieberkuhn, which are numerous clusters of minute depressions, covering almost the entire surface of the mucous membrane of the small intestines; and to the latter class belong the tubelike follicles first described by Dr. Boehm, and which are equally numerous in the mucous membrane of the large intestine. Besides these simple forms of crypts, or follicles, there are numerous other modifications of structure in the glandulee of the mucous membranes; some of which are highly complicated—the interior of the follicle being composed of both sacs and tubuli, bound together by a most delicate cellular tissue. But, whether simple or compound, or however various in their conformation the substance of glands may be, Nature has arranged them, in all cases, apparently for the purpose of gaining the largest extent of secreting surface ; no one kind of conformation, moreover, is peculiar to one gland. In some instances their substance consists of a mass of oval sacs, or cells, having no excretory opening, but being completely closed, and, apparently, unconnected with the secreting action of the membrane. Of the latter, according to Henle,* are the mucous follicles of the lips, cheeks, etc. Clusters of these • Elements of Physiology, by J. Miiller, M. D. vol. 1, p. 479. PHYSIOLOGY OF THE MUCOUS FOLLICLES. 17 oval-shaped cells, of different sizes, containing, some of them, glandular matter, and others, globules of mucus, but all being hermetically sealed, may be found attached to a branch of the excretory duct. But as there is no opening communicating with the duct, it is supposed by Henle, Baly, and other physiologists, that the contents of the cells are, from time to time, discharged into the excretory opening, in consequence, either of the membrane of the cells bursting, or of its becoming dissolved at the part where it is connected with the duct. Besides the simple tubuli of Lieberkuhn, which are found occupying almost the entire extent of the lining membranes of the small intestines, there are the glandulce agminatce, or glands of Peyer, aggregated together, in large patches, along the mucous membrane of the small intestine, opposite the insertion of the mesentery. These glands, like the follicles of the lips and mouth, possess no excretory opening. The clusters are small closed sacs, each about a line in diameter; and they are surrounded by a zone of small openings, like the foramina of Lieberkuhn, but which do not penetrate the walls of the sac. The contents of these saculi is a greyish white mucus, which is not discharged until the delicate membrane that closes the cavities, and which is very liable to ulceration, is destroyed by disease. Thus it is that the so-called glands of Peyer become open cells, or follicles, and in this 18 PHYSIOLOGY OP THE MUCOUS FOLLICLES. state are they found after that inflammation of the membrane, which is the frequent concomitant of certain febrile and other diseases. In the glandular of the mucous membrane of the stomach, a structure still more difficult and complex is presented. On examining the interior of a healthy stomach, numerous small depressions or cells, of a regular and nearly an oval form, may be observed upon its mucous surface. The floor of each of these cells is perforated by several minute openings, which are the mouths of secreting tubes. These latter are not simple tubuli, but they assume towards their inferior extremities a saculated structure ; that is, each of these secreting organs is composed of numerous cellular dilatations, all attached to one common tube, and this tube penetrates the floor of the superficial cell in the manner described. It is this secreting apparatus which elaborates the gastric fluid. By recent microscopic investigations, it has been ascertained that the mouths of these tubuli remain closed when the stomach is empty, and that it is only during the period of digestion that the peculiar fluid which they elaborate is secreted. This accords with the experience of Dr. Beaumont, who observed, in the case of Alexis St. Martin, that the gastric fluid never appeared to accumulate in the cavity of the stomach whilst the patient was fasting.* * See the case of St. Martin, with the observations and experiments of Dr. Beaumont. 19 PHYSIOLOGY OF THE MUCOUS FOLLICLES. Situated in the duodenum is a layer of glandular bodies, differing, entirely, from those already described, and, indeed, unlike all the other glandular of the alimentary canal. These are the glands of Brunner; so called from having been first properly described by the physiologist of that name. They are not found in the lining membrane, but are situated in the sub-mucous tissue, and are sufficiently numerous to form a continuous layer, which surrounds the whole intestine. These glands are small solid bodies, in their healthy state, not exceeding in size that of a hemp-seed; yet they are composed of numerous minute acini, or lobules, of which about six hundred are computed to exist in each gland.* Their ducts unite in one common excretory tube, which, penetrating the mucous membrane, opens upon its interior surface. It has been ascertained by Dr. Boehm, that the glands of Brunner exist, only, in the duodenum; beneath the mucous coat of which they are exceedingly numerous. It is in the duodenum that the chyme, after the digestive process in the stomach is completed, is mingled with the bile and the pancreatic fluid. An immediate alteration, both in its sensible and chemical properties, is effected in the chyme by this admixture. The abundant secretion furnished by the glands of the duodenum, must have an important influence in effecting this change. Of the •Principles of Human Phys. by Wm, B. Carpenter, M.D. p. 537. 20 PHYSIOLOGY OF THE MUCOUS FOLLICLES. peculiar nature of their secretion, however, nothing is known. Embraced in the above description, are the principal glandular bodies, which are found in the mucous membrane, lining the alimentary canal. The follicles which are scattered along the lining membrane of the fauces, pharynx, and air passages, include such as are both simple and compound, in their conformation. The mucous follicles of the lips and mouth are simple closed cells, resembling the glandulae agminatse, in their having no excretory opening. In the mucous membrane, which unites the base of the tongue with the epiglottis, are clustered together several follicles, having their excretory ducts opening into a common dilated orifice, the foramen cacum, situated at the back of the tongue. Placed near this opening, are the lenticular papilla of the tongue; they consist of twelve or fifteen large mucous follicles, of a conoid shape, disposed in two lines, which converge to an angle just before the foramen caecum. The amygdala, or tonsils, seem to be composed, entirely, of an aggregated mass of follicles, enveloped in folds of the mucous membrane. On the internal and convex surface of these bodies, are seen a large number of deep and irregular sulci, or depressions. The walls of these cavities are lined by mucous membrane, whose surface presents numerous small apertures, which lead into follicles, or cells, that secrete the PHYSIOLOGY OF THE MUCOUS FOLLICLES. 21 mucous and viscid fluid with which the cavities are generally filled. The glands of the pharynx are large and abundant ; they are of an ovoid form, and are situated beneath the mucous membrane, but are not imbedded in the sub-mucous tissue, as are those of the oesophagus and trachea. These glands are particularly numerous around the posterior nares, and under the cervical portion of the pharyngeal membrane; two of them, more complicated in their structure, being lobulated, and of larger size than the rest, are situated at the margin of the opening of the Eustachian tube. The follicles of the Uvula are also large, and they are particularly numerous around the inferior extremity of this organ. The oesophageal glands, like those of Brunner, which have been described, are imbedded in the sub-mucous tissue of the oesophagus; they are composed of small lobulated bodies, or cells, —several of them having their excretory ducts united in one common tube, which opens upon the surface of the oesophageal membrane. The tubuli of these follicles pass obliquely through the mucous membrane in such a manner that substances that are swallowed do not find ingress to their cavities. In the larynx the mucous follicles are very numerous in that part of the lining membrane which occupies the upper part of this organ. On its 22 PHYSIOLOGY OF THE MUCOUS FOLLICLES. surface may be seen the openings of some sixty or seventy excretory tubes, which pass into follicular cells, situated in the sub-mucous tissue. Placed in the substance of the epiglottis are numerous other glandular, which have their openings on the laryngeal surface of this structure; one of these, consisting of several granules, is imbedded in a mass of fat, which is located between the epiglottis and the os hyoides; from it, ducts pass backwards, through foramina in the epiglottis, to open upon the posterior, or laryngeal surface of this cartilage; from its connection with this body it is named the epiglottic gland. Other glands are placed in the thickness of the superior vocal cords, within the ventricles of the larynx, and in the folds of the mucous membrane, in front of the arytenoid cartilage. The secretion from the laryngeal follicles is intended for the lubrication of the vocal ligaments, and it is directed upon them by small valvular folds of the mucous membrane, which are arranged in such a manner as to effect this object. The follicles of the trachea are still more numerous than those of the larynx ; they are small, flattened, ovoid cells, situated between the fibrous and muscular layers of the membranous portion of the trachea, and, in some places, beneath the muscular fibres ; so that their excretory ducts have to penetrate not only the muscular layer, but the mu- 23 PHYSIOLOGY OF THE MUCOUS FOLLICLES. cous membrane, in order to open upon its interior surface. In their normal condition, the fluid secreted by the mucous follicles of the air passages is bland and transparent, and not abundant in quantity; but disease, as we shall find, greatly increases and vitiates their secretion. CHAPTER III. Pathology of the Throat, Larynx, and Bronchi. The physiological and pathalogical relations which exist between the throat and the respiratory tubes, are not justly regarded by medical writers in discussing the nature of those diseases which affect these different parts. Affections of the throat are, ordinarily, arranged by nosologists, in connection with those of the oesophagus; or, are treated independently of those diseases which occur in the larynx, trachea, and bronchi. Pathologically considered, the relation which exists between the fauces, tonsils, and pharynx, on the one hand, and the respiratory tubes on the other, is much more intimate and important, than the connection which exists between the throat and the oesophagus. In almost all the inflammatory affections of the air-passages, whether primary or consecutive, the diseased action has its origin in the fauces and pharynx, and extends, by continuity, from thence to the respiratory tubes; whilst the membrane lining the oesophagus, may escape inflammatory action altogether, or become but partially implicated. 25 THROAT, LARYNX, AND BRONCHI. These pathological relations, therefore, and the community of symptoms, will be kept in view, in examining into the nature of those lesions which affect these organs. The exact, pathological conditions, which exist in the throat and the air-passages, in diseases of these parts, have been, until recently, but imperfectly understood. Indeed, at the present day, several affections of the larynx and trachea are confounded by different writers, or their origin assigned to morbid conditions which do not exist; whilst, on the other hand, accumulated pathological facts show, conclusively, that there are other affections of the air-passages, whose characteristics and morbid relations are still involved in obscurity. To point out the seat and nature of one of these affections; to investigate its causes; and, from a knowledge of its true pathology, to establish correct principles of treatment, are among the objects of the present inquiry. In order, however, to establish the proposition that there exists an abnormal condition of the throat, and the air-tubes, constituting a distinct species of disease, and which, hitherto, has been confounded by writers, and medical practitioners, with other disorders of these parts, under the names of " Bronchitis," " Chronic Laryngitis," &c, it will be necessary, in the first place, to glance, briefly, at the principal pathological condi- 3 26 PATHOLOGY OP THE tions upon which these, and other known disorders of the respiratory apparatus are supposed to depend. Structural changes consequent on superficial inflammation of the mucous membrane of the throat. It is well known, that the mucous membrane, which is found lining the throat, and air-passages, is, in its healthy state, of a slightly red, or pale rosecolour. In disease, it becomes changed, passing from the naturally healthy hue, into a deep scarlet, and ultimately, becoming purple, or violet, according to the form, and intensity of the inflammation. Subjected to the influence of acute, inflammatory action, the mucous tissue presents a red, or violet colour, which is nearly equally diffused over its whole surface; but in all the chronic forms of the disease, we find the inflammation appearing in irregular, circumscribed patches. These patches present highly coloured centres, which become paler, towards their circumferences, gradually fading away into the natural colour of the healthy membrane.* Of the minor forms of morbid action, which affect the throat, there are several varieties. In one, the membrane which lines the fauces, tonsils, and pharynx, is seen to present a bright red appearance, accompanied with tumefaction, and followed by a free discharge of mucous upon its surface. * Gendrin, Hist. Anat. des Inflam. 27 THROAT, LARYNX, AND BRONCHI. In another variety, the membrane appears tense, and highly inflamed. The capillary vessels, which before the occurrence of inflammation, were imperceptible, become distinctly visible, while the surface of the membrane, which in the preceding variety pours out a free discharge of mucus, remains dry and glossy. There is yet another, morbid condition of the throat, consequent upon inflammation of the mucous tissue, differing essentially, from the foregoing varieties. In this form, the inflammation is subacute, in its character. The investing membrane is relaxed, pale, and cedematous; infiltrations of serous fluid take place, beneath the Epithelium, or into the substance of the subjacent parts. But in all these varieties of superficial inflammation of the throat, which are, ordinarily, caused by vicissitudes of temperature, and the presence of cold, and humidity, the apparent tumefaction, and cedema of the mucous tissue, are dependent upon the serous infiltrations which occur beneath the membrane, and not upon an actual hypertrophy of the membrane itself. Structural changes consequent on plastic inflammation of the lining membrane of the air-passages. Among the severer forms of disease, there is one condition of the mucous membrane, the result of inflammation, which is distinguished from all other pathological conditions, of these parts, by the pecu- 28 PATHOLOGY OP THE liarity of the discharge that covers the surface of the inflamed tissue. This consists of an albuminous exudation; amounting in some instances to coagulable lymph, which invests the parts, that are subjected to this form of inflammation, with a dense adventitious membrane. This modification of disease, in the mucous tissue, appears in two forms. 1. In one variety, the inflammation, invariably, commences in the fauces, and pharynx. On examining the throat, a deep redness of the tonsils, and velum, will be observed, with white, or ashcoloured patches of albuminous concretion, covering the surface of the inflamed membrane. In some cases, these pellicles appear separate, and distinct; in others, they coalesce, and coat, with one, uniform crust, the entire, secreting surface, of the mucous tissue. In the early stage of the disease, they resemble superficial sloughs, are easily detached, and when removed, the sub-jacent membrane is seen to be of a vivid red, without ulceration, but deprived of its Epithelium. The redness of the membrane is greatly augmented, after the removal of the crusts; the albuminous concretion is increased, and the mucous surface is again coated, with an exudation, more dense, and tenacious, than the first. If the disease is unchecked, the inflammation, and the concrete exudation, may be extended into the larynx, and the bronchial tubes. M. Brettonneau has recorded several cases where a false 29 THROAT, LARYNX, AND BRONCHI. membrane was found lining the oesophagus, as far down as the cardiac extremity.* In other instances, it presents an unbroken tube, extending from the top of the pharynx, to the primary divisions of the bronchi. Ordinarily, however, the affection is confined to the fauces, and pharynx; it is only in severe cases, that the membrane of the larynx, and trachea, becomes involved in the disease. When the inflammation extends to the larynx, however, it proves rapidly fatal. 2. The second, and* beside the preceding, the only variety of inflammation of the mucous tissues, of the air-passages, whose product is an albuminous exudation, commences with catarrhal symptoms, and is confined, in its attacks, to children, and persons before the age of puberty; whilst the above form of disease, begins with pain, redness, and swelling of the tonsils, and back of the throat, generally; and attacks, moreover, individuals of all ages. The early, morbid changes, which result from this second form of plastic inflammation, are not positively known; as the seat of the inflammation is not within view, as is that of the preceding variety, but is, generally, restricted to the tissues of the trachea, and larynx. In those instances, in which an early inspection of these parts, has been obtained, the mucous sur* * M. Bretonneau, Trait6 de la Diphthlrifce. 30 PATHOLOGY OF THE face of the trachea, and, often, of the larynx, and bronchi, appears reddened, and tumid, and is covered with viscid mucus, having here and there, shreds, or patches, of concrete albumen. The lymph is, undoubtedly, poured out, at first, in a liquid state, and, becoming concrete, afterwards forms an adventitious, tubular membrane, which extends, often, from the tip of the epiglottis, to the bifurcation of the trachea, and entering, in some instances, into the ramifications of the bronchi, penetrates, even, the pulmonary vesicles, at their termination. But, in most cases, this false membrane is found to be more concrete, and firm, in the trachea, than in any other portion of the respiratory tube; for, it is the tracheal membrane that constitutes the special seat of the inflammation. Here, the surface of the mucous tissue presents, often, a bright, vascular redness, and is seen coated, with a dense, firm, adventitious membrane; whilst, lower down in the trachea, and in the bronchi, the albuminous exudation is, generally, found in a semi-fluid state, and mixed with an abundant quantity of viscid mucus. In addition to the preceding, morbid alterations, which result from inflammation of the respiratory apparatus, there are other important lesions of these parts, which are the consequence of severe inflammation of the mucous membrane of the larynx, and epiglottis, and of the sub-mucous, eel hilar tissues of these organs. 31 THROAT, LARYNX, AND BRONCHI. In the preceding, severe form of diseased action, the tracheal membrane, let it be remarked, constitutes the essential seat of the inflammation, and the characteristic product is an albuminous exudation, and the formation of an adventitious membrane, without ulceration, upon the free surface of the mucous membrane; in the variety, which we are now considering, the mucous, and the sub-mucous tissues of the epiglottis, and of the rima of the glottis, are the portions of the respiratory tube, essentially implicated, in the attack of inflammation, and the result, is a thickening, and, often, an ulceration of the mucous membrane which lines the epiglottis, and the lips of the glottis, with a serous, or a sero-purulent infiltration, of the sub-mucous tissues of these parts. The high state of inflammation of the epiglottis, and the consequent effusion of serum into this cartilage, renders it cedematous, and erect, by which it fails to cover and protect the opening of the larynx j and, the distension of the lips of the glottis, from the same cause, approximates their edges, and, thus, at length, the passage into the trachea, becomes nearly obliterated. So rapid, indeed, in some instances, is the progress of this form of inflammation, and, so extensive the serous effusion, into the cellular tissue, of the upper extremity of the wind-pipe, as to obstruct the entrance of air into the larynx, and prove destructive to life, in a very few hours, after the com- 32 PATHOLOGY OF THE mencement of the disease. To the pathological condition which results from this form of inflammatory action, is attributed the cause of death, in the case of the illustrious Washington. But at the time of his death pathologists were wholly unacquainted with the true nature of the disease of which he died. At that period, and for a long time subsequent to it, this form of inflammation was confounded with that which we have just considered, which terminates in albuminous exudations; and thus it was that his disorder was improperly termed " Cynanche trachealis." As the case of Gen. Washington is deeply interesting to every American reader, and is, moreover, acknowledged to be the "first accurately reported history of this form of inflammation which is to be found in the annals of medicine," and therefore of especial interest to the pathologist, I shall call attention to the history of it, as given by the intelligent physicians, who attended him, during his last illness.* " On the night of Friday, the 10th December, 1799, having been exposed to rain on the preceding day, General Washington was attacked with an inflammatory affection of the upper part of the wind-pipe, called in technical language, Cynanche trachealis. The disease commenced with a violent ague, accompanied with some pain in the upper and fore part of the throat, a sense of stricture in the * Drs. James Craik and Elisha E. Dick. THROAT, LARYNX, AND BRONCHI. 33 same part, a cough, and a difficult, rather than a painful deglutition, which were soon succeeded by a quick and laborious respiration. " The necessity of blood-letting suggested itself to the General: he procured a bleeder in the neighbourhood, who took from his arm in the night, twelve or fourteen ounces of blood. He could not by any means be prevailed upon by the family to send for the attending physician till the following morning, who arrived at Mount Vernon at about eleven o'clock on Saturday. Discovering the case to be highly alarming, and foreseeing the fatal tendency of the disease, two consulting physicians were immediately sent for, who arrived, one at half-past three, and the other at four o'clock in the afternoon. In the meantime were employed two pretty copious bleedings, a blister was applied to the part affected, two moderate doses of calomel were given, and an injection was administered, which operated on the lower intestines, but all without any perceptible advantage, the respiration becoming still more difficult and distressing. Upon the arrival of the first of the consulting physicians, it was agreed, as there were yet no signs of accumulation in the bronchial vessels of the lungs, to try the result of another bleeding, when about thirty-two ounces of blood were drawn, without the smallest apparent alleviation of the disease. Vapours of vinegar and of water were frequently inhaled; ten grains of calomel were given, Sue- s'' 34 PATHOLOGY OF THE ceeded by repeated doses of emetic tartar, amounting in all to five or six grains, with no other effect than a copious discharge from the bowels. The powers of life seemed now manifestly yielding to the force of the disorder; blisters were applied to the extremities, together with a cataplasm of bran and vinegar to the throat. Speaking, which was painful, from the beginning, now became almost impracticable ; respiration grew more and more contracted and imperfect, till half-after eleven on Saturday night, when, retaining the full possession of his intellect, he expired without a struggle. He was fully impressed at the beginning of his complaint, as well as through every succeeding stage of it, that its conclusion would be mortal; submitting to the several exertions made for his recovery, rather as a duty, than from any expectation of their efficacy. He considered the operations of death upon his system as coeval w 7 ith the disease; and several hours before his death, after repeated efforts to be understood, succeeded in expressing a desire that he might be permitted to die without farther interruption. During the short period of his illness, he economized his time, in the arrangement of such few concerns as required his attention, with the utmost serenity; and anticipated his approaching dissolution with every demonstration of that equanimity for which his whole life had been so uniformly conspicuous." It has been stated that, the infiltrations into the THROAT, LARYNX, AND BRONCHI. 35 sub-mucous, or cellular tissues of the upper extremity of the wind-pipe, which are the sequent of this form of inflammation, and which characterize the disorder, are of a serous, or of a sero-purulent nature. When the disease falls in its full force upon the superior portion of the larynx, infiltration of the lips of the glottis, quickly supervenes, impeding the passage of air into the wind-pipe, and causing a rapid, and fatal termination of the complaint. In such cases, it has been observed by Ryland,* and other pathologists, that serum, only, is effused into the sub-mucous tissue of the aperture of the glottis. But where the progress of the affection has been less rapid, and the fatal termination has been for a few days delayed, the fluid, found within the meshes of the cellular structure, is, under these circumstances, of a sero-purulent nature, whilst the saculi laryngis are often found in these cases, bathed in pus. Ulceration of the mucous membrane, although rarely occurring among the lesions which result from the present form of inflammation, is, nevertheless, sometimes observed, in those instances which have not proved very rapidly fatal. Cruveilhier has recorded several cases of this nature ; in one of which, the whole internal surface of the larynx, was found covered with small, superficial ulcerations.! * Treatise on the diseases and injuries of the Larynx and Trachea, by Fredk. Ryland, p. 34. Diction, de Modecine, &c. Art. Laryngite. 36 PATHOLOGY OF THE Ulcerations, however, both superficial and deepseated, are more likely to occur among those Organic lesions, which are consequent upon sub-acute inflammation of the superior portion of the respira- tory tube. Structural lesions of the upper extremity of the larynx, resulting from the above sub-acute form of inflammation, are more frequent, and much more numerous, than are those which follow an attack, of the acute form of inflammatory action. The earliest, organic changes, that occur in these parts, consequent upon chronic inflammation of the tissues, are seldom observed, as the lesions are not, ordinarily, of a grade sufficiently serious, to effect a fatal termination, at this stage of the disorder. Increased vascularity of the mucous membrane, not generally diffused, but occurring in patches, is one of the earliest morbid changes, induced by this form of inflammation. Sooner, or later, the morbid action continuing, this condition of the membrane is followed by a rough, irregular, and hardened state of the tissue ; and by an increase of thickness, of that portion of it, which lines the entrance of the glottis, and the laryngeal surface of the epiglottis. Infiltrations of the cellular tissue, of serous, purulent, and often of tuberculous matter, with ulcerations of the mucous, and the sub-mucous tissues, are the frequent concomitants, of sub-acute inflammation. The size and shape of these ulcers, 37 THROAT, LARYNX, AND BRONCHI. are greatly varied. In some instances, they are small, rounded, and superficial; in others, they are large, irregular, and deep-seated; penetrating, not unfrequently, the sub-mucous, and cellular tissues, and destroying, sometimes, even, portions of the cartilages themselves. Ossification of the cartilages of the larynx, is another alteration of structure, of frequent occurrence in cases of chronic inflammation, of these parts. Under ordinary circumstances, the cartilages become ossified in an advanced period of life ; but Trousseau and Belloc have demonstrated, that this condition, to which the tissues are naturally liable, in the course of time, is accelerated by the irritation of sub-acute inflammation, so that, ossification of these cartilages, in young persons, is of frequent occurrence, in protracted cases of this form of disease.* Organic lesions consequent on inflammation of tlie bronchial mucous membrane. The pathological changes, which result from inflammation of the lining membrane of the bronchial tubes, and of the pulmonary vesicles, are numerous, and important. Lesions of this membrane are consequent upon two forms of inflammatory action; the acute, and chronic. In the more intense, and extensive variety, the morbid action may not only extend through the bronchial tubes, but descend * Chronic Laryngitis and Diseases of the Voice, by MM. Trousseau and Belloc, p. 21. 38 PATHOLOGY OP THE into the vesicular texture, and involve the whole, lining membrane of both lungs. The first change which presents itself, in this form of inflammatory action, is a tense, and highly inflamed condition of the bronchial, mucous surface. In the earliest stage, this tissue, throughout, is often found tumid, and dryi After a longer, or shorter period, the membrane begins to pour forth a glairy, transparent mucus, of extreme tenacity, which is combined with a frothy serum, and is marked, in some instances, with streaks of blood.* So abundant is this discharge of adhesive, frothy mucus, when the inflammatory action is unchecked, as to prove rapidly fatal, in some cases, by blocking up the bronchi, and their ramifications, with this morbid secretion. Under these circumstances, the lungs do not collapse, upon the admission of the atmosphere to their external surface; being prevented by the obstruction in the bronchial tubes. The surface of the mucous membrane, in such instances, has been found to present a variety of shades, varying from a light crimson, to a deep, dark red, which either presents itself in patches, or is generally diffused over the whole surface, whilst the membrane itself, is considerably thickened, and is so softened, occasionally, that it may be easily abraded. Organic lesions, occurring from a chronic form of inflammatory action, of the bronchial mucous mem- * Watson on Acute Bronchitis, p 478. 39 THROAT, LARYNX, AND BRONCHI. brane, are much more frequent, than those consequent upon the preceding variety. Resulting from this modification of diseased action, the most prominent, morbid changes, are alterations in colour, in the bronchial tissues, a thickening, and in some instances, an ulceration of the membrane, and a dilatation, or an enlargement of the bronchi, and of their ramifications; attended, from an early stage of the disease, with a mucous, and subsequently with an albuminous, a muco-purulent, or a puriform expectoration. As in the preceding, active form of disease, the mucous membrane of the air-passages, is found, in this variety, to present various shades of colour. Generally, however, the tint is of a dark livid, or violet hue ; but in some instances, when the morbid action has been long-continued, and has been attended with an abundant* puriform expectoration, the surface of the membrane is paler than usual—or is even perfectly white, throughout the whole extent of the bronchi and their ramifications. A thickening of the mucous membrane, is a lesion of frequent occurrence, in chronic inflammation of the respiratory tubes. This organic change, may result from a serous infiltration, occurring beneath the mucous tissue, or from congestion, or cedema; or it may result from a permanent hypertrophy of the membrane itself. Ulceration of the bronchial, mucous membrane, consequent upon inflammation of this tissue, although sometimes pre- 40 PATHOLOGY OF THE sent, is of rare occurrence. This lesion, as the sequent of inflammation, is much more frequently observed in the larynx, than in the bronchial tubes. But the most important lesion, resulting from the above form, of inflammatory action, is the dilatation of the air-tubes, and the consequent expansion, of their lining membrane. Pathologists have remarked several varieties, of this change of calibre, in the bronchial tubes. In one variety, several of the sub-divisions of a bronchus, may be found dilated, throughout their whole extent, so as to exceed in size, even the bronchus itself. This enlargement of calibre, may be confined to a few branches; or the ramifications of an entire lobe may be so continuously dilated, as to be, nearly, of an equal diameter throughout; and, when examined, to present the appearance of the fingers of a glove. Formerly, it was supposed that this dilatation of the bronchial branches, depended upon a simple distension of the walls of their lining membrane ; but, modern pathology has demonstrated, that the bronchial parietes become thickened, and their circular fibres, actually, hypertrophied, coetaneously with their dilatation. In another form of bronchial dilatation, the tube is not uniformly distended, but is enlarged at different intervals, so as to present a series of alternate expansions, and contractions; and in a third variety we may have a bronchial tube, dilated at its extremity, into one large globular expansion; whilst 41 THROAT, LARYNX, AND BRONCHI. its walls, instead of being hypertrophied, as in the preceding variety, are found wasted away, thin, and transparent. The physical signs which accompany this last form of bronchial dilatation, are almost exactly those, which indicate the presence of a pulmonary abscess, and with difficulty are they distinguished from those of the latter lesion; especially, when the dilatation is accompanied—as is frequently the case—with a muco-purulent expectoration. It is such cases of bronchial disease, that are frequently mistaken for pulmonary phthisis ; for, not only are the physical, but the rational signs, which accompany the two diseases, strikingly similar; and thus it is, that many of those vaunted cases of consumption, for which cures have been claimed; instead of having been tubercular phthisis, have been, in reality, cases of bronchial dilatation, attended with puriform expectoration. By critical exploration, however, and by a comparison of the prominent indications, of the two affections, these different lesions, in most instances, may be distinguished. The physical signs which accompany dilatation of the bronchial tubes, although manifested by similar sounds, differ in their location from those consequent upon phthisis. In the former, the morbid sounds are, ordinarily, heard in the lower lobes of the lungs; but in the latter, they proceed from their upper portion. CHAPTER IV. Follicular Inflammation of the Throat and Airpassages. The pathological conditions of the lining membranes of the air-passages, which now have been briefly examined, constitute the principal, morbid alterations, to which pathologists, hitherto, have ascribed the known, primary disorders of the respiratory tubes. That there occur, often, in the tissues of these parts, other structural lesions, which, frequently, are productive of important disease —lesions which, hitherto, have not been properly appreciated, by pathologists, I shall now proceed to demonstrate. In the foregoing pages, I have examined, to some extent, the structure, and physiology of the numerous glandulae, or mucous follicles, which are found scattered along the whole extent of the lining membrane of the respiratory tubes. These glandular bodies are, themselves, the primary seat of important, structural changes. That peculiar affection of the throat, which, under the appellations of "Bronchitis," " Chronic Laryngitis," "Clergymen's Sore Throat," etc. etc. has occurred, especially, during the last ten, or fifteen years, so frequently, among public speakers and others, 43 THROAT AND AIR PASSAGES. consists, primarily, and essentially; as I shall he able, I think, to demonstrate; in a diseased condition, of the glandular follicles, of the mucous membrane of the throat, larynx, and trachea. Commencing, generally, in the mucous follicles of the isthmus of the fauces, and of the upper portion of the pharyngeal membrane, the disease may be extended, until the glandulae of the epiglottis, larynx, and trachea, and sometimes those of the oesophageal membrane, are extensively involved in the diseased action. The structural changes, to which the mucous follicles of the throat, and air-passages, are liable, are : Inflammation, which may result in Ulceration, Hypertrophy, Induration, or in a Deposition of tuberculous matter in the follicles themselves ; attended, in most of these conditions, by a greatly increased, and vitiated, mucous secretion. The disease of the mucous glandulae may be primary, and uncomplicated, and be limited, entirely, to the fauces and pharyngo-laryngeal membrane; or, it may be complicated with hypertrophy, and induration of the tonsils, and with elongation of the uvula. It may accompany, or be consecutive to, other affections of the air-passages, and co-exist with Laryngitis, Bronchitis, or with Pulmonary Phthisis. But, before adducing such facts, and illustrations, as will be necessary, to establish any general, synthetical principles, regarding the nature of the 44 FOLLICULAR INFLAMMATION OF THE disease, it may not be uninteresting, to examine, briefly, its general history. History of Follicular Disease of the Throat and Airpassages. This affection of the glandulae of the pharyngolaryngeal membrane, not having been considered, by practical, medical writers, as a distinct disease, its literary history has never been given. Not, indeed, until within the last twelve or fifteen years, has the progress, or the prominency of the disease been such, as to call the attention of practitioners, to its marked and distinctive symptoms. No writer upon medicine, anterior to the above period, has, so far as I have been able to discover, made any allusion to the essential nature, and characteristic features, of the disease. But, whatever may have been the opinion of medical men in general, since the attention of practitioners has been drawn to the complaint, respecting its true pathology, the idea conceived, and entertained, by some, that it is a new disease, cannot, I think, be generally received ; for the same physical causes, which may now tend to induce the disease, have always been in operation. That the complaint may have existed for an indefinite period of time, and yet have escaped the observation of medical writers, so far as not to have been considered a distinct disease, will not appear so surprising, when we recollect that, that formidable, and often, 45 THROAT AND AIR PASSAGES. fatal malady, croup, was scarcely recognized, as a distinct disease, until the middle of the last century; that, laryngitis was confounded with the other forms of cynanche, and, in fact, was not identified, and separated from them, till after the commencement of the present century; and that, to Dr. Badham, who, in 1808, wrote on inflammation of the mucous membrane of the bronchi, is due the merit, of having called the attention of the profession, expressly, to this interesting form of disease; and, of giving to it, the appropriate name of bronchitis. With regard, therefore, to the past existence, of follicular inflammation of the air-passages, it may be said, as M. Rayer-Collard has remarked of croup: " Les causes qui concourent b. la production de la maladie ont existe de tout terns, et il serait bien extraordinaire qu'elles fussent restees inactives, et pour ainsi dire, silencieuses pendent une langue suite de siecles, pour se reveiller avec une energie aussi feroce que subite."* The first case, of well-marked, follicular disease, which came under my notice, was that of a clergyman ; and occurred in the early part of 1832. During the preceding year, however, the attention of practitioners, in different parts of New England, had been called to the fact, that, many clergymen, in different sections of the country, were seriously affected ; and, in some instances, were wholly incapacitated for public speaking, by " a distemper * Diet, des Sci. Med. Art. Croup. 46 FOLLICULAR INFLAMMATION OF THE of the throat," which was characterized by symptoms of a peculiar nature, and of unusual severity. By inquiries, directed to this point, I have not been able to ascertain that, any strongly marked cases, of this form of disease, had been observed prior to 1830. During this year, it will be remembered, that an epidemic influenza prevailed in this country, which, not only extended over all the United States, but spread throughout Europe; and, so far as is known, over the whole civilized world. Whether this epidemic, or the causes upon which it depended, had any agency in increasing the frequency of the disease, under consideration, or, in changing its character into one of a more malignant nature, it is impossible now to determine. Certain it is, however, that while the influenza of this period, was the precursor of epidemic cholera, in some parts of the World, in many portions of the United States, it was early followed, by the above form of follicular disease. That this affection, in its more aggravated form, is of recent origin; or, that it was formerly confounded with other diseases of the air-passages, we have the concurrent testimony of various writers, who have alluded to the prevalence of the complaint. Prof. C. A. Lee, of New York* who published in 1836, "An inquiry into some of the causes, of disease among the Clergy " —remarked, under the head of " Chronic Laryngitis," upon the alarming degree of prevalence which this disease 47 THROAT AND AIR PASSAGES. had attained, among that class of persons; and adds: " It is but a few years since this disease was unknown, almost by name • or if now and then a case did occur, it was generally of so mild a character, as to yield to very simple treatment."* For some time, after the appearance of the disease in this aggravated form, it seemed to be confined in its attacks, to public speakers, and of these, the clergy were the most frequent sufferers. Hence, the affection was early called, the " Clergyman's Sore Throat." It was soon found, however, that individuals of every profession, of all occupations, and of different ages and sexes, were liable to the disease. Of nearly four hundred cases, that have fallen under my observation, only about seventy-eight; or one in five, of this number, were, in any way, public speakers. When, however, the affection does occur, in those persons who are in the habit of exercising the vocal organs, by public speaking, singing, teaching, &c, it is always, for obvious reasons, attended with symptoms of a more aggravated nature, than when it appears under ordinary circumstances. The various appellations, both in popular, and medical technology, which have been given to this disorder, have served to convey most erroneous impressions, to the professional, and the non-professional public, with regard to the true seat, and nature, of the affection. * Literary and Theological Rev. Sept. 1S36. 48 FOLLICULAR INFLAMMATION OF THE Dr. Mason Good, in his Nosology, has remarked, that "We are overloaded with terms to express the same idea, and of these terms, a great number are so loose and indefinite, as to convey no precise idea, whatsoever; whilst others, on the contrary, cannot fail to excite an erroneous one." Such, precisely, has been the result of applying to the follicular disease, of the pharyngo-laryngeal membrane, the terms " Bronchitis," and " Chronic Laryngitis"—one, or the other of which appellations, have been, universally employed, by the profession, to denominate the above affection : designations, which have served to convey no correct, or definite idea, of the nature, or seat of the malady ; but, on the contrary, to " excite an erroneous one." This, will readily be admitted, when we remember the difference in the location of the several diseases, and the different lesions, which constitute their characteristic features. Bronchitis, as has been demonstrated, consists, essentially, of an inflammation of the lining membrane of the bronchial tubes, and of the pulmonary vesicles ; whilst the disease, of which we are treating, is, primarily, located in the fauces, and superior portion of the respiratory apparatus; and has, for its peculiar essence, a diseased condition of the glandular follicles of the mucous membrane, which lines these parts. Chronic Laryngitis, again, is a term which is ap- 49 THROAT AND AIR PASSAGES. plied to a sub-acute form of inflammatory action, affecting, principally, the mucous, and sub-mucous, cellular tissues, of the larynx, and epiglottis; and, which is followed, by an increase of thickness, and, often, by an erosion, or ulceration, of that portion, especially, of the lining membrane, which occupies the entrance of the glottis, and the laryngeal surface of the epiglottis. But, in this affection, the mucous follicles, are the seat of the disease; and these may be inflamed, and even ulcerated, whilst the intervening membrane is, in some instances, not only free from inflammation, but, actually paler than natural. These appellations, therefore, being "loose and indefinite," should, in their application to this form of disease, be discarded from medical technology. We may have recourse to the dead languages, for a name ; but the term follicular disease of the pharyngo-laryngeal membrane, is one, sufficiently scientific, and accurate, for all useful purposes. As this disease, however, in its advanced stage, seems to be constantly attended, with a secretion; either within the mucous follicles, of a peculiar, concrete substance, resembling tubercle ; or with an infiltration of this tuberculous matter, in the sub-mucous, cellular tissues, it may, with propriety, be denominated tubercular sore throat. 4 50 FOLLICULAR INFLAMMATION OF THE Description of Follicular disease of the Air-passages. This peculiar malady consists essentially, in its formative stage, of an inflammation of the mucous glandulae; which is sub-acute in its character ; and, which may result, as above stated, in hypertrophy, ulceration, or induration of these glandulae, or in a deposition of tuberculous matter into the substance of the follicles, themselves. In its simple, and uncomplicated form, the affection commences, invariably, in the mucous follicles of the fauces, and pharynx; and is extended thence, by continuity, to the glandulae of the epiglottis, larynx, and trachea; and, in some instances, to those of the oesophageal membrane. So insidious, frequently, is the onset of this disease ; and so gradual, its progress, that, in some instances, it will be found to have continued many months; and to have made considerable advance, before the presence of any prominent, local symptom, shall have called the attention of the individual, to the existence of the affection. He then, perhaps, becomes aware of an uneasy sensation, in the upper part of the throat; accompanied, by a frequent inclination to swallow; as if some obstacle, in the passage, might be removed, by the act of deglutition; or, more frequently, there is an attempt made, and often repeated, to clear the throat, by a kind of screatus, or hawking; and, to relieve it, of a sensation of " something sticking at the top 51 THROAT AND AIR PASSAGES. of the wind-pipe." About the same time, there is observed, an alteration in the quality, or timbre of the voice; there is experienced, in the vocal organs, a loss of power, and a hoarseness is present, which at first, is hardly perceived, in the morning, or after a full meal; but, which is increased towards evening, and after speaking, or reading, longer, or louder, than usual. The mucous secretion, which in a healthy condition of the glands, is bland and transparent, becomes viscid, opaque, and adherent; and is increased in quantity. Frequently, there is a slight soreness, felt about the region of the larynx, but seldom is any cough present, at this stage of the disease. In this condition, the symptoms may remain, for a long period; sometimes, for years; nearly disappearing, at times, and, then, again, being greatly aggravated, by vicissitudes of temperature, increased exercise of the vocal organs, and by various, other morbific causes. If we inspect the throat, and fauces, during the progress of the above symptoms, we shall find the epithelium ; which in the healthy state of the mucous tissue, covers its surface, more or less destroyed; its absence being manifested, by the slightly raw, or granulated appearance, which the membrane presents; the mucous follicles will be found hypertrophied, and will appear distinctly visible; especially, those, studding the upper, and posterior part of the pharyngeal membrane. (See plate I.) If the disease has been long-continued, 52 FOLLICULAR INFLAMMATION OF THE a portion of the follicles may he found indurated, or, in some instances, filled with a yellowish substance, having a resemblance to, and presenting the physical characters of, tuberculous matter; whilst striae of opaque, adhesive mucus; or of a muco-purulent secretion, may be seen, hanging from the veil of the palate, or coating the posterior wall of the pharynx. As the disease advances, and the follicles, situated at the root of the epiglottis, and in front of the arytenoid cartilage • and the still more numerous glandulae, of the laryngeal, mucous membrane, become involved in the morbid action, all the above symptoms appear greatly aggravated; the hoarseness is much increased, and is constant; speaking, or reading aloud, is attended with great difficulty ; and when continued, for any period, is followed by pain, and increased soreness, in the region of the larynx; and by a sensation, of extreme languor, not only about the vocal organs, but throughout the whole system. In some cases, where the disease affects the glands, situated in the ventricles of the larynx, and near the vocal chords, the voice becomes completely extinguished; or, if by great effort, the patient essays to speak aloud, the vocal resonance is uneven, harsh, and discordant. In such cases, notwithstanding the situation, and extent of the disease, there is seldom present, any decided, or troublesome cough; and, in this respect, follicular disease differs, essentially, from THROAT AND AIR PASSAGES. 53 all other, equally grave, laryngeal affections.— Cases have fallen under my observation, repeatedly, where the affection had advanced, until the symptoms present, indicated extensive disease of the follicles of the larynx, and of the membrane covering the vocal ligaments;—until the ulceration of these glands, situated at the root of the epiglottis, could be felt, upon the laryngeal surface, and yet the patient would remain free, or nearly free, from a cough, notwithstanding an abundant, acrid secretion, poured out by the diseased follicles, would occasion an incessant hawking, to clear the upper part of the wind-pipe, and the pharynx, of this tenacious mucus. As illustrative of many points in the above description of uncomplicated, follicular disease, I Iiave selected the following cases: CASE I. In this case, I was more than ordinarily interested ; for, besides being that of a highly respected, and personal friend, it was the case, of one, whose worth is known, and whose fervid eloquence, in the pulpit, has been felt, and acknowledged, by thousands in America. A part of the history of his case, enclosed in a communication, which I received from him, on the subject of his disease, I shall give in his own words: " My attack came on in the summer of 1835. 54 POLLICULAR INFLAMMATION OF THE For several months, previous to the attack, my labours had been quite arduous. The disease came on, at first, in the form of hoarseness —the throat being slightly inflamed, and the uvula a little elongated. " My general health, at this time, was very good, and had been, for two or three years. Soon after the attack, I left the city, and spent six weeks, in travelling; but returned home, without any improvement. Indeed, the hoarseness increased, in a few weeks, so that I could only converse for a few minutes, at a time, without being nearly shut up to a whisper; and the symptoms of the disease, already noticed, became more confirmed. The throat, at this time, was covered with small protuberances, or tubercles, of a deep red; the blood vessels in the membrane of the throat, were filled to repletion with blood; and a slimy fluid was constantly collecting, about the back parts of the mouth. I had no cough, however, at any time; and, scarcely ever, any severe pain. Finding that I must give up to the disease, I suspended all my official duties in September, and became a prisoner at home, under the directions of my physicians, for three or four months. During this period, I lived quite abstemiously —I was leeched, once or twice, and blistered for several weeks, continuously, on the back of the neck, and, subsequently, on the throat; I was, at the same time, using a variety of gargles. The effect of all this, was merely to keep 55 THROAT AND AIR PASSAGES. the disease in check —not to remove, or even reduce it. In December, following, this gentleman was put under more appropriate treatment. Efficient, topical remedies, were applied, directly, to the " diseased spots," which, with other means, were effectual in arresting the complaint. In February, he began to preach once a week, and continued to do this, for several months ; then, twice a week, and thus, gradually, came to resume his entire official duties. In February, 1838, he thus writes: " I have now been discharging all my public duties, without inconvenience, for a year. I consider my throat to be well, although it is left in a weaker condition than it was formerly, so that a cold always affects it, more readily, than any other part of my system." CASE II. The subjoined case, is also that of a clergyman, eminent, and extensively known, as an eloquent preacher, and an accomplished writer; and is given in his own words. I place the higher value upon these cases, inasmuch, as they are those of men of intelligence and observation ; and because, moreover, in communicating to me, a history of their malady, they have described the principal, characteristic symptoms, without possessing any knowledge, whatever, of my views, as to its peculiar nature. 56 FOLLICULAR INFLAMMATION OF THE In a letter received from the Reverend gentleman, to whom allusion is made, above, he thus writes: —" About five years ago I perceived that public speaking was always followed by soreness in the throat, which I did not much regard, as the lapse of a day uniformly relieved it. Three years since, the efforts of public speaking, became more painful, and from that time, until the present, I have been sensible of permanent disease of the throat. I did not desist from preaching, until about tw T o years ago, when I was compelled, by the urgency of the symptoms. " My voice failed; the wind-pipe seemed to close, and every word was uttered, with a strain upon the vocal organs, which was followed by general prostration of the system. " My present condition is as follows :—constant uneasiness, in the region of the larynx, frequently, a sore sensation about the external parts, more sensible upon pressure ; some inflammation internally, but not very low down; a constant inclination to swallow, or to clear the throat, as if there was some obstruction ; and all these symptoms are aggravated by long conversation, or by taking cold. "I have no cough, andean detect no pulmonary weakness, as yet. Since I have abstained from preaching, I have increased very considerably in weight; my appetite is good, and my general health is unimpaired. "Within the last six months, I have at several THROAT AND AIR PASSAGES. 57 times, for a few days together, felt so much better, as to entertain hopes of a release from my disease ; but, upon trial of my voice, in a very moderate way, I discovered that the soreness would return. "While I remain quiet,I am comparatively easy in my feelings; and I know not that I am worse now than I was two years ago. "I am much occupied in my editorial duties,and if it was not for this, I am persuaded my spirits would be much depressed. I have seen a number of cases, much more distressing than my own, promoted, perhaps, by continuing to preach when really unfitted by disease ; and these I have remarked, are accompanied by mental depression, arising as I supposed, from the stern necessity of abandoning a beloved profession, and, perhaps, from the pecuniary embarrassment, into which a family might be thrown." This last allusion, to the connection which exists between the mind and the disease, relates to a characteristic of this affection, to which I shall again refer. In the above cases; so far as the description goes, the disease in its primary and simple form, is correctly portrayed; and I have now lying before me, ten or fifteen letters, from various individuals —most of them clergymen, or other public speakers, residing in different parts of the United States ; describing the disease, as it has occurred in themselves ; in all of which descriptions, the leading, 4* 58 FOLLICULAR INFLAMMATION OF THE pathognomonic symptoms of the malady, have a most marked, and apparent relationship. But, I shall pass by these cases, and present others, which have fallen under my immediate observation. CASE III. In June, 1841, Rev. Mr. S. of this city, aged 34 years, came under my care, for an affection of the throat, which, for the four years preceding this period, had incapacited him for public speaking. The disease came on much in the same way, as its access is described to have been, in the preceding cases. Whilst engaged in his official, public duties, he had observed for some time, an increasing irritation, and soreness, about the fauces and throat, accompanied by a hoarseness, and a frequent inclination to clear the voice when speaking. These symptoms, which, ordinarily, passed off, after a few days of rest, were disregarded until his voice failed, and he suddenly broke down, under his pastoral labours. Finding himself entirely unable to discharge his professional duties; although still possessing a good degree of general health—and after resorting to various measures, to restore, to a sound condition his vocal organs, all of which proved ineffectual, he resigned his ministerial charge, and sailed foi Europe : cherishing the hope—in which his numerous friends ardently participated—that the THROAT AND AIR PASSAGES. 59 sanative influence of a sea-voyage, and a foreign tour, would prove efficient, in removing his most troublesome, and perplexing malady. After an absence of many months, he returned to his home, invigorated by this long relaxation, from his duties, and although there still remained some sensibility of the larynx, and a slight huskiness of the voice, yet, he felt, that with due caution, he might, with safety, gradually resume his public duties. A single attempt, however, to speak in public, soon after his return, entirely dissipated this hope. His voice, again, gave way; hoarseness, with every other morbid symptom, which previously attended his disease, returned, in a still more aggravated form than at first. In this condition his case remained:—marked by an occasional remission of the symptoms, but attended by no permanent improvement,—until the period above mentioned, when, as I have stated, he came under my care. His condition at this time, was as follows: —His general health, although impaired by the longcontinued, local disease, was still very good; yet his countenance exhibited a sallow hue, and was marked by that care-worn, and anxious expression, which I have often observed in those cases of tubercular sore throat, which have been protracted, through a long period of time. Constant hoarseness was present, and his voice, when uttered aloud, was rough and hollow. Speaking was 60 FOLLICULAR INFLAMMATION OF THE accomplished with difficulty, and if continued, as in ordinary conversation, for a short time, only, was followed by soreness and increased hoarseness, and, sometimes, for a short period, by complete aphonia. His throat, on being inspected, presented an enlarged, and cavernous appearance; as if the pillars of the fauces, and the pharyngeal muscles, had become atrophied, or had been wasted away, by disease, in a manner greatly to enlarge the posterior fauces. The mucous membrane, lining these parts, was covered by diseased follicles, some of them greatly enlarged, and indurated, others slightly hypertrophied, and filled with a semi-fluid substance, resembling tuberculous matter. On pressing down the tongue, the epiglottis could be seen, standing above its base, erect, and ; its edges red, and slightly ulcerated, whilst a vitiated, mucous secretion was being constantly poured out, from the diseased glands, occasioning an incessant hawking, to relieve the throat of this cause of irritation. Pressure upon the thyroid cartilage, increased the pain and soreness, which were constantly felt in the larynx. This last symptom, together with the permanent hoarseness, and the partial extinction of voice, w T as plainly indicative, of the mucous follicles of the ventricles, of the larynx, and of those around the chordae vocales, being involved in the disease. Yet, there w T as no cough present, nor could a rigid examination of the chest, detect any morbid altera- 61 THROAT AND AIR PASSAGES. tions, in the pulmonary organs. All mental excitement affected him injuriously; it had a tendency, invariably, to aggravate the local difficulty —although no effort, whatever, might be made to exercise the vocal organs. The tongue was coated, his pulse, seventy-six in the minute, and quite feeble. The Reverend gentleman was first placed upon an alterative plan of treatment. Pills, composed of two grains of extract of conium and the eighth of a grain of hydrarg. chlorid. corrosiv. were administere —one morning and night; and the iodide of potassium was exhibited twice a day, in three grain doses; entire rest of the vocal organs was enjoined, and he was directed, moreover, to have a small amount of the following ointment applied, morning and night, over the cervical portion of the vertebral column. ft Ant. et Potass. Tart. 3ij. Camphori pulv. 3ss. M. Cerate Simp. fj. June 20th.—The antimonial ointment, having produced a copious pustular eruption, on the back of the neck, its use was continued, only on each alternate day; sufficient to maintain that degree of counter irritation, which had already been established. July 9th. —The secretion, from the mucous follicles, of the fauces, and pharyngeal membrane, is less adhesive, but has increased in quan- 62 FOLLICULAR INFLAMMATION OF THE tity, since the administration of the muriate of mercury; but the glands themselves, present the same enlarged, and diseased appearance as at first; while the hoarseness, and the pain and soreness, in the laryngeal region, are unabated. The isthmus of the fauces and the pharynx were now freely cauterised, by applying directly to the parts, a sponge, —attached to the end of a piece of bent whalebone, —which had been saturated in a solution of the nitrate of silver, of the strength of forty grains to the ounce of water. Under this application, repeated every alternate day, the follicles assumed a more healthy appearance, and became less apparent; but the hoarseness, and the soreness, within the larynx, continued. On the 14th, I determined to cauterise the larynx, and having pressed down the tongue with a spatula, I passed the sponge; dipped into the solution of the nitrate of silver, of the above strength, over the top of the epiglottis; which could be seen standing, erect, at the base of the tongue ; and plunged it between the lips of the glottis, into the larynx, and down to the chordae vocales. A momentary spasm of the glottis ensued, by which the fluid was pressed from the sponge, in sufficient quantity, to bathe the whole surface of the laryngeal membrane. Its application w T as immediately followed, by a fit of coughing, and a free expectoration of viscid mucus. The irritation, however, soon subsided, and was succeeded, the next day, by a sensation of relief 63 THROAT AND AIR PASSAGES. about the larynx which the patient had not experienced for years. On the 17th, the cauterization of the larynx was repeated; and again on the 20th. By this time, the improvement of the patient was very manifest; the huskiness of the voice, and the sensibility of the larynx, had nearly disappeared, and he was enabled to speak, and to read aloud, for a considerable length of time, without experiencing, subsequently, any of that soreness, within the larynx, or of that distressing sensation of fatigue, which, for a long period, had constantly followed any attempt, to exercise the vocal organs. The topical medication was continued, every few days, until the eighth of August, when the Reverend gentleman ventured to resume his official duties; and, on this day, preached in the morning, and read service in the afternoon. It w T as his first attempt, with one exception, to speak in public, for the last four years; and this effort w 7 as followed by no increased sensibility of the larynx, nor by any unusual fatigue; and he has since enjoyed a good degree of general health, and an ordinary immunity from laryngeal disease. The above case did not come under my care until the disease had passed through its earliest stages; consequently, the first manifestations of the malady were not observed. In the following 64 FOLLICULAR INFLAMMATION OF THE case, I had an opportunity of observing the disease, from its commencement, and of watching the progress and development of the symptoms, through its formative stage. CASE IV. K. H. E., Esq., a lawyer of eminence, in this city, aged 38 years, suffered from an attack of acute bronchitis, in April, 1840. Under the most active treatment, he recovered from the disease, and resumed his professional duties. In 1841—2, he was a member of the Common Council, and, in addition to the duties of a full practice, which necessarily involved much public speaking, he was frequently engaged in the exciting debates of the honourable body of which he was a member. Early in 1842, he began to be sensible of a slight huskiness of the voice, and of an uneasy sensation in the throat, after public speaking. These symptoms would all subside, after a little rest, but only to be renewed, at each subsequent, public exercise of the vocal organs. It was observed, that this hoarseness gradually increased, and that the irritation, about the throat, impelled the individual to make frequently repeated efforts, at hawking, as if to remove some obstruction from the larynx. Being in attendance upon his family, during the progress of these symptoms, I had frequent opportunities to inspect his throat, and I observed that 65 THROAT AND AIR PASSAGES. the follicular glands, of the isthmus of the fauces, and of the superior portion of the pharyngeal membrane, were slightly hypertrophied, and were pouring out an altered, and increased secretion. Believing on his part, that these morbid symptoms would pass away, no special attention, to his case, was required, or given, until the latter part of July, 1842. At this time, a permanent hoarseness was present; the voice was rough, and uneven, with a constant irritation, and a sensation of soreness in the laryngeal cavity;—symptoms that were all greatly increased, by every effort made, and continued, to speak, or read aloud. The diseased follicles now presented a very different appearance from that which they had exhibited, a few weeks before. The posterior fauces, and pharyngeal membrane, were studded with elevated tubercles, with inflamed bases, or granulations of different sizes, like pustular inflammatio —bearing a marked resemblance to the papulae of varioloid. The most pendant portion of the uvula, which was greatly elongated, was also covered by similar diseased follicles. Compelled now, by the severity of the disease, to relinquish, in a great measure, his professional duties, he applied to me for medical aid. August 4th. —Removed the diseased portion of the uvula, and after waiting a few days, to allow the truncated part to heal, I applied the nitrate of 66 FOLLICULAR INFLAMMATION OF THE silver, in substance, to each enlarged follicle, that could be seen, and ordered pills, composed of the tenth of a grain of bichloride of mercury, with two grains of the extract of conium; one to be taken night and morning. 24th. —The affected glands are much less in size; the huskiness of the voice, and the sensibility of the larynx yet remain. Passed the index finger of my left hand, over the back of the tongue and laryngeal face of the epiglottis. The base of this cartilage, and the lips of the glottis, were slightly cedematous. Cauterized the fauces and pharynx, with a solution of the nitrate of silver, of the strength of forty grains, to the ounce of water; discontinued the pills, and ordered, one teaspoonful, of the following solution, to be taken in sugared water, three times a day:— ft. Potassii. Iodid. 3ij. Aq. distil, M. The patient complains of a dull pain in the back of the neck; counter irritation, by means of antimonial ointment, w 7 as employed, along the cervical portion of the vertebral column. September 6th.—The enlarged follicles have nearly disappeared ; the mucous membrane, of the fauces and pharynx, appears smooth, and of a healthy colour; but the hoarseness, and sensibility in the laryngeal cavity, are, in no degree, relieved. The least excitement, he remarks, affects him, injuriously, there; and if he attempts to read to his 67 THROAT AND AIR PASSAGES. family, or to converse, in an ordinary tone of voice, with a friend, all these symptoms are greatly aggravated. Confident from these symtoms, that the follicles, about the vocal ligaments, were diseased, I determined to cauterize the interior of the larynx. This was effected by passing the sponge, wet with the solution, over the laryngeal face of the epiglottis, and pressing it between the lips of the glottis into the laryngeal cavity. By the spasmodic action that succeeded, the fluid was expressed from the sponge, and this latter being quickly withdrawn, its removal was followed by a convulsive cough, and a free expectoration of adhesive mucus. The unpleasant irritation, thus produced, in the larynx, subsided, in a few minutes, and, as is very generally the case, in such instances, was followed, in the course of the subsequent twenty-four hours, by marked relief. As the effects of the cauterization, however, did not entirely pass off, for several days, the employment of topical medication was not renewed, until the thirtieth, when the pharynx, and the interior of the larynx, were, again freely cauterized. This operation was repeated • at first every third, or fourth day, for some time; then, every week, until the first of November, when the hoarseness, and the sensibility about the vocal ligaments, had disappeared, and the patient was enabled to resume, and again to discharge, his professional 68 FOLLICULAR INFLAMMATION OF THE duties, without any other inconvenience, than a debility of the vocal organs, which, however, under the use of local and general tonics, soon passed away. In all cases of sub-acute inflammation of the mucous follicles, the tendency of the morbid action, is to terminate, ultimately, in ulceration; although, as we have seen, these glands may remain, in a state of hypertrophy, or induration, in some instances, for years, before this form of structural lesion shall occur. Ulcerations of the follicles of the air-tubes, differ, essentially, in their appearances, from those ulcerations of the mucous membrane, which are the frequent consequence, of inflammation of that tissue. In the latter, when the result of chronic inflammation, the ulcer commences by destroying the epithelium, and then, extending its circumference, and depth, penetrates the mucous tissue, and appears in the form of a superficial ulceration, with irregular edges, and a rough, sloughy base. Ulcerations of the glandulae, are preceded by chronic inflammation, and hypertrophy of these bodies, and when thus engorged, the follicles appear like small points, beneath the mucous membrane. If the irritation continues, infiltration of puriform, or tubercular matter, takes place within the cavities of the glands, by which the parietes 69 THROAT AND AIR PASSAGES. are distended, and finally, are ruptured ; and they are then seen, in the form of small, reddish elevations, with irregular, hardened edges, and having central ulcerations, which often extend into the sub-mucous, cellular tissue. Follicular Disease, terminating in Ulceration of the Mucous Glandular. CASE V. In January, 1840, G. B., aged 37, a merchant of this city, came under my care, when labouring under a most severe form, of pharyngo-laryngeal ulceration, consequent upon long-continued, chronic inflammation of the follicles of these parts. The subject of this case was a gentleman of the highest respectability, and who had never suffered from syphilitic disease. When called upon to prescribe for him, the affection had existed over four years. Coming on, in the insidious manner that has been described, the disease had made considerable progress, before his case was deemed of sufficient importance, to require medical treatment. At length, he placed himself in the hands of some Homoeopathic physicians of this city, under whose treatment he remained for two or three years. In the mean time, the disease, of course, continued to advance, until extensive ulceration of the pharyngo-laryngeal follicles, had taken place. Still placing his confi- 70 FOLLICULAR INFLAMMATION OF THE dence in this " fabric of a vision," —Homoeopathy, he visited Paris, and put himself under the care of the celebrated Hahnemann, who treated his case, for three or four months; —but with as little success, as had attended the prescriptions of his satellites, in New York. Discouraged at last, or losing confidence in the plan of treatment, proposed by Hahnemann, he came back to New York, and, soon after his return, placed himself under my care. His general health, at this time, had become much impaired, doubtless, through the long-continued influence of the local disease. The whole throat; which presented an atrophied, and cavernous appearance, was studded with diseased follicles, some of which were greatly enlarged, and vascular, or were filled with tuberculous matter; whilst others were broken down, and destroyed by ulcerations. The uvula was elongated, and the epiglottis, which could be seen above the back of the tongue, was erect and cedematous, and its circumference was serrated with ulcerations. On examining the epiglottis, with the finger, an extensive and deep ulcer could be felt at its base, on the laryngeal surface of this cartilage; whilst the pain in the larynx,—the soreness experienced on pressure over the thyroid cartilage, together with the constant hoarseness, and irritation, in the laryngeal cavity, showed, conclusively, that the ulcerations had extended to the vocal ligaments. The 71 THROAT AND AIR PASSAGES. patient complained of a dull pain, and a sensation of great weakness, under the sternum; there were present, also, a cough, emaciation, erratic pains, in the chest, and other constitutional symptoms, that indicated the presence of tubercles in the lungs; but, notwithstanding many of the rational symptoms of phthisis were present, a careful examination of the chest was made, without detecting any structural lesions in the pulmonary organs. Bronchial irritation, however, existed to a considerable extent. The patient was directed to take, morning and night, one of the following pills: — Rj. Extract. Conii. 3i. Hydrarg. Chlorid. Corros. gr. iv. Opii. pulv. gr. iii. Fiat Massa, in pilulas, No. xxx. dividenda. Full doses of the iodide of potassium, along with the extract of sarsaparilla, were exhibited, and counter irritation established, over the course of the cervical vertebra. Under the use of these remedies, the secretions about the fauces, and larynx, soon became less viscid, but were increased in quantity. The uvula continuing to be relaxed, was now truncated, and the fauces, and the pharyngeal membrane, were freely cauterized, with a concentrated solution of the crystals of nitrate of silver. This form of topical medication was repeated— at first, every other day, then twice a week, and, 72 FOLLLICULAR INFLAMMATION OF THE finally, once a week, during the period of six weeks, or two months, when it was found that the ulcers, about the throat, had healed ; the enlarged follicles, had disappeared, and the whole interior, of the pharyngeal cavity; as far down as could be seen, was covered with a healthy looking membrane : Yet, notwithstanding, the soreness within the larynx, the cough, and the huskiness of the voice, remained; and, on examining the epiglottis, a deep, and irregular ulcer, occupying the location of the epiglottic gland, could still be felt, at the root of this cartilage, on its laryngeal surface. Confident that the same topical medication, that had been successful in removing the disease, above the epiglottis, would be equally efficacious, if it could be applied to the ulcers below this cartilage, and around the vocal ligaments, I determined to enter the larynx, and, if possible, arrest the disease, in this cavity. By pressing down the tongue of the patient, the lingual face of the epiglottis could be seen above its base; retaining the parts in this position, a sponge which was attached to the bent end of a whalebone, and saturated with the solution, was passed over the top, and back of the epiglottis, and being brought forward, was pressed down, directly, into the laryngeal cavity. The operation excited a momentary spasm of the glottis, by which the fluid was discharged from the sponge, and brought into immediate contact with the diseased surface. This application was followed by the expectoration 73 THROAT AND AIR PASSAGES. of a great quantity of viscid, muco-purulent matter, during the day, and by subsequent, marked relief, to the affected organ. At the end of a few days, the operation was repeated; and on this occasion, a solution of the crystals of nitrate of silver, of the strength of forty grains of the salt, to an ounce of water, was employed. Continuing this application, in the same manner, in this case, and for about the same length of time, in which it had been employed, in treating the diseased follicles of the pharynx; I had the satisfaction, of witnessing the disappearance of the hoarseness; of all laryngeal, and pectoral irritation, and of seeing my patient restored to robust health. Ulceration of the mucous glandulse, it has been stated, is one of the most frequent results of chronic inflammation of these bodies. When this morbid lesion occurs in the follicles of the laryngeal membrane, it exerts a decided influence, upon the vocal sounds. From the observations of Louis, Andral,* and other modern pathologists, we learn that the symptoms developed, and the effects produced, upon the voice, by ulceration of the larynx, differ, materially, according to the seat, and extent of the *Clinique Medicale, tome II. p. 208. 5 74 FOLLICULAR INFLAMMATION OF THE disease. This was found to be the case, in the twenty-two instances, recorded by M. Louis, of laryngeal ulceration, accompanying phthisis. In fourteen of these patients, in whom small, superficial ulcerations were found, seated, either within the ventricles between the arytenoid cartilages, or at the point of juncture of the chorda? vocales, the symptoms noticed, were hoarseness, more or less marked alteration, in the character of the voice, with heat and pricking pains, in the laryngeal region;—symptoms, which, ultimately, were followed, by the voice becoming more or less, completely extinct. In eight cases, of deep ulceration of the larynx, which destroyed, to a greater or lesser extent, the chordae vocales, the same symptoms, developed w ith much more intensity, existed; and were accompanied, moreover, with a cough, which had a peculiar, cracked, or whistling character. Dr. Ryland, in his Treatise on the Diseases of the Larynx, and Trachea, remarks: that when the mucous membrane, covering one of the vocal chords, only, is affected, the voice is rendered raucous and hoarse; if the investing membrane of both chords ulcerates, the voice loses its power, and becomes little more than a rough whisper. If, not merely the mucous membrane, but the thyroarytenoid ligaments are injured, or destroyed, the state of aphonia is complete; no proper, vocal sound is distinguishable; and a whisper, which is THROAT AND AIR PASSAGES. 75 simply an articulation of the ordinary respiration, alone remains.* Under the head of " Chronic Laryngitis " in the above Treatise, the author has given several cases of long-continued, ulceration of the larynx, attended with hoarseness, laryngeal cough, and complete aphonia, and which ultimately terminated in death. I shall here take the liberty of subjoining one of these observations, abridged from the original. CASE VI. Ann Baker, aged 28, applied at the Infirmary, February 16, 1836, for medical relief, on account of soreness of the throat generally, and particularly of the laryngeal region, cough, difficulty of swallowing, and general fever. Pressure over the thyroid cartilage and friction of the larynx against the spine, increased the soreness of the throat. The remedies employed, afforded her no particular relief. On the 24th of March, she was much w T orse; the cough was frequent, and attended by mucous expectoration; deglutition was most painful, and the attempt to swallow liquids, produced feelings of imminent suffocation, and an instant rejection of the liquid through the nostrils ; the voice was reduced to a whisper; respiration was hurried, * Treatise on the Diseases of the Larynx, and Trachea. By Fredk Kyland, p. 91. 76 FOLLICULAR INFLAMMATION OF THE and there was, also, hectic, and emaciation : death ensued on the evening of the 25th, in the midst of an unusually severe fit of dyspnoea. Dissection. —Permission could only be obtained to examine the throat; but, as there were no particular indications of thoracic disease, this restriction was of little consequence. There were two or three, broad, superficial ulcers, at the lower part of the pharynx, and on the back of the tongue, close to the root of the epiglottis. The mucous membrane, of both the anterior and posterior surfaces of the epiglottis, was covered with ulcers, intermixed, with red, projecting granulations, or caruncles, and the upper edge of this organ was festooned, and, as it were, eaten away, to the extent of about a third of an inch. The lips of the glottis, were greatly thickened, so as, internally, to diminish the area of the larynx, and also to project, externally, much more than usual. The mucous membrane, covering these thickened parts, and that lining the cavity of the glottis, the ventricles of the larynx, and that part of the organ, immediately below the vocal chords, were superficially ulcerated throughout. M. Cruveilhier has also recorded some cases of disease, denominated by him, laryngeal phthisis, w T hich demonstrate the effects produced upon the character of the voice, by ulceration of the laryngeal cavity. The following brief observation I shall record *. 77 THROAT AND AIR PASSAGES. CASE VII.* A man, aged 40, entered the Maison Royale de Sante, with all the symptoms of laryngeal phthisis: emaciation without fever, voice extinct, frequent cough, and purulent expectoration. The examination of the fauces showed an erosion of the edges of the epiglottis, and ulceration of its anterior face. This man had suffered from laryngeal cough and hoarseness, for eight or nine months, but had continued to work, till about a fortnight before his admission. Deglutition was very difficult, on which account he abstained as much as possible from food; he was free from fever, and the lungs appeared to be sound. He died at a time when the event was least expected. Sectio Cadaveris. —The circumference of the epiglottis was eroded and, as it were, festooned by the effect of ulceration. The superior orifice of the larynx, and the mucous membrane covering its posterior face, were thickened, ulcerated, and covered with caruncles I have introduced these cases, for the purpose of showing some of the symptoms which indicate the presence of ulceration, in the laryngeal cavity; and, also, of exhibiting the changes which these alterations of structure will effect upon the voice, particularly, when occurring in the vicinity of the vocal ligaments. * Cruveilhier, Anat. Path, du corps Humain, 5 livraison pi. 2. 78 FOLLICULAR INFLAMMATION OF THE The following cases, in which I had every possible evidence which symptoms can indicate, of ulceration of the follicles of the laryngeal membrane, and of those even, around the vocal chords, will illustrate the beneficial effects which follow the direct application of remedies, to the affected part. The subject of the following case, is an intelligent young clergyman, from the country. A short time previous to his coming under my care, I received, in a letter from him, a brief account of the commencement of his disease, which I shall take the liberty of giving in his own words: CASE VIII. W , Sept. 25, 1841. Dear Sir.—1 have been, for the last six months, afflicted with the distemper called "Ministers' Sore Throat." I have an iron constitution, and had enjoyed perfect health, for nine years before my attack. I was taken last spring with pain in the throat— mostly back of the palate; could see no connection between it and a cold. My voice soon became hoarse, and it hurt me some to talk. In about a week, I got better, and though I could still feel a soreness, I talked, debated, and studied, as usual. The disease came again, worse than before ; pain more severe; voice more husky; and 79 THROAT AND AIR PASSAGES. it hurt me worse to talk. The palate was relaxed, and all the throat, in sight, appeared red, and inflamed. There was a slight pain and soreness in the larynx, or top of the wind-pipe, and speaking was followed by a sensation of great fatigue and uneasiness. It will be of no use to tell the many remedies I have tried —nothing I have done, or taken, has afforded me any permanent relief, or seemed, at all, to reach the disease. I now speak but little, and that little with difficulty. Excitement, if I do not speak, is very injurious to me, and I have to be very cautious, and not get at all excited or I cannot sleep," &c. In October, 1841, about eight months after his attack, this gentleman came to New York, and placed himself under my care. The disease, in the mean time, had made serious progress, and his condition w T as as follows :—-Considerable debility, and emaciation were present; the voice was reduced to a rough whisper; or, if by great exertion, it was uttered aloud, the act caused pain in the larynx, and the vocal resonance was hoarse, and discordant; there w T as irritation, with pain, and soreness, in the laryngeal region, and the patient manifested a frequent desire, by hemming, to clear the throat, but there was no decided cough present. On inspecting the fauces, the cavity of the throat was found to be very large. The muscular layers which connect the pharynx with the vertebral column, were wasted away, and the posterior 80 FOLLICULAR INFLAMMATION OF THE fauces presented the cavernous appearance which almost always, is present, when follicular disease has long existed. The mucous membrane, lining the sides, and the posterior wall of the pharynx, was covered with tubercles, or enlarged, mucous follicles. Some of the glands were destroyed, by ulceration, leaving small pits or depressions in the membrane, the bottoms of which were covered with a whitish-looking, adhesive mucus. On dedepressing the tongue, the superior half of the epiglottis could be seen above its base, thickened, with its circumference and lingual surface, eroded by ulcerations. The presence of ulcerations within the laryngeal cavity, was, also, indicated by the loss of voice, and by the pain and soreness, which was felt, whenever pressure was made over the thyroid cartilage. October 17th—The whole of the pharyngeal membrane, the lips of the glottis, and the lingual surface of the epiglottis, were freely cauterized with a strong solution of the nitrate of silver. Small doses of calomel and opium, were exhibited, night and morning; the patient was ordered five, or six grains of the iodide of potassium, during the day, and counter irritation, over the cervical portion of the spinal column, was also established. 18th.—The posterior fauces were again cauterized, and, to-day, the sponge saturated with the above solution, (forty grains of the silver to an ounce of water) was plunged into the laryngeal 81 THROAT AND AIR PASSAGES. cavity. Considerable irritation, and a free expectoration of viscid mucus, followed this latter application. On the 20th, the caustic, in substance, was applied to several of the most enlarged follicles, in the patient's throat, and the larynx again sponged with the solution. This last application to the larynx, and pharyngeal membrane was repeated every day, for a week; and, subsequently, every second and third day for three weeks longer. At the end of this period, the diseased follicles had nearly disappeared; the ulcerations around the edge of the epiglottis, had healed; and the voice of the patient, though still feeble, and imperfect, was in a great degree restored. Mr. T. now proposed to leave New York, and though more applications w T ere deemed necessary, to effect a perfect cure, yet, as he was anxious to return to his friends, such sanative measures were advised, as he himself, could pursue, and he left the city. He was directed to use his vocal organs for a short time, with great care; to gargle his throat, night, and morning, with the chloride of soda, properly diluted, and occasionally, to sponge the fauces, and pharynx, with a strong solution of the nitrate of silver. This plan of treatment was continued, for several months, when his voice was sufficiently strong to enable him to speak in public. In the course of the following year he received 5* 82 FOLLICULAR INFLAMMATION OF THE and accepted, a call to become the pastor of a church in one of the towns of New England; and from that time to the present, he has been occupied in the full discharge of all his official duties, without experiencing any return of his laryngeal difficulties. CASE IX. In July, 1844, G. S. J., a merchant of Norwalk, Conn., forty years of age, came to New York, for medical advice. He had suffered under follicular laryngitis for nearly two years, and for a period of over fourteen months, had been unable to utter a sound, above a whisper. The following is an abstract of the history of his case. In the fall of 1842, being actively engaged in business, after somewhat more than ordinary exertions, he found his voice began to fail; he grew hoarse; and there was a sense of uneasiness, and pain about the throat. Debility came on, and was attended with a great degree of nervous irritability. So great were the difficulties, arising from his hoarseness and prostration of strength, that he was obliged to relinquish his business, and " take to medicine." Still these unfavourable symptoms increased; and in May, 1843, he became completely aphonic; and this condition of the voice has continued up to the present period. July 30th.—The patient appears to be suffering under great debility; there is emaciation, with 83 THROAT AND AIR PASSAGES. feeble pulse, and pain in the thorax, but especially under the lower portion of the sternal bone. The natural voice is completely extinguished, and his words are articulated in a whisper, not above the ordinary respiration ; there is a sense of uneasiness, and constriction in the upper part of the throat, and soreness is complained of in the cavity of the larynx. On examining the throat, an unusually large cavity, behind the veil of the palate, is presented. The membrane lining this cavity is studded with granulations, interspersed with many ulcerated points. The uvula is greatly elongated, and enlarged, and the tonsillary gland, on both sides, is hypertrophied and ulcerated. (See plate III.) The epiglottis;—one half of which can be distinctly seen, —is thickened, and its circumference serrated with ulcerations; the lips of the glottis, examined by the finger, are plainly oedematous, and every symptom is present, wiiich indicates ulcerations in the vicinity of the vocal ligaments. July 31st. —I excised the diseased tonsils, and the elongated uvula; removing more than one inch of the pendulous extremity of the latter organ. August 1st. —Applied a strong solution of Argent, nitrat. (forty grs. to the oz.) to the fauces, and pharyngeal membrane, and ordered counter-irritation to be established over the cervical, and upper portion of the dorsal vertebrae. As the patient was suffering from weakness, and nervous irritability, 84 FOLLICULAR INFLAMMATION OF THE he was directed to take, three times a day, a teaspoonful of the following mixture : — r>. Ext. Hyosciamus, 3iss. Sesqui oxydi ferri, 3ij. Syrupi tolutant. Tinct. Cinch, aa fj. 01. Gaultheria, gtt x. Aq. distil.fij. M. August 2d. —The application to the posterior fauces, yesterday, and about the epiglottis; —for the attempt was not made to go below this valve; —was followed by a copious expectoration of viscid mucus from the throat, and a sensation of relief which the patient had not experienced in these parts for many months. I now determined to pass the aperture of the glottis, and cauterize the interior of the laryngeal surface ; but in attempting to introduce the sponge, some difficulty was experienced, on account of the extreme irritability of the parts. By depressing the roots of the tongue, however, I succeeded, at length, in passing the sponge, previously saturated with the strong solution, into the glottis, by which the interior of the laryngeal cavity was bathed with the fluid. A momentary constriction, at the upper part of the wind-pipe, and considerable irritation, follow ed this application; but the subsequent free discharge of adhesive mucus, and the great relief it brought, encouraged me to repeat the operation. August 3d.—Cauterized the fauces, and pharyngeal membrane, and again introduced the sponge 85 THROAT AND AIR PASSAGES. into the glottis. On this occasion, the patient complained much less than when topical medication was employed, for the first time, below the epiglottis; although the solution was of the same strength; namely; —forty grs. of the salt to an ounce of water. The application of the above solution, to the posterior fauces, and within the glottis, was continued, daily, for about a week, when the ulcerations about the pharynx, had healed, and the mucous membrane began to assume a healthy appearance. About the same time, the soreness, and irritation, in the laryngeal cavity, and the pain of which the patient had complained, under the sternum, entirely disappeared, and on the twelfth day from that on which the topical remedy was first employed, the voice of the patient returned, and vocalization, in the course of a few days longer, was fully established. This day, September the 19th, Mr. S. J. called at my office in perfect health. Since the middle of last month, he had experienced no pain, or irritation, whatever, in the throat, or pulmonary organs. Under the use of general tonics, his health, and strength, have returned, and the volume, and power of his voice are as great, perhaps, at this time, as at any period of his life. From the above case it will be seen that the disease, even in its more aggravated form, is not confined, altogether, to public speakers. Persons of 86 FOLLICULAR INFLAMMATION OF THE all professions, and occupations, as has been previously stated, may be the subjects of its attack. Females, however, are much less liable to the affection than men. This immunity from laryngeal and tracheal diseases, in the sex, has been observed, by MM. Serres, Louis, and other pathologists. The latter, in his interesting work on pulmonary phthisis, has reported, among his valuable, statistical observations, fifty-three cases of ulceration of the epiglottis; of which thirty-nine occurred in men, and fourteen in women; also, eighty-six cases, where lesions were found in the larynx, sixty of which were in men, and twentysix in women; and of ulcerations of the trachea, one hundred and seven cases are recorded by Louis; of these, thirty were in females, and seventy-seven in men.* The same difference, with regard to the frequency of attack, in the two sexes, I have observed to exist in follicular disease of the throat. Of the four hundred cases, which have fallen under my observation, not more than one in four of these, have been among women. That it may occur, however, in females, in as severe a form, as in men, the following case will prove. * Researches on Phthisis. By P. C A. Louis, M.D. pp. 42-3. Sydenham Society Edition. 87 THROAT AND AIR PASSAGES. CASE X. Mrs. F. G., aged 32, of Easton, Perm., came to New York for medical aid, the 1st Sept. 1844. Hereditarily predisposed to tubercular disease, she had, on several occasions, during the three, or four years, which preceded her visit to this city, exhibited some of the earliest symptoms of pulmonary phthisis. Two years, or more, ago, when labouring under a slight cough, dyspnoea, and other pulmonic symptoms, she, with her husband, went to live in a malarious district, in New Jersey. Here, in the course of the year, she contracted an intermittent fever, under which, in a mild form, she suffered for several months. But, in June, 1843, she left her residence, in New Jersey, and went to reside in a more healthy region of country; where, under the influence of a salubrious atmosphere, all symptoms of ague passed away, and along with these, disappeared, also, her pulmonic difficulties. About eight months ago, she began to experience a slight uneasiness in her throat, accompanied by soreness, and a constant desire to clear the passage; symptoms, which were soon followed by hoarseness, a slight cough, increased tenderness in the laryngeal region, and a difficulty in swallowing. So urgent, indeed, had this latter symptom become, that, for several weeks, preceding her visit to New York, she had found it 88 FOLLICULAR INFLAMMATION OF THE very difficult to swallow her food, unless taken in liquid form, or made soft by careful mastication. I saw her on the 3d of September, and found her pale, feeble, and emaciated; pulse languid; voice hoarse and raucous, and at times reduced to a whisper; cough frequent, and accompanied by a slight expectoration of viscid mucus. She complained of a difficulty of deglutition; a sense of smarting in the gullet, and soreness, whenever pressure was made over the thyroid cartilage. On inspecting the throat, the enlarged cavity of the posterior fauces was found covered with diseased, follicular glands; some of them in a state of ulceration, and others w ere filled with a puriform matter. About one-third of the epiglottis was in sight; its circumference, and lingual face, were extensively ulcerated, which accounted for the pain, and difficulty, which the patient experienced, in deglutition ; the uvula was considerably elongated, and the curtain of the palate was pale, relaxed, and (Edematous. Some dullness was observed, in the left lung, on percussing the chest, but a rigid examination, into the condition of the thorax, was not instituted at this time. The elongated uvula was immediately truncated, and, on the following day, topical remedies were freely applied to the posterior wall of the pharyngeal membrane, and the lingual face of the epiglottis. The iodide of potassium, in combination with the extract of sarsaparilla, was also exhibited. The 89 THROAT AND AIR PASSAGES. topical treatment, to the posterior fauces, and pharynx, was continued for several days, and was followed by a marked abatement of some of the more prominent symptoms ; —the difficulty of deglutition was in a good degree removed, the cough was alleviated, but the pain, and soreness, in the laryngeal cavity, were unabated. September 9th.—In the presence of my friend, Dr. C. L. Mitchell, I cauterized the interior of the laryngeal cavity, with a solution of the nitrate of silver, of the strength of two scruples of the salt, to an ounce of water. A free expectoration of viscid mucus, followed this application ; which afforded, to the patient, great relief. She was now placed upon a tonic plan of treatment, and the topical remedies were repeated daily, for one week ; and, subsequently, every alternate day, for a week or two longer. Under this treatment, I had the satisfaction of seeing my patient restored, apparently, to good health. The cough, and the tenderness, about the larynx, subsided; impeded deglutition was removed, and every vestige of disease about the throat, disappeared. A few weeks since, Mrs. G. was in the city, in excellent health: she has passed through two winters, since being treated, but has had no return of the laryngeal disease. Hitherto, ulceration of the larynx has been considered by many pathologists, as, necessarily, a fatal disease. In Dr. Porter's remarks on the 90 FOLLICULAR INFLAMMATION OF THE pathology of the larynx and trachea, he declares that if the mucous membrane of these parts is ulcerated, or the cartilages degenerated, the disease may be considered as totally incurable.* Dr. Thompson, also, of London, says : If the inflammation of the mucous membrane in phthisis trachealis be allowed to run on to ulceration, it is as fatal as consumption of the lungs. In the last three cases, the symptoms were so prominent as to leave no doubt on the minds of several intelligent, medical gentlemen, who saw them with me, of the presence of ulcerations in the laryngeal cavitv. In the case of several individuals, whose history, subsequently, will be introduced, the indications of this morbid condition of the parts, were still more manifest. It has been stated that the disease of the mucous glandulae, may be primary, and uncomplicated, and be limited, principally, to the fauces, and the pharyngo-laryngeal membrane; or, that it may be complicated with an elongation of the uvula, and, with hypertrophy and induration of the tonsillary glands. By the relation of the preceding observations, it is intended to illustrate the disease, as it appears in its uncomplicated form; although, in some of the cases which have been given, the mucous follicles of the tonsils and the uvula, have been more or less involved in the progress of the disease. To such * Observations on the Surgical Pathology of the Larynx and Trachea By Wm. Henry Porter, p. 110. 91 THROAT AND AIR PASSAGES. an extent had this morbid condition of the follicles of the tonsils advanced, in the following illustrations, as to form, by the extensive hypertrophy of these glands, a prominent feature in the history of the cases. It was stated, in a former chapter, that the tonsils were made up of an aggregated mass of mucous follicles, bound together, and surrounded by, or deposited in, cellular tissue. A morbid action is set up in these lacunae, which being communicated to their investing tissues, a deposition of fibrinous matter takes place, that gradually becomes organized, and incorporated with the proper glandular substance, thereby increasing the size of these bodies, in some instances, to a very great extent. As all adventitious growths take on irritable or inflamed action, much more readily, than naturally organized parts, these enlargements are liable to become violently irritated, from causes of a slight nature. Hypertrophy of the tonsils, it is well known, may be the result of various exciting causes. Repeated attacks of inflammation is most liable to terminate in an enlarged, and indurated condition of these glands. A morbid condition of the digestive organs; eruptive fevers, and a strumous diathesis have, all, been considered as predisposing, or exciting causes, of hypertrophy of the tonsillary glands. In the subsequent cases, the enlargement and 92 FOLLICULAR INFLAMMATION OF THE ulceration of the tonsils, arose from, or was dependent upon, a diseased condition of the lacuna?, of which these glands are principally composed. CASE XI. A. E. G., a merchant of Boston, aged 25, a robust and healthy gentleman, took a severe cold in May, 1842, which was followed by a dry, hard cough; pain in the chest, slight dyspnoea, and other symptoms of chronic, bronchial inflammation. Under the treatment of a skilful physician, these symptoms subsided; but his cough never left him entirely; and, moreover, a chronic, sore throat set in, which increasing with other unfavorable symptoms, obliged him to relinquish his business, and seek for the recovery of his health, During the following year, he came to New York, and was here subjected to various plans of treatment, without receiving any permanent relief. Three or four months before my first visit to him, he had placed himself under the care of a prominent Homoeopathic physician of this city, by whom he was treated up to the period at which I was called to attend him; and by whom he was assured, three days before he came under my care, that every vestige of disease was removed from his throat! June 11th, 1844.— Present State. —The whole outward, or rational symptoms, manifested by this patient, are those which indicate an advanced stage THROAT AND AIR PASSAGES. 93 of pulmonary phthisis. He is pale, and greatly emaciated; countenance presents an anxious, and haggard expression ; he has copious night-sweats; dyspnoea, and a constant, harassing cough, which is attended by a free expectoration of muco-purulent matter; the voice is thick, and hoarse, and deglutition is performed with much difficulty. The dyspnoea is greatly increased whenever the patient lies down; and for many weeks, no other individual has been able to sleep in the same room with him, on account of the laboured, and stertorous breathing which is constantly present, during sleep. The throat, on inspection, is found to be, apparently, entirely filled up with two enormously enlarged, and ulcerated tonsils, (See plate V,) between which, the uvula; which is also hypertrophied; appears wedged in, like the key-stone of an arch. No portion of the pharyngeal membrane can be seen, as the morbid mass completely blocks up the view. How respiration can be carried on, or deglutition performed, with the throat in this state, it is difficult to imagine; and still more difficult is it, to comprehend, how a learned physician, could have pronounced such a throat, to be in a healthy condition! On exploring the chest, no morbid signs are detected, except such as indicate the presence of some degree of bronchial irritation. But there is soreness, in the region of the larynx, and pain, 94 FOLLICULAR INFLAMMATION OF THE which is increased by pressure over the thyroid cartilage. This gentleman was advised, and readily consented, to submit to a prompt removal of the enlarged tonsils, and uvula. The operation was performed, and the morbid mass entirely cleared from the obstructed arches. After clearing the isthmus faucium, the mucous lining of the pharynx could be seen, injected, its follicles enlarged, and in an ulcerated condition, at many points along its posterior wall. June 13th.—Since the operation, the patient has slept quietly at night, and appears greatly refreshed, by the rest thus obtained.—Cauterized the pharynx, and the glottis, with a solution of the crystals of nitrate of silver, of the strength of two scruples, to the ounce of distilled water; the Iodide of Potassium was exhibited in five grain doses twice a day; and, for the cough, the following mixture was ordered : fy. Tr. Sanguinaria, Tr. Actea racemosa, aii |j. Morph. Sulph. gr. iv. M. Capiat gutt. xxv—xxx. bis ter ve in die. 15th. —Again cauterized the pharyngeal membrane and the upper part of the larynx: The above remedies to be continued. This plan of treatment, in connection with constitutional means, was pursued, until the 15th of 95 THROAT AND AIR PASSAGES. July, when the topical remedies were omitted, and the patient directed to employ, twice a day, the following gargle: fy. Argent. Nitrat. gr. xv. Aqua Rosae, liv. M. Pro gargarism. At this period, the cough, and night perspirations had subsided ; all soreness and irritation in the throat, had disappeared, and the patient was, evidently, gaining in flesh and strength. On the 8th of July he left for the country, where he remained until the 16th of August, at which time he returned to the city, in good health. In the preceding case, the pharyngo-laryngeal affection may, in some respects, be considered as having been complicated with bronchial disease; but the inflammation of the bronchial vessels, which, undoubtedly, had existed, to a considerable extent, in the earlier stages of the disease, was not present when the patient came under my care. The effect, however, of the inflammation was still remaining; and this consisted in a dilatation of some of the bronchial tubes. This alteration of structure had led to a great error in diagnosis j for, misled by the external, or rational signs; the emaciation, and dyspnoea; the night-sweats, and the free, muco-purulent expectoration, of the patient, several physicians, both in this city and Boston, who had examined the case, had mistaken the bronchial dilatations for tubercular cavities, and 96 FOLLICULAR INFLAMMATION OF THE had pronounced it to be one of confirmed phthisis. That it was not tuberculous disease, time has proved, by establishing the permanency of the cure. It is now over two years since this patient was under treatment; during this period he has passed through two severe winters, in which he was constantly engaged in business; and yet he has been, and still remains, in excellent health.* * This case, after it was drawn up, was seen by my friend, Dr. A. L. Cox, of this city, who returned it, with the following note :—" Here I would humbly remark, that the facts present no such proof whatever; since recoveries from tuberculous phthisis, have occurred, beyond all doubt, and, in my opinion, the gentlemen were probably right in their diagnosis. " All that is requisite, to establish this position, is to prove, that patienls do occasionally recover their health, who have tubercles. The case of my preceptor, the late Dr. Parrish, of Philadelphia, is in point. He had tubercles at about twenty years of age. In 1823—his* health having then been good for twenty years —he informed me of his case; and said that such was the prejudice of medical men, that they would listen to no facts, or arguments, on the subject; and that he did not speak of it, as it only made them laugh. The Doctor requested me, if in my power, at the time of his death, to be present at the autopsy, and to bear witness to the conversation then passing. 11 He died, somewhere about 1840— I was not present at the post-mortem, being in this city. But several gentlemen of the first respectability, in his own city were there, and they bear testimony to the fact, that several tubercles, in the summit of both lungs, existed, in an indolent condition, from which, for more than thirty years, he had felt no inconvenience whatever ; and his final sickness had no connection with the original disease. I therefore demur from the conclusion that because your patient recovered, he could not have had tubercles." 97 THROAT AND AIR PASSAGES. CASE XII. S. S., aged 28, a gentleman from Pittsfield, Ms., came to New York for medical aid, January 31st, 1843. For more than five years, he had suffered under an affection of the throat, for the relief of which, most of the ordinary remedies had been, unavailingly employed. He had, also, been subjected to Homoeopathic treatment, for a period of six months, under a practitioner of this character, at Albany'; and with as little benefit to the patient, as had occurred to the individual, in the preceding case. The disease was first manifested by a slight pain, and soreness, in the throat; symptoms, which were increased by exposure to cold, and by exertions of the voice; a cough, and hoarseness came on, and, at length, the voice, at different periods, became almost extinct. Present State. —The patient is feeble and emaciated ; the voice hoarse, and unnatural, being reduced, at times, to a rough whisper. He complains of pain, and of a pricking sensation in the throat; the patient has suffered long, under a harrassing cough ; there is difficulty of deglutition, and respiration is evidently obstructed, in the upper airpassages. An inspection of the throat, and airpassages reveals an extremely diseased condition of these parts. The tonsils are greatly hypertrophied; all that part of the throat which can be seen, is studded with enlarged, and ulcerated fol- 6 98 FOLLICULAR INFLAMMATION OF THE licles; the epiglottis is (Edematous, and the pricking pain, and tenderness, below the os hyoides, the marked change in the character of the voice, and the dry and harsh cough, denote a highly diseased state of the parts, within the larynx. Respiration appears normal, and the chest, on percussion, sounds well. The enlarged tonsils, were excised; and, on the second day, after the operation, the topical application, of a strong solution of the crystals of nitrate of silver, was employed j the patient was directed to take the Iodide of Potassium, with the extract of sarsaparilla, twice, during the day; and the tinct. of sanguinaria, and laudanum at night, to allay the cough. Appropriate, constitutional remedies were conjoined with these means j and, under this plan of treatment, he gradually improved ; the cough, and ulceration of the throat, subsided ; the natural resonance of the voice returned ; and along with the disappearance of the local difficulties, there was a corresponding improvement, in his general health. Follicular Disease, complicated with Elongation of the Uvula. The uvula, it will be remembered, is abundantly supplied with mucous cryptae, which are especially large, and numerous, towards its inferior extremity. In follicular disease of the throat, the mucous THROAT AND AIR PASSAGES. 99 glands of the uvula seldom remain long, unaffected. Hence, wherever the affection has existed, for any considerable period of time, elongation, or hypertrophy of the uvula, dependent, primarily, upon a diseased condition of its follicles, will be found to be present, to a greater or lesser degree, in a large majority of the cases. The result of this morbid action may be, either a simple prolongation of the mucous, and cellular tissues, which invest the uvula; or, an elongation or hypertrophy, of its muscular substance. In the former alteration, the tissues being extended beyond the muscular portion of the uvula, form, at its extremity, a kind of sac, into which an effusion of serous matter takes place, causing simple elongation of this organ. In the latter, morbid condition, there is an infiltration of serous, or fibrinous matter, in the cellular tissue, by which the uvula is gradually enlarged; and, in some instances, elongated to such an extent, as to produce most serious irritation about the epiglottis, and upper portion of the respiratory tube. Dr. Stokes, in his interesting work, on Diseases of the Chest, after enumerating various, milder forms of symptoms, which he has observed to result from this chronic, organic lesion, declares, moreover, that he has seen cases, presenting all the usual symptoms of phthisis ; except the physical signs; such as cough, puriform, and bloody expectoration, hectic, emaciation, and quick pulse, which were produced by relaxation, and elongation of the 100 FOLLICULAR INFLAMMATION OF THE uvula, and, in the treatment of which, the ordinary means, either altogether failed, or were but partially successful.* The following cases are illustrative of some of the preceding remarks. CASE XIII. August 24th, 1842.—I was requested to see M. T., aged 26; a country merchant, who had come to the city, for the double purpose of procuring medical aid, and of purchasing his stock of goods. For about a year, he had been labouring under a troublesome affection of the throat,. the symptoms of which had greatly increased within the few months which preceded his visit to New York. His throat, during this period, had been constantly sore, but his general health appeared to have suffered but little, from the disease. He complained of an incessant, and most teasing irritation at the upper portion of the larynx, which induced some cough, and caused a constant inclination to clear his throat by hemming; whereby he expectorated, w T ith much difficulty, a tenacious, viscid mucus. On inspecting his throat, the cause of the difficulty was quite apparent. The follicles were enlarged; the whole mucous lining of the fauces was injected * A Treatise on the Diagnosis and Treatment of Diseases of the Chest. By Wm. Stokes, M.D., &c. pp. 230-1. 101 THROAT AND AIR PASSAGES. and (Edematous ; and the uvula was enlarged, and elongated, to a very great extent; hanging loosely, from the septum; its muscular fibres being destitute, apparently, of all contractile power. The remedy, in this case, was as obvious as the cause. The uvula was removed, and a few applications of the nitro-argentine solution, were made to the fauces, and pharyngeal membrane. The relief which followed these measures, was prompt, and effectual; the teasing cough, and irritation about the throat disappeared : and, as I learned a year after this treatment, there was no return, whatever, of these unpleasant symptoms. CASE XIV. J. V., the Captain of one of our River steamboats, had suffered for several years, under disease of the throat; which, besides affecting, unfavorably, his general health, had so changed the character of his voice, as greatly to interfere with, and, at times, to interrupt, altogether, the discharge of his duties as commander of his vessel. Besides the hoarseness, with which he was affected, there was present, a constant soreness, and irritation in the throat; symptoms that were often increased by the exposures to which he was subjected, by his profession. But what alarmed him more than all this, was the frequent occurrence of a sense of suffocation, which would suddenly seize him, when 102 FOLLICULAR INFLAMMATION OF THE lying in a horizontal position; causing him to spring, quickly, to an erect posture, by which, alone, he was relieved from a sense of immediate suffocation. Alarmed by these symptoms, and unable to divine the cause of them, he was induced to seek for medical assistance. On inspecting the fauces, I found the throat exhibiting that granulated, and cavernous appearance, which is often present in those cases, where follicular disease has burrowed, for a long period, about the pillars of the fauces, and in the tissues of the pharynx. But what gave me the most surprise, was the enormously enlarged, and elongated uvula, (See plate IV.) which was hanging in the Captain's throat, with its extremity lying on the back of the tongue. It was over two inches, in length, and at its largest diameter, nearly half an inch in thickness ! The cause of the patient's most distressing symptom, was now apparent. When lying upon his back, the elongated uvula would hang before the opening of the glottis, and in the act of inspiration, its extremity would, occasionally, be drawn into the aperture> producing that suffocating sensation, with which the patient had been so frequently annoyed. The operation, for the removal of this morbid growth, was immediately performed. This was followed by the exhibition of topical, and general remedies, as in the preceding cases, of pharyngolaryngeal disease; under the employment of which, 103 THROAT AND AIR PASSAGES. the cough, the irritation about the throat, and every other symptom of laryngeal disease, rapidly disappeared, and the Captain, in a few weeks, was enabled to resume, and, ever since, has been occupied in the discharge of, his official duties. The following case is of interest, inasmuch as it illustrates the morbid effects that may be produced by an elongated uvula, in the absence of all other exciting causes: CASE XV. In 1841, E. B., aged 26 j a merchant of this city, suffered, severely, from follicular laryngitis. During this year he left the North, and spent a part of the inclement season in one of the Southern States. But his disease continuing to increase, he came back to New York, and, after his return, placed himself under my care. At this time, there was debility, loss of flesh, with cough, and hoarseness, and a constant irritation about the throat; an examination of which, revealed an extensively diseased condition of the follicles of the fauces, and of those of the pharyngeal membrane. His uvula was moderately elongated, but not to that extent that seemed to require excision. Under the use of those topical, and general remedies which are comprised in the plan of treat- 104 FOLLICULAR INFLAMMATION OF THE merit that was employed in many of the preceding cases, this patient was restored to a good degree of health; the hoarseness, and soreness of his throat, disappeared; the mucous membrane assumed a healthy appearance ; and he regained strength, and flesh, so that he was enabled, again, to attend to his business. His cough, however, never left him, but, on the contrary; notwithstanding the employment of many of the ordinary remedies, for its removal ; continued to increase, and was attended, after a while, with a free expectoration of mucopurulent matter. The occurrence, at length, of erratic pains, about the chest, with debility, and other unfavourable symptoms, led the patient and his friends, to apprehend the presence of confirmed, pulmonic disease. At this crisis; after having resorted to various, remedial measures, without benefit, I proposed the excision of the patient's uvula; which, although but moderately elongated, w 7 as, evidently, a source of irritation. To this, the patient acceded; the uvula was removed ; and, from that hour the cough ceased, the pain in the chest, and every other indication of thoracic disease, which had been present, soon passed way j and from that hour to the present, the patient, has been free from all pulmonic disease. Had this cause of irritation been suffered to remain, there can be little doubt, that an organic disease of the lungs, would have been developed, 105 THROAT AND AIR PASSAGES. which, ultimately, would have proved fatal. A confirmation of this opinion will be found in the following case which is related by Dr. Morton.* CASE XVI. A gentleman who, for several months, had been harassed with a dry cough, and whose uvula was greatly elongated, applied to me for relief. I removed his uvula, and the cough ceased entirely. This was three years ago. He died in August of the present year, of inflammation of the bowels, and as his family requested an autopsy, I availed myself of the opportunity of examining his lungs : the right lung, especially towards the apex, contained a great number of these granulations tuberculoid) in the diaphanous state, but no tubercles, and the parenchyma was healthy. The left lung contained a few of the same bodies. There can be little doubt but that these substances were remains of vesicles inflamed and filled up during the catarrh of which I have spoken. Had the catarrh been suffered to proceed, the ganulations would have been developed in proportion, and their extensive accumulation would have constituted that state of the lungs which Bayle designated by the specific name of granular phthisis. * Illustrations of Pulmonary Consumption. By S. G. Morton, M.D., p. 25. 6* 106 FOLLICULAR INFLAMMATION OF THE Follicular Disease, Complicated with Laryngitis. In most cases of follicular disease of the throat, the inflammation, in its earlier stages, is limited to the mucous crypta? of the pharyngo-laryngeal membrane. In some instances, however, after the disease has continued for a longer or shorter period, the lining membrane may become involved in the morbid action, and we shall then have, supervening upon the original, glandular disease, an inflammation of the intervening mucous tissue ; or follicular disease, complicated with chronic laryngitis. The following cases are offered as examples, which illustrate this complicated form of the affection: CASE XVII. In September, 1841, I was called upon by a young clergyman, from one of the New England States, who, for the last two years, had laboured under an affection of the throat, which, at length, had incapaciated him, entirely, for the performance of all public duties, and had even rendered him incapable of reading, aloud. Three weeks before the above date, he had returned from a sea voyage ; having been absent for several months, for the purpose of regaining his health. Six, or eight weeks before he came under my care, and while at sea, he observed that the back part of the throat 107 THROAT AND AIR PASSAGES. was becoming more inflamed ; and the epiglottis could be seen projecting above the back of the tongue, and presenting a highly inflamed appearance. After he landed, a physician was called who bled him, and applied cups to the neck, Which reduced the inflammation, and afforded him temporary relief. September 11th.— Present State. —The patient's general health seems but little affected. He is not emaciated ; his appetite is good 5 and he manifests no hereditary tendency to pulmonary disease, but his throat appears extensively affected. The muscular parts about the fauces, and over the cervical vertebra?, are wasted away, and the cavity of the throat is very large ; the lining membrane of these parts is covered with tubercles, or enlarged, and diseased follicles j while the intervening, mucous membrane is injected, and inflamed ; the epiglottis can be seen projecting above the back of the tongue, its investing membrane looking red, and vascular ; the voice is rough, and hoarse; there is heat, and dryness of the throat, present, with pain in the laryngeal region, which is increased by every exertion of the voice, and on pressing the larynx against the spine. This patient was directed to give the organs of voice, entire rest, to use mucilaginous drinks, and low diet, and to take, night and morning, one of the following powders: 108 FOLLICULAR INFLAMMATION OF THE Rj. Hydrarg. chlorid. mitis gr. xxv. Opii pulv. gr. iv. Misce. et in pulveres decern divide. These powders were continued, as above, until the mineral had produced, in a slight degree, its specific effect. This condition being established, in the course of a few days, the calomel was omitted; the patient was put upon a free use of the iodide of potassium, and the fauces, the pharyngeal membrane, and the glottis were freely cauterized with a solution of the crystals of nitrate of silver. Under this plan of treatment, the patient rapidly improved; and in less than two weeks after commencing the employment of the topical remedies, he tested the ability of his voice by reading through one of Shakspeare's plays, aloud. He soon recovered, and returned to the discharge of his official duties. Follicular Disease of the Air-passages, Complicated with Chronic Bronchitis. More, perhaps, than with any other morbid condition of the respiratory apparatus, is follicular disease complicated with a catarrhal condition of the bronchial tubes. Of the large number of cases, of disease of the mucous glandula?, which, from time to time, have 109 THROAT AND AIR PASSAGES. come under my observation, more than one half of them, have been conjoined with, more or less, of bronchial irritation. In a large proportion of these cases, the latter affection has been secondary; or, has supervened upon the primary, glandular disease. Commencing in the upper part of the airpassages, follicular laryngitis may exist, independent of any inflammation of the bronchial membranes. Ordinarily, however, the morbid action is communicated, sooner or later, to the surrounding, mucous tissue, and, in this way, the irritation may be extended into the bronchi, and their ramifications. In the above, complicated form of the disease, the cough, which is generally present, is attended by an expectoration of transparent, adhesive mucus. As the disease advances, this discharge increases in quantity, and is characterized by the presence of opaque, or albuminous matter, commingled with the more transparent, liquid mucus. The constant presence of this latter, heterogeneous, or mucopurulent expectoration, is the test which Andral has given, of the existence of chronic inflammation of the mucous lining of the bronchial tubes. From the above number of cases I shall select the following, to illustrate this complicated form, of follicular bronchitis. 110 FOLLICULAR INFLAMMATION OF THE CASE XVIII. C. E. H., thirty years of age, a gentleman of this city, engaged in an extensive mercantile business, began to suffer under an affection of the throat, in the fall of 1842. The disease commenced with the ordinary symptoms —with slight pain and soreness in the throat; constant irritation in the larynx; and a hoarseness, which was increased at night, and after any unusual exertion of the voice. These symptoms, which were greatly aggravated during the following winter, became considerably mitigated in the summer months. The return of cold weather, however, in the fall of 1843, aggravated all his unfavorable symptoms. At the advice of his physician, and friends, he now relinquished his business, and sailed for Santa Cruz, where he spent the following winter: but his health was but very little improved by his residence on this Island. On his return to New Orleans, in April, 1844, his hoarseness, and cough, increased ; and he there had an attack of hemoptcesis, which continued for several days. Returning to New York, in May, he spent the summer months in this city; but his health did not improve, as it had done, during the warm season of the preceding year. When this gentleman came under my care, the 11th of September, his case presented the following points: There was considerable emaciation, with debility and night-sweats; and a severe 111 THROAT AND AIR PASSAGES. paroxysmal cough, attended by an expectoration of opaque, or yellowish sputa, which were occasionally streaked with blood. There was slight dullness, on percussion, at the summit of the left lung; and mucous ronchi were detected near the middle, and at the base of both lungs. The throat bore the appearance of having been long affected by follicular inflammation; the pharyngeal membrane was injected, its follicles, and those of the tonsils, diseased, and in some places, were destroyed by ulceration; the uvula was elongated; the voice was hoarse ; and the patient complained of a constant irritation, at the bronchial division of the trachea. As the diseased uvula was considered a source of irritation, its elongated portion was removed. September 13th. —Topical remedies to the throat were employed—the pharyngo-laryngeal membrane being freely cauterized, by a solution of argent, nitratis crystalli —and the patient was ordered to take, night and morning, one of the following pills: Rj. Hydrarg. chlorid. corros. gr. iv. Extract conii 3ss. Extract Beladon. gr. x. Misce. In pil. xxx. dividend. The iodide of potassium was, also, exhibited, in full doses, during the day. 18th. —During the severe paroxysm of coughing last night, blood was again expectorated, and the 112 FOLLICULAR INFLAMMATION OF THE sputa to-day are tinged with the same. The topical remedy was again employed; the antimonial ointment was directed to be applied to the cervical portion of the spine; and the patient was ordered the following expectorant: ft. Tinct. Sanguinaria, fiss. Tr. Opii, fss. 01. Gaultheria gtt. x. M. Twenty-five drops to be taken on going to bed, and the same number twice during the day. The application of the nitrate of silver to the fauces, and the pharyngo-laryngeal membrane was repeated, on each alternate day, and the above remedies continued up to the 27th, when the patient expressed himself greatly relieved. His cough was much less troublesome; the night-sweats had ceased; and the soreness, and irritation in his throat had nearly subsided. The pills were now omitted; the expectorant, and the hydriodate of potash were continued, and the following tonic mixture was ordered: R;. Extract conii, 3j. Sesqui oxydi ferri, 3ij. Syripi tolutant. Tinct. Cinch, aa Aq. font. 3ij. M. Cap. coch. parv. ter in die. After the 27th of September, the topical remedy was employed, every third, or fourth day, only, for three weeks longer, when the patient's throat 113 THROAT AND AIR PASSAGES. presented no appearance of follicular disease, whatever ; his cough, and hoarseness, had entirely left him, and he w T as regaining, rapidly, both his strength, and flesh; —having added four pounds to his weight, during the above three weeks. On the third of November, following, I, again, explored his chest, but, at this time, could detect, no sign of bronchial irritation, nor any other evidence of thoracic disease. March 7th, 1845.—Saw this day, my patient, at his counting-room in Front street, having every appearance of being in the possession of robust health. He has passed through a severe winter, without experiencing any return of a laryngeal, or bronchial disease, notwithstanding he has been much exposed, from having been, during the last three months, constantly engaged in an active business. CASE XIX. Severe Case of Bronchial Disease, Consequent upon, and Complicated with, Follicular Laryngitis. Mr. H. S., aged twenty-five, an intelligent gentleman from Worcester, Co., Massachusetts, came to New York, for medical assistance, in November, 1844. Three years before, in 1841, he was seized, without any perceptible cause, with irritation in the throat; soon followed by hoarseness, loss of voice, and other marked symptoms of laryngeal 114 FOLLICULAR INFLAMMATION OF THE disease. For many months, before this attack, he had been in excellent health; had perceived no difficulty about his throat until, one day, in attempting to answer a question, he found himself, suddenly, unable to articulate, except with great difficulty. From that time, he perceived a constant irritation in his throat; his voice became permanently hoarse, and was, soon after, reduced to a rough whisper. A cough now set in, which continued severe, through the winter; and, being attended with a free expectoration, with wandering pains about the chest, and other indications of thoracic disease, it alarmed him, and his friends, and he was advised, before the return of another cold season, to make a sea-voyage, and spend the winter months in some milder climate. He sailed for Havre; travelled somewhat during the autumn, and spent the winter in the South of France. But little improvement, however, was effected by this change of climate; so that, he returned in the following year, in almost the same condition, in which he was, when he left home. His case, in coming under my care, (November 3d, 1844,) presented the following symptoms: There was pallor, with debility, and loss of flesh; his voice was reduced to a rough whisper, or, when considerable effort was made, could be uttered in hoarse, broken sounds; pressure over the thyroid cartilage, produced pain, and caused cough. The cavity of the posterior fauces was very large, and 115 THROAT AND AIR PASSAGES. was studded with hypertrophied, and ulcerated follicles; the epiglottis, and the edges of the arytenoid cartilages, seemed cedematous to the touch; a condition which arose, probably, from a thickening of their mucous lining. The patient had suffered, for many months, and was still labouring under an harassing, paroxysmal cough, which was especially severe, on lying down at night, and on rising in the morning; and was attended with a free expectoration of viscid phlegm in which compact masses of opaque, muco-purulent matter were suspended. On examining the chest, the right side sounded clear, on percussion, but respiration was slightly faint; a dull sound was elicited by percussion, over the apex of the left lung, and mucous ronchi were heard at its base and middle portion. These were the principal, morbid signs that could be detected; but fearing, from the many other unfavorable symptoms which my patient presented, that his lungs were tuberculous, I requested a medical friend, who has had extensive experience as an auscultator, to examine his case : The following are the memoranda which he made: Respiration, faint at the apex of right lung; clear, lower down; slight, mucous rale in the inferior, and posterior part of right lung. Left lung —res- faint at its summit, with large mucous rales distinct; sonorous rales, after coughing; mucous rales in the lower, posterior part of the left 116 FOLLICULAR INFLAMMATION OF THE lung. Percussion gives slight flatness under the left clavicle. These morbid signs, together with the above, laryngeal symptoms ; viewed in their most favorable aspect, indicated follicular laryngitis, complicated with extensive, bronchial disease, and with dilatation of the bronchial tubes. Commenced the fifth of November with the use of the topical remedy; and having freely cauterized the posterior fauces, and epiglottis, on the following day I passed a small sponge, saturated with a strong solution of the crystals of the nitrate of silver, into the aperture of the glottis. Of the following pills the patient was directed to take one, night and morning: ft. Extract Hyosciamus. 3j, Hydrarg. chlorid. mitis, gr. xxx Opii pulv. gr. iij. Fiat massa, in pilulas viginti dividenda. These pills, together with daily cauterization of the pharyngo-laryngeal membrane, were continued until the twelfth; when symptoms, indicating the presence of slight mercurialization arising, the pills were discontinued. The patient was now put upon the use of the iodide of potassium; general tonics were exhibited, and the topical, remedial measures, to the pharynx, and glottis, were continued. This plan of treatment was persevered in, for several weeks, before any marked improvement, in the patient's symptoms, was apparent. 117 THROAT AND AIR PASSAGES. On the 30th of the month ; twenty-five days after the commencement of the use of topical remedies, the patient expressed himself " able to speak much easier;" there was less huskiness of the voice; his cough was mitigated, and a marked improvement in his general health was manifest. Some cough and bronchial irritation still remaining, counter-irritation, by means of the external application of antimonial ointment, over the sub-clavicular region, of each side, was employed ; and the applications of the nitrate of silver were continued until the eighth of December. By this time, all evidence of disease, about the throat had disappeared; there was neither pain or irritation felt within the larynx, and the lining membrane of the fauces, and of the pharyngeal cavity, as far down as could be seen, presented a smooth, and healthy appearance. About this time my patient left the city, for his home; and as there still remained some cough, and huskiness of the voice; a symptom depending, probably, upon a thickening of the mucous membrane of the vocal ligaments,—he was directed to take the proto-iodide of iron, and to apply externally to his throat, the following irritant: ft. 01. Tiglii. gtt. xxv. Spir. aetheris sulph. 1\. Misce. A few w T eeks after his return home, I received a letter from him, informing me of his continued 118 FOLLICULAR DISEASES COMPLICATED improvement; that he had regained six pounds of flesh in four weeks; that his voice was clearer; and that he had full expectation of being restored to good health. Several months later; after having passed through the winter; the accounts received from him are still more favourable; vocalization has been re-established, and his health, in a good degree, restored. Follicular Disease of the Air-passages, Complicated with Phthisis Pulmonalis. A diseased condition of the follicles of the tonsils, and of those of the pharyngo-laryngeal membrane, is a frequent concomitant of tuberculous affection of the lungs. But this disordered state of the mucous glandulae of the air-passages, although often conjoined with thoracic disease, is not, in all cases, the sequent of pulmonic affection: on the contrary; a morbid condition of these follicles is, in many instances, the antecedent, and tends, directly, especially in individuals of a strumous diathesis, to awaken tuberculous disease of the lungs. M. Louis, I am aware, from having found ulceration of the larynx in one-fourth part of the cases of phthisis, which he examined; and having observed the absence of this alteration of structure, with very few exceptions, in a large number of non-tuberculous patients; was led " to regard 119 WITH PHTHISIS PULMONALIS. ulcerations of the larynx, more especially those of the trachea and epiglottis, as lesions proper to phthisis; "* and, when occurring, as supervening, in all cases, upon tubercular disorganization. Laennec,| on the contrary, declares, that this developement [ulceration] is of frequent occurrence, on the tracheal membrane, in persons exempt from pulmonary phthisis. Mr. Porter, also, in his " Observations on the Surgical Pathology of the Larynx and Trachea," speaks of cases where extensive ulceration of the trachea had terminated in cicatrization. After recovery, in one instance, the patient lived upwards of a year, in the enjoyment of good health; but dying at length, of another disease, dissection revealed an extensive but perfect cicatrix, situated in the upper portion of the trachea. As a general rule, however, the conclusion to which Louis arrived, is correct: Ulcerations of the mucous membrane of the larynx and trachea are seldom observed except in connection with tuberculous disease; but ulceration of the follicles of this membrane are occurring, frequently, as I have had occasion to show, independently of phthisis. This morbid condition of the glandular will also be found, in many instances, conjoined with pulmonary lesions. When co-existing with tubercular phthisis, the cough, the dyspnoea, and all the characteristic symptoms of this latter disease, are * Researches on Phthisis, &c, p. 46 f De P Auscultation Mediate 2 erne edit, to i. p. 267. 120 FOLLICULAR DISEASES COMPLICATED greatly aggravated, and the affection passes through its stages, and reaches its fatal termination, much sooner, ordinarily, than when its progress is unattended with follicular disease of the pharyngolaryngeal membrane. Although but little can be expected, from any attempt made to prevent the final denouement in these cases where disorganization of the lungs has occurred, yet, in many instances, the harassing cough, the difficulty of deglutition, and the dyspnoea, which are often present, in this combination of disease, are signally relieved, and the sufferings of the patient greatly mitigated, by the employment of topical medication, upon the diseased, laryngeal surface. So marked, indeed, has this relief been, in some cases which have fallen under my observation ; even when tubercular cavities have been present; as to awaken in the minds of the patients, and their friends, strong hopes of their final recovery. In other instances —and these have been, not a few —where follicular laryngitis has preceded thoracic disease, I have seen the symptoms of incipient pulmonary affection, rapidly disappear after the removal, by topical medication, of the primary, follicular disease. In the following highly interesting case, the symptoms, it will be observed, resembled, in a striking manner, those manifested in case No. VI., which I have abridged from Ryland, where a postmortem revealed an extensive ulceration of the 121 WITH PHTHISIS PULMONALIS. cavity of the glottis, and of the ventricles of the larynx; and also, a destruction, from the same cause, of the superior margin of the epiglottis. CASE XX. Mr. B., aged thirty-eight; a merchant from Mobile, came under my care, about the middle of October, 1844. For several years he had complained of an irritation of the throat, which was attended with a slight cough, and an occasional hoarseness; symptoms, which were disregarded until last January, when, after taking a severe cold, they were all greatly aggravated; the voice became constantly hoarse; there was soreness and heat in the laryngeal cavity ; the cough increased, and was attended by an expectoration of viscid mucus, and, occasionally, with haemoptysis. In September, following, this gentleman came to New York, and was under medical treatment several weeks, before I saw him, without any alleviation of the unfavorable symptoms. October 19th. — Present State. —His voice is extremely hoarse and uneven; at times, nearly extinct; there is a constant pain, and a pricking sensation in the region of the os hyoides; deglutition is accomplished with the utmost difficulty; indeed, for several weeks, the patient has been able to take liquids, only, and the swallowing even 7 122 FOLLICULAR DISEASE COMPLICATED of these, is attended with so much pain, that, although enjoying a good appetite, he is disposed to forego, as far as possible, the use of food. There is one peculiarity in Mr. B.'s case: he cannot take his food by the spoonful; whenever he attempts this, the liquid is rejected, instantly, through the nostrils; but he is able to drink it in a continual stream, until he arrives at the last swallow, when it produces a feeling of suffocation, and is rejected with violence ! He has severe and spasmodic fits of coughing, which occur, frequently; and are attended by a viscid, mucous expectoration; his cough has that peculiar cracked, or whistling character, which, according to Louis, is indicative of ulceration of the chordae vocales. There is dyspnoea, with considerable emaciation, present, and the patient complains of having profuse " cold sweats " at night. On inspecting the fauces, the pharyngeal membrane is found marked with patches of ash-coloured ulcerations, intermixed with prominent granulations, or enlarged mucous follicles. The epiglottis is thickened, and its superior margin eroded by ulcerations; considerable oedema can be distinguished about the lips of the glottis, by which the opening into the larynx is sensibly diminished. The uvula is elongated, and its pendulous extremity is studded with diseased follicles, by which it is greatly enlarged. The diseased portion of this organ was imme- 123 WITH PHTHISIS PULMONALIS. diately removed; and, on the second day after truncating the uvula, the fauces, the posterior wall of the pharynx, and the opening of the larynx, were freely cauterized with a strong solution of the crystals of nitrate of silver. The patient was directed to use the following solution: R.. Potass, iodid. 3ijss. Tinct. cardamon. Aqua distil, aa fij. M. A desert spoonful to be taken twice, daily, in an equal amount of compound syrup of sarsaparilla; the antimonial ointment to be applied over the cervical part of the spinal column; and, night and morning, one of the following pills was ordered : ft. Extract Hyosciamus, 3j. Hydrarg. chlorid. corros. gr. iv. Misce. riant pilulae triginta. It was found necessary to apply the topical remedy, for several days, to the laryngeal surface of the epiglottis, and to the lips of the glottis, before the sponge could be introduced into the larynx; as the size of the opening into this cavity was diminished by the oedema of the parts. On the 25th, the glottis was entered, and the interior of the laryngeal cavity, was freely cauterized with the nitro-argentine solution. In the course of a few days, the improvement was decided; the cough and hoarseness were greatly diminished, and the patient could take his food, with much less pain, and without any of that 124 FOLLICULAR DISEASE COMPLICATED rejection of the liquids, which had occurred in attempting to swallow, before the topical remedies were employed. It will be unnecessary to follow out the details of the plan of treatment pursued in this case: cauterization of the fauces, glottis, and cavity of the larynx, was continued every day, or each alternate day, for several weeks • counter-irritation over the superior portion of the spinal column, was kept up, and along with the alterative remedies, prescribed at the commencement of the treatment, the patient was put upon the use of general tonics. Under this plan of treatment, the improvement of his health was marked and rapid. By the last of October he was able to swallow solid food without pain, or inconvenience; his strength increased; his voice was improved; and before he sailed for Mobile, which was in November, he had regained several pounds of flesh, whilst every evidence of ulceration of the throat had disappeared ; and all this mitigation of the disease took place, notwithstanding the symptoms which have been enumerated —in connection with the morbid, physical signs, which auscultation revealed, —indicated the presence of extensive, tuberculous disease of the lungs. These latter indications increasing, after he left New York, he died, not long after his return to Mobile, of pulmonary phthisis. 125 WITH PHTHISIS PULMONALIS. In the subjoined case, topical medication was employed under circumstances, and at a stage of the disease, which precluded all hope of deriving any permanent benefit, from this measure. The case is introduced as an additional illustration of the influence of topical remedies in relieving the difficulty of deglutition, and in mitigating the harassing cough, which are often present, in follicular laryngitis, complicated with pulmonary consumption. CASE XXI. J. A. B., of New York, aged forty; had suffered for several years, preceding 1843, from sore throat. The affection would nearly disappear when the summer w as present, but would return on the approach of autumn, and continue during the winter months. In August, 1843, when bathing at Rockaway, he contracted a cold which affected his throat, more severely than ever. He soon became hoarse ; there was slight pain in the throat; some difficulty of deglutition, and a constant irritation, at the top of the larynx. These unfavorable symptoms continuing to increase, on the accession of cold weather, he sailed for Europe, where he remained, in England and on the Continent, seven or eight months; but returned to New York, in the latter part of the summer of 1844. During his absence, he consulted several eminent, European physicians, 126 FOLLICULAR DISEASE COMPLICATED by one of whom, his uvula, which had become greatly elongated, w r as removed. After his return home, he placed himself under the care of a Homoeopathic physician, by whom he was treated up to the time when I was called to see him. November 29th, 1844.— Present State. —The patient manifests all the usual rational, and many of the physical signs, of confirmed phthisis. There is present great feebleness, emaciation, hectic, and night-sweats; and the signs developed by an exploration of the chest, indicate the presence of tuberculous disorganization in the apices of both lungs. The throat, on inspection, presents a highly diseased, and cavernous condition; the muscular fibres on the posterior wall of the pharynx, being wasted away by the long-continued disease; the mucous follicles of the fauces, and of the pharyngeal membrane are hypertrophied, and many of them in an ulcerated condition. The epiglottis is also ulcerated, along its superior border; and, moreover, is greatly expanded, presenting that singularly thinned, and elongated form, which Dr. Stokes* terms the " leaf-like expansion," or the "battle-door" shape of the epiglottis; a lesion which, in a case he has recorded, coincided " with double perforating ulcers of the ventricles." The patient experiences constant, pricking pains in the larynx; his voice has a peculiar cracked, or uneven * A Treatise on the Diagnosis and Treatment of Diseases of the Chest. By William Stokes, M.D., p. 217. 127 WITH PHTHISIS PULMONALIS. character, and at times it becomes quite extinct. But his greatest suffering arises from the severity of his cough, and the great difficulty which he experiences whenever any attempt is made at deglutition. To palliate these distressing symptoms, which were dependent for their unusual severity, upon the manifest ulceration of the epiglottis, and the larynx; I determined to apply topical remedies to these diseased parts. A solution of the nitrate of silver, of the strength of forty grains of the crystals to an ounce of water, was, accordingly prepared, and the epiglottis, and the interior of the larynx, was freely cauterized, with this preparation. On withdrawing the sponge, it was found to be loaded with purulent matter; and this occurred at each time, until several applications had been made. But the good effect of the topical treatment soon became apparent; after a few applications, the tussis ferina was changed into, comparatively, a mild cough; the patient became able to swallow his food without difficulty; and, indeed, remained relieved of these distressing symptoms, while he continued to live; —for the disease of the lungs, necessarily, passed on to a fatal termination. Permission was not obtained to examine the body. CHAPTER V. Malignant Follicular Disease of the (Esophageal Tube. All pathologists agree, that the oesophagus is remarkably exempt from structural disease. It must be admitted, however, that our knowledge of the diseases which do occur in this tube, is still very imperfect. A great deal remains to be investigated, before their pathological history, and diagnosis, can be correctly established. Indemnity from disease, in the oesophagus, is attributed, in part, to the peculiarity of its organization. Its mucous membrane, is less vascular than that of the air-passages, and is, moreover, defended by a thick epithelium which extends beyond the cardiac orifice of the stomach. The follicles of the oesophagus are less numerous, than are those of the larynx and trachea; and, besides, they are deeply imbedded in the sub-mucous tissue; while their excretory ducts pass obliquely through the mucous membrane of the oesophagus, and open upon its surface, in such a manner, that particles of the food, —as the morsel is swallowed, —are prevented from finding their way into the cavities of the glandulse. 129 OF THE O3S0PHAGUS. Hence, idiopathic disease, affecting primarily these follicles, is, of comparatively rare occurrence. But a morbid action, which has its origin in the glands of the fauces and pharynx, is, not unfrequently, extended, by continuity, to those of the oesophageal membrane, where it often manifests a marked tendency to assume a scirrhous, or a malignant form. This cannot be better illustrated than by an exhibition of the following cases : CASE XXII. March 18, 1839.—I was requested to meet, in consultation, my friend, Dr. A. G. Smith, in the case of Mrs. A., aged 62; a lady of this city, who, for many months, had been labouring under a stricture of the oesophagus. The disease had existed for several years. In the early stage of the disorder, she had complained, for a long period, of soreness and irritation in the back of the throat j accompanied, at times, with a " burning sensation," and with some difficulty in swallowing. For a long time, however, this latter difficulty was slight, but for several months antecedent to the period of this, my first visit, the patient had been able to swallow liquids, only, and these, even, in the smallest quantities. On inspecting the throat, its cavity was found enlarged, while the mucous lining of the fauces and pharynx, was pale, and its surface rough with granulations. 7* 130 FOLLICULAR DISEASE Situated on the side of the neck, there was, also, at this time a small tumor occupying the space between the cornu of the os hyoides and the thyroid cartilage. This tumor had existed for many weeks; but it had been observed of late, by the patient, and her attendants, to have increased in size, and along with this enlargement, there had been a correspondent increase, in the difficulty of deglutition. At times, whole days would pass, during which the patient would not be able to swallow a particle of food, either in a solid or liquid state; the consequence of this, was great debility, with considerable emaciation of the body. This was her condition, at the time when I first saw her. On several previous occasions, Dr. Smith had succeeded in passing a small bougie, down the oesophagus, and, in each instance, this operation was followed with an ability to swallow a small amount of liquid food. At this time, there was introduced, with some difficulty, a bougie, about four lines in diameter, and this was immediately followed with the introduction of one, two sizes larger. • The patient, who had been unable to swallow for nearly twenty-four hours, previously, swallowed some food, soon after withdrawing the bougie ; and she continued able to take nourish ment, in small quantities, for the two succeeding days. At the end of this period, it became necessary again to introduce the largest bougie ; and this operation was repeated each second, or third day, 131 OP THE GLSOPHAGUS. during the two following weeks. By this time, however, not only had the inability to swallow, increased, but it became exceedingly difficult, to pass the smallest of the bougies. The tumor, which had been observed on the side of the oesophagus, had, during this period, considerably enlarged, and had extended down to the level of the crycoid cartilage. Suspecting that the pressure of this tumor upon the upper portion of the oesophagus, was increasing the stricture, and operating as an additional hindrance to the passage of food, and the bougie, I made an effort to raise it from its bed, by inserting the points of my fingers under its base, and drawing it upwards and backwards, towards the mastoid process. In this, I succeeded, and while it was retained in this position, the patient could swallow better than she had been able to do, for several preceding days. Under these circumstances, I proposed to my colleague, that we should remove the tumor. He acceded, and the patient herself desiring the operation, the tumor was carefully dissected out, by Dr. S., on the 22d of April. It proved to be, what we had anticipated, a scirrhous enlargement, of one of the lymphatics. A re-union, by the first intention, followed this operation; the patient could again take nourishment, in small quantities, and this ability to swallow continued for several weeks after the removal of the tumor. About the 1st of June, the difficulty of deglutition again returned j the patient soon lost 132 FOLLICULAR DISEASE all power of swallowing, and was in danger of dying, from actual starvation. On the 4th of June, we succeeded in passing through the stricture, the smallest tube of Hutchinson's stomach pump, and, immediately, pumped into the stomach, some liquid nourishment. From this time, until her death, w r e had no difficulty in administering, by means of this invaluable instrument, all the nourishment that this suffering lady required. But, notwithstanding this, she gradually sunk, under the influence of the disease. On the 7th of June, she was attacked with severe rigors, which were repeated on the 8th and 9th, and were attended by a diarrhoea; under which she sunk, rapidly, and died on the 11th of the month. Autopsy. —Assisted by Dr. Smith, I examined the body, fourteen hours after death. On making an incision, along the side of the larynx and trachea, we found that the parts, which had surrounded the removed gland, had healed kindly, and were in a healthy condition. The whole chain of glands along the side of the neck were enlarged, and in a scirrhous condition. On cutting into one of the largest of these tumors, which was situated over, and near the union of the clavicle and sternum, it was found to be in an ulcerated condition, and to contain a quantity of bloody serum; its walls were bounded, on one side, by the trachea and oesophagus j the muscular coat of the latter, and also that of the jugular 133 OF THE O3S0PHAGUS. vein, were also destroyed by the ulcer. Had the patient lived, it must have made its way into the oesophagus, in a very short time. On laying open the oesophagus, the investing membrane of this tube was found greatly thickened, for several inches below its orifice; the mucous glands, throughout its whole extent, presented, though in a much higher degree, the same morbid appearance, that had been observed to exist in the follicles of the pharyngeal membrane; being much enlarged, and filled, many of them, with matter, apparently of a tuberculous nature. The stricture itself, it was discovered, depended upon a diseased condition of a cluster of the follicular glands, which were situated in the upper portion of the oesophagus. These glands were in a scirrhous condition, and had so enlarged as nearly to obliterate the passage. The disease, undoubtedly, had originated in the follicles of the pharynx and oesophagus ; while the lymphatics, external to these, had become affected, secondarily. Both orifices of the stomach, and the stomach itself, were in a healthy condition. The mucous membrane of the trachea and bronchi was injected j the follicles of the larynx, were slightly hypertrophied, and the lining membrane of this cavity, as well as that of the epiglottis, appeared vascular and thickened. No ulcerations were observed in the larynx. 134 FOLLICULAR DISEASE CASE XXIII. C. C, aged 56 j an intelligent lady of the Society of Friends, came to New York, for medical aid, in January, 1844. For several years, she had suffered under a difficulty in her throat, which, at this time, had increased to such an extent as to render it impossible for her to swallow food, except such as could be taken in a liquid form. January 14th.— Present State. —The patient is thin and pallid; she is debilitated, from having lived more than a twelve-month upon fluids, but her general health appears to be but little impaired ; the appetite is good; voice is husky, but there is no cough; sounds from the chest are normal. She admits of the presence of no pain, except a slight uneasiness under the right breast; but complains of dryness of the throat, and of soreness, felt, whenever any attempt at deglutition is made. The mucous lining of the fauees appears injected, and the follicles of the pharynx are in a hypertrophied condition, but no ulceration of any of these glands is apparent; the epiglottis is healthy, and the patient complains of no pain, or irritation in the laryngeal region. Evidently,, the disease, which, from the history of the case, and the appearance of the throat, must have had its origin in the glands of the pharynx, 135 OP THE OESOPHAGUS. had extended down the oesophagus, and had involved the follicles of that tube, in its morbid action. The pharynx, and the upper part of the oesophageal tube, were cauterized, with a solution of the crystals of nitrate of silver, of the strength of one scruple of the salt to an ounce of water; and the patient was put upon the free use of Lugol's solution of iodine. Topical medication was not employed but once, in this lady's case, as she left the city, immediately after the first application, and did not return, until the end of two w eeks, at which time she came back, complaining less of the soreness, and difficulty of deglutition, but still unable to swallow food, except in a fluid form. The ability to take liquid nourishment continued until about the 16th of February, following, when the power of deglutition entirely failed. Residing in Westchester County, about fifteen miles from New York, no efficient aid was obtained, and the patient passed nearly three days, without receiving into the system, any sustenance whatever. On the 19th of February, I was requested to visit her, without delay : arrived, I found her nearly exhausted, from fasting; there was constant nausea; and occasional efforts at vomiting, were made, but nothing was ejected from the stomach. Liquids taken into the mouth, would pass down the oesophagus, apparently, to the cardiac orifice, and then be returned. A bowl of thin soup, was immediately* procured, 136 FOLLICULAR DISEASE and I passed Hutchinson's second size stomach tube, down the oesophagus, intending to pump this nourishment into the stomach. The tube passed the cardiac orifice, so readily, that I withdrew it, in order to introduce the largest size. Before doing this, however, I directed the patient to swallow a spoonful of the soup, which she did without any difficulty, and the whole amount was taken into the stomach, immediately, by the spoonful; proving very grateful, and refreshing to my patient. I did not see this lady again, until the 27th of July ; nearly six months afterwards, but from the period of the introduction of the stomach tube, until the day of her death, which occurred on the 2d of August, she continued to swallow food, in a liquid state, in sufficient quantities to sustain life j but she wasted, gradually away ; and when I saw her, on the 27th of July, she was greatly emaciated, and very feeble; her voice was husky and faint; and there was present, at this time, much bronchial irritation. On the 2d of August, she was seized, suddenly, with a violent cough; accompanied with great dyspnoea, and a burning pain, under the upper portion of the sternum. Under these distressing symptoms, she sunk, rapidly, and died, in a few hours. Autopsy, twenty-four hours after death. —In the inspection of the body I was assisted by my friend, Dr. Robert Nelson. The stomach was in a healthy condition'; the lungs, also, were healthy, with one 137 OF THE OESOPHAGUS. exception, which will be named hereafter. The bronchi w T ere divided, just above their sub-divisions ; the oesophagus, at the cardiac orifice, — which latter, was in a healthful condition, —and these parts, including the pharynx, the trachea, the larynx, epiglottis, and the tongue, were all removed together. The oesophagus was adherent to the dorsal and cervical vertebrae, by a cellular structure, which was in a diseased condition. The oesophagus was laid open by an incision from behind, and found to be extensively diseased, throughout nearly its whole extent. The mucous glands, at its upper portion, were in a scirrhous condition, while all those below, were destroyed by ulceration. Commencing near the level of the cricoid cartilage, a deep, ragged ulcer, was found, occupying the anterior half of the oesophagus, and extending down, several inches, below the bifurcation of the trachea. Near its centre, it had destroyed, not only the cellular, and muscular coats of the oesophagus, but had involved a portion of the posterior wall of the trachea, and, at one point, had penetrated the left bronchus ; thus forming a direct opening from the oesophagus, into the lungs. Through this opening, which was of sufficient size to admit the tip of a finger, matters, from the oesophagus, had found their way into the cavity of the lungs; producing the symptoms of suffocation, and proving the immediate cause of death. Numerous, bony spicula, were discovered, penetrating 138 FOLLICULAR DISEASE the ulcerated portion of the oesophagus. They were found to be portions of the ossified rings of the trachea, and bronchi, which had become carious, and were broken up. A few tubercles were deposited in the summit of the left lung; some of which, near the ulcerated opening, had suppurated: the remainder of the left, and the entire right lung, were in a perfectly healthful condition. Traces of considerable inflammation, were found in the trachea; its mucous membrane was thickened; its follicles were hypertrophied, and, in some places, these, together with the lining membrane, were destroyed by ulceration; some portions of the rings of the trachea, and of the bronchi, had become carious, and were broken up. The lips of the glottis, the epiglottis, and the arytenoid cartilages, were greatly Gedematous. But, still more severely, had the thyroid, and the crycoid cartilages, suffered. The left lateral part, of the former of these cartilages, was denuded by ulceration, and in a state of necrosis ; while one-half of the crycoid cartilage, of the same side, was also denuded, and nearly destroyed by necrosis. These several, diseased portions, from which the drawings of Plate No. VI. were made, were removed, and have been preserved among my specimens of morbid anatomy. CHAPTER VI. Pathology of Follicular Disease of the Air-Passages. The attention of many eminent pathologists has, of late, been directed to the investigation of the nature of those anatomical lesions, which are the result of inflammatory action in the follicles of the gastro-intestinal, mucous membrane. The frequent occurrence of ulceration in some portion of these glandular in typhus fever, dysentery, tabes mesenterica, cholera infantum, tubercular phthisis, etc. etc., has been long observed, and the influence which, in their pathological states, they exert upon the character, and duration of these diseases, is, at the present day, acknowledged, and, to a considerable extent, understood. But our knowledge of the pathology of the mucous follicles of the pharynx, and of the laryngo-tracheal membrane, is still limited and unsatisfactory It has been remarked, by some writers, that the presence of disease in the glands of the respiratory system is of rare occurrence, in comparison with the frequency with which it has been found to exist in the intestinal, mucous follicles; and the difference, in this respect, in these different tissues, 140 PATHOLOGY OF FOLLICULAR DISEASE has been attributed to the great predominance of mucous crypts, in the gastro-intestinal membrane, as compared with those of the respiratory apparatus. Unquestionably, the occurrence of lesions, in the glandular of the intestinal membrane, is more frequent, than in those of the respiratory tube ; but it is equally true, that disease of the investing membrane of the latter; originating in its follicles, has been repeatedly overlooked, or, has been attributed to other lesions which have not existed. Dr. Stokes* has assigned another cause of the increased frequency of follicular disease in the gastro-intestinal membrane, namely; the greater exposure of these glands to chemical and mechanical stimulation. But, this opinion is sustained, neither by the nature of the lesions, nor by the anatomical structure of the parts; for, with a manifest appearance of design, these glandulse of the digestive canal, are so arranged, anatomically, that they are protected from the influence of hurtful agencies which may come in contact with the mucous surface. The numerous follicles of the stomach and duodenum, as we have seen, are situated in the submucous tissue ; and numbers of these cryptai have their ducts united in one common excretory tube, which, penetrating the mucous membrane, opens upon its interior surface. These tubuli, except during the period of digestion, remain constantly •Cyclopedia of Practical Med. Article Enteritis. 141 OF THE AIR PASSAGES. closed ; while the glands of Peyer ; —which, according to Andral, who has furnished a table of the relative frequency of follicular ulceration, in different parts of the canal, are the most frequently diseased of all the intestinal follicles, —have no excretory openings, whatever; but are closed sacs, that taking on a diseased action, burst, at length, and discharging their contents, become open, ulcerated cells. If we could refer, with propriety, to the above exciting cause, as a source of frequent, follicular disease, then might we expect the repeated occurrence of change of structure, in the mucous glands of the lining membrane of the oesophagus; for, throughout the whole extent of the digestive canal, no follicles are more constantly exposed to chemical and mechanical stimulation, than are these; and yet, we have found that the presence of disease in the oesophageal, mucous glands, is much less frequent, than is its occurrence in those of the respiratory apparatus. And this is in strict accordance with the physiological law, laid down by Bichat, in his pathology of the mucous membranes; that, organs the most active, are, also, the most subject to disease* Hypertrophy of the Follicular glands.— It has been remarked, in a former chapter, that among the structural changes which are the pro- * Pathological Anatomy. By Zavier Bichat, p. 81 142 PATHOLOGY OP FOLLICULAR DISEASE duct of chronic inflammation of the mucous follicles of the throat and air-passages, are, hypertrophy, induration, altered secretion, ulceration, and a deposition of tuberculous matter in the follicles themselves. Hypertrophy of the secreting organs is among the most common lesions, with which the glandular system is affected. Of this morbid change, we have frequent examples in the enlargement of the liver, the testes, the thymus gland, and in the formation of the true bronchocele. Thus it is in follicular disease of the pharyngo-laryngeal membrane. One of the earliest changes observed, is hypertrophy of the mucous glands. The investing membrane of the respiratory tube, as we have seen, is studded with mucous follicles, which, in their normal state, are scarcely visible ; but, affected by disease, a deposition of textural matter follows, and these glands become, not only apparent, but, in some instances, greatly enlarged. Hypertrophy is not always a morbid process; as it sometimes depends upon an increased nutrition of the part; but the altered secretion, and the changed structure, which attend this form of it, mark it, as being united with disease, or, as constituting, in itself, diseased action. Not only are the cryptse of the fauces, pharynx, and air-passages, enlarged, in follicular disease, but, in many instances, the lenticular papillae, those large mucous 143 OF THE AIR PASSAGES. glands, which are situated at the back of the tongue, just before the foramen ctecum, are found in an hypertrophied condition. Induration of the Follicular Glands. — Hypertrophy of the mucous follicles, is not always accompanied with induration. In a large majority of instances; even where the disease has existed for years, this morbid alteration is not present. Cases do occur, however, where the chronic inflammation, which is attended by enlargement, is productive, also, of induration of the follicle. In the solitary glands, this change is of rare occurrence ; but in the mass of follicles, which are aggregated in the tonsils, long continued inflammation is, generally, accompanied by induration; a condition of these glands which has been, frequently, but improperly, pronounced to be scirrhous degeneration of the tonsils. The induration, in these cases, which is not of a malignant character, depends, undoubtedly, upon the presence of a deposition of fibrin, which, during the process of inflammation, has been lodged in the cavity of the follicle, or in the interstitial substance with which it is surrounded. The matter thus deposited, very readily becomes vascular, is supplied with blood vessels, and at length becomes organized : but this process takes place to a limited extent, for when excised, the enlarged tonsil seems to possess but little sensibility. 144 PATHOLOGY OF FOLLICULAR DISEASE But there is another kind of induration, which, not unfrequently, takes place in the mucous follicles, of which the tonsils are composed, when these glands are affected by chronic disease; it arises from the presence of calcareous matter, which is sometimes secreted by these follicles, and is found deposited in the dilated orifices which lead to their cavities. In many instances, on removing an enlarged tonsil, I have found calcareous concretions, of various sizes, imbedded in the centre of the gland. Mr. Yearsley, of London, who has recently published an interesting work, on the morbid condition of the tonsils and uvula, remarks, that, in chronic disease of the tonsillary glands, he has, not unfrequently, found the hypertrophied gland filled with solid matter, of a dirty white colour, which, from its calcareous appearance, he has considered not unlike the deposite on the teeth, and supposes it may originate in the same way as the crusta petrosa, from the salivary, and other secretions, of the mouth. In several instances, the same author states that he has found calcareous deposits imbedded in the centre of the diseased growth; and, in one instance, a calculous closely resembling a piece of rock coral, in its arrangement. Dr. A. L. Cox, also, of this city, who has had most extensive experience in the treatment, and excision of hypertrophied tonsils, informs me, that he has often met with deposits of calcareous matter, in these glands, and, on several 145 OF THE AIR PASSAGES. occasions, had seen them so large as seriously to arrest the progress of excision. Morbid secretion of the Follicular Glands. —The fluid secreted by the mucous follicles of the air-tubes, being intended to lubricate these passages, is, in the normal condition of the glands, bland, and transparent; not abundant in quantity, and possessing no qualities of an acrid, or an irritating nature. It consists, according to modern, microscopic observations, of water, combined with a viscid substance, which is termed mucus, and which constitutes about five per cent, of the w hole amount. When, however, the mucous crypts become the seat of that chronic inflammation, of which we have been treating, the fluid which they elaborate is, at once, increased in quantity, and vitiated in quality. Many years ago, M. Brenet, physician at Dijon, demonstrated by repeated experiments, that irritation of secretory, or follicular surfaces, by artificial means, was of power to change the nature, the quantity, and quality of the fluids which they secrete in their usual state. Chaussier,* who alludes to these experiments of Brenet, states, that, from a great number of researches and experiments which he had made, he had established the fact, that the fluids of the secretory organs, most of which, in their healthy state, are more or * Vide Letter to Broussais, appended to " Proposition CC." 8 146 PATHOLOGY OF FOLLICULAR DISEASE less acid, contract, when in a state of disease, or from prolonged irritation, an alkaline quality which renders them acrid, and irritating. Thus, the tears which constantly lubricate the surface of the eye, and which, in their healthy state, are mild and thin, and are neither acid nor alkaline, become, when inflammation occurs in the organ of vision, abundant and scalding; and in flowing over the cheeks, mark their course by a red line; fully demonstrating, that their nature is changed, that they have become acrid, and have assumed an alkaline character. It is the same, adds Chaussier, with all the secretions which are augmented by any grade of irritation. Thus, in some cases of coryza, the humor which flows from the nostrils, becomes so acrid, as to occasion the swelling of the upper lip; and in violent irritations of the bronchi and lungs, the secretions which are poured out, always assume an alkaline character. It is after this manner that disease, affecting the mucous follicles, changes their naturally bland, and trasparent secretion, into an acrid, and adherent discharge, which, instead of protecting and lubricating the parts, becomes, not only a source of irritation to the investing membrane, but serves to extend the disease to other, and more distant follicles. Another pathological condition, dependent upon a morbid state of the follicles, is that which sometimes results in a discharge of blood, poured out 147 OP THE AIR PASSAGES. from diseased, secretory surfaces. Hemorrnages from the surfaces were arranged by Bichat, in two distinct classes; namely, those dependent upon the rupture of a vessel, and those arising from exhalation.* Modern pathologists, however, have not been able to confirm the opinion of Bichat, with reference to the existence of exhalant vessels, but they maintain the opinion that, hemorrhages of the mucous membrane, occurring where no perceptible lesion exists, depend, nevertheless, upon the rupture of vessels which, from their minuteness, are themselves invisible. At the time of writing these pages, I have under treatment, a young gentleman of this city, who, for a long period has suffered under follicular disease of the throat, and who without manifesting any symptoms of phthisis, has had repeated hemorrhages from the pharyngeal, mucous membrane. The spot, indeed, can be distinctly seen from whence the blood exudes, and, yet no abrasion of the surface, nor the rupture of any vessel can be detected. Mr. Yearsleyf relates a similar interesting case, where the patient became seriously alarmed upon observing that several mornings in succession he spat blood. Apprehending the approach of phthisis he consulted a physician, by whom he was subjected to prolonged, and severe treatment, with- * Pathological Anatomy. By Zavier Bichat, p. 64. f Loc. cit. pp. 35-6. 148 PATHOLOGY OF FOLLICULAR DISEASE out producing any effect upon the supposed haemoptysis. At length the attention of the physician became directed to the throat, in which were found enlarged tonsils, and a highly vascular condition of the mucous membrane. On close examination, it was plainly seen, that the blood exuded from the enlarged pharyngeal veins, and the very spot whence it escaped, could sometimes be denned. When the nature of the case w r as apprehended, the appropriate remedies soon removed the morbid condition of the parts. The secretion of a fluid, possessing all the sensible, and chemical properties of pus, is the frequent result of disease of the pharyngo-tracheal follicles. When the disease in these glands has passed on to the stage of ulceration, the purulent secretion is marked, and abundant, and its source is apparent; but, it sometimes occurs, where no structural lesion, either of the follicles, or of the lining membrane, can be detected. Indeed, Andral,* and other pathological writers, have recorded cases, in which a free, purulent expectoration, has continued for some time before death, where inspection, after death, has revealed no alteration of structure, nor any other evidence, whatever, of inflammation having taken place, during life. Generally, however, when purulent secretion takes place, in follicular inflammation, the glands are found to be, more or less, in an ulcerative condi- * Pathological Anatomy, vol. II. p. 4S2 149 OF THE AIR PASSAGES. tion ; in many instances they may be seen, in the posterior fauces, and on the pharyngeal membrane, some of them ulcerated, others distended with purulent matter. The fluid, likewise, which is poured out from the follicles of the tonsils, when these glands are hypertrophied and inflamed, is, not unfrequently, of a purulent nature. I have, on a former occasion,* expressed the opinion that tuberculous deposits are sometimes found on the surface of the membrane lining the larynx, or collected in the mucous follicles of this cavity. I am perfectly aware of the high authority opposed to this statement, and I should not presume, from a limited observation, to express such an opinion, if I were not sustained, on the other hand, by authority not to be altogether disregarded. In M. Louis' work on Phthisis, published in 1825, this author declared that, not "in a single instance, had he met with tuberculous granulations, in the substance, or on the surface of the epiglottis, larynx, or trachea." In the second edition of his Researches, published eighteen years afterwards, and recently issued by the "Sydenham Society," Louis reiterates the assertion, though not as positvely, and unconditionally as in his former work. He says, from his additional experience, "It may be regarded," in his opinion, "as a law of the system, that tubercles, so com- * See New York Jour, of Medicine, Vol. IV. No. XII. p. 354. 150 PATHOLOGY OF FOLLICULAR DISEASE monly, and abundantly developed in the lungs, are not produced, at least after the age of fifteen, in the upper air-passages; if such an occurrence does ever take place, it can only be regarded as a singularly rare exception to the ordinary course of things.* Authority on this subject, coming from such a source, claims the highest consideration, and any one of limited experience, may well hesitate to entertain, or express, an adverse opinion. But it is the prerogative of all to investigate, and no opinion in medicine, should be received as an established principle, which depends upon the authority of a single individual, however weighty his authority may be. The members of the medical profession in America, —a large proportion of them at least, — have been quite disposed to receive the views of the French pathologists as established truths, about which further investigation is considered medical heresy ! A few years ago, it was promulgated by the French School of Pathology, that a morbid condition of the mucous, glands of the small intestines, is the essential characteristic of typhus fever ; and this doctrine was received by a large class of the medical profession, in this country, as an axiom in medicine. So, too, the physiological system of Broussais j a system having enough of truth * Researches on Phithisis, by P. C A. Louis, p. 45. Sydenham Society Edition. 151 OF THE AIR PASSAGES. mingled with it to give it an air of great plausibility, was esteemed, by a part of the profession, in America, as a revelation in medical science. But it has fallen, says a late medical writer, before close observation and logical reasoning, and left the followers of Broussais, comprising almost the entire existing generation of French physicians, at sea without a compass.* The same disposition obtains with many of our profession, to receive, unquestioned, the opinions and conclusions of Louis, on the subject under consideration; and, certainly, to no single authority could they refer with higher confidence. Others, however, whose opinions should have some weight with the profession, have questioned these conclusions. Among these, M. Andral, in 1840, declared that the mucous membrane of the larynx, is, frequently, the seat of tuberculous deposits —an opinion, I believe, to which he still adheres. In Dr. Williams' work on Pulmonary Consumption, he remarks:—"If tubercle be, as we suppose, a degraded condition of the fibrin or nutrient principle of the blood, we may expect it to be deposited wherever the nutrition or the secreting process is carried on; —wherever lymph or pus is occasionally found, —wherever, in short, blood-vessels run. Tuberculous matter," he adds, " has been met with in coagula in the heart, spleen, and blood-vessels ; and it may be deposited in tis- * British and Foreign Medical Review. 152 PATHOLOGY OF FOLLICULAR DISEASE sues, and on surfaces, independently of irritation of these parts." M. Tonnelle, a writer to whom Louis alludes, in his second edition, assures us that he has found tuberculous productions in the cavity of the larynx, among which were slightly softened tubercles, which had produced ulceration of the mucous membrane. Dr. Carswell declares, " That the mucous system is by far the most frequent seat of tuberculous matter ; —that the presence of tuberculous matter in the larynx, in the trachea, and in its larger divisions, is not often observed," but that " he has met with it, in a few instances, in the follicles of these parts, and occasionally in the saculi laryngis;" and he then makes this pertinent inquiry : —" May it not be owing to the facility with w 7 hich tuberculous matter escapes, that we do not find it acccumulated on the mucous surface of the larger bronchi, or the trachea, or that of the intestines V* In short, Dr. Carswell supposes that tuberculous matter may often be secreted upon the free surface of the membranes of these parts, but that not being entangled, or confined in any mucous crypt, it is removed as soon as it forms. This view of the subject, in my opinion, explains the wiiole difficulty of the matter. M. Louis has not met with tuberculous deposits, on the surface of the epiglottis, larynx, or trachea, in adults, simply because all morbid secretions, and especially those of inorgan- 153 OF THE AIR PASSAGES. izable matter, operate as irritants upon these parts, and are thrown off as soon as formed. Again; this view of the subject is sustained by the fact, — a fact which Louis recognizes,—that tuberculous matter is frequently found filling the smaller bronchi; being secreted upon the mucous surfaces of the terminal branches, it is there arrested while it is thrown off from the free surface of the trachea, and larger bronchi. The opinion here advanced is also corroborated by another important fact. It has been shown by M. Tonnelle, and admitted by Louis, that before the age of fifteen, tuberculous matter may be deposited in the larynx; or, in other words, there may be lodged in the upper air-passages of the child, while the expulsive powers of the chest are feeble, morbid secretions, which are thrown off, as soon as formed, when those powers are strong, as in the adult. Sustained by these facts and conclusions, I am still of the opinion that, in several instances which have fallen under my observation, I have found in enlarged mucous follicles of the upper air-passages, and imbedded in the tissues of these parts, morbid deposits, presenting all the physical characters of true tuberculous matter.* * After the sheets of this work were put into the hands of the publisher, I received, through the agent of the " London Sydenham Society," the able pathological work of Professor Hasse, —of the University of Zurich, — which has just been issued by that Society. 8* 154 PATHOLOGY OF FOLLICULAR DISEASE Whenever such deposits are observed, however, their appearance may always be looked upon, as indicative of the presence of a tuberculous diathesis. Ulceration of the Follicular Glands.—The observation has already been made, that, in all cases In this work, the above views, with regard to the deposition of tuberculous matter in the air-passages, are fully sustained. Besides the erosions to which M. Louis alludes, as being often found on the laryngeal face of the epiglottis, and the posterior surface of the trachea ; —and which owe their origin, undoubtedly, to the contact of these parts with tuberculous matter expectorated from the lungs,—there are other lesions of the mucous membrane of these parts, which present a notable difference from the above. These are termed by Professor Hasse, real tuberculous ulcers. " Louis, indeed," he remarks, " disputes their tubercular nature. Nevertheless, the generally well-marked tubercular granulations within these ulcers, and the determinate character of their microscopic elements, remove all doubt as to their true origin. They are most frequent in the larynx,—in its upper half, and at the posterior or anterior angle of the vocal chords, —but often occupy the whole inner surface of the organ. In many instances they extend to the lower side of the epiglottis,—sometimes beyond it, to the root of the tongue, even to the pharynx, and now and then to the entrance of the oesophagus. In the trachea they are less frequent than in the larynx, and chiefly confined to its posterior membranous walls. They are most rare of all in the bronchi." " The opportunity of observing these ulcers," still further remarks Prof. Hasse, '* at the outset, is rare ; they would, however, appear to originate in various ways. Tubercle commonly accumulates within the capsules of the muciperous glands, elevating the latter into little eminences, and, ultimately, when the softening process is completed, leaving corresponding ulcers in their stead. In many instances, again, tubercles form, in the first instance, within the mucous membrane, the process being, probably, as follows : instead of normal cells, tubercle-cells form beneath the epithelium-cells, crowd together, in part reach the surface and are shed, in part irritate the contiguous textures, producing, first, loss of substance and afterwards ulcers. In other cases, again, tubercle is from the outset deposited within textures still more deeply seated."—An Anatomical Description of the Diseases of the Organs of Circulation and Respiration. By Charles Ewald Hasse, M.D., &c. pp. 358-9. OF THE AIR PASSAGES. 155 of long-continued chronic irritation of the mucous glandulee, there exists a tendency, in the morbid action, to terminate, ultimately, in ulceration. Ulceration is always preceded by some degree of inflammation; but irritation, and engorgement of the cryptse, may continue for a long time, in many cases, before the occurrence of that process, —a solution of continuity with suppuration,—which constitutes true ulceration. In other cases, after the irritation has persisted for some time, the engorged follicle presents a small, ash-coloured point; which is surrounded by an inflamed base, and has red, and slightly elevated edges. In follicular disease these ulcers, which, ordinarily, spread slowly, are, generally, first observed about the arches of the palate, and on the back of the pharynx; they next attack the laryngeal face of the epiglottis, and the epiglottic glands, situated at the base of this cartilage, and spreading by continuity, they in some instances, invade the mucous follicles in the ventricles, and around the chordae vocales. Indeed, there is no part of the larynx and trachea, that may not be the seat of ulceration. In their early stages, ulcerations of the mucous glandulae are small, and superficial; continuing for a long time, not only are the glands destroyed, but the mucous, the sub-cellular tissues ; and even the cartilages themselves, may become involved in the ulcerative process. Intimately connected with the pathology of this 156 PATHOLOGY OF FOLLICULAR DISEASE disease, are those morbid conditions of the mucous membrane which, sooner or later, occur, to some extent, in all forms of follicular disease. One of the earliest, and most common alterations which take place in the mucous linings, of the air-passages, in the early stage of follicular disease, is an increase in their thickness. Invited by the chronic irritation which has been set up in the diseased follicles, there is, at first, an additional quantity of blood received into the contiguous mucous, and sub-mucous cellular tissues. This is followed by an infiltration of serum, within the substance of these tissues, by which interstitial deposition, they are rendered swollen and pulpy. In the more chronic, and long-continued form of inflammation, an interstitial infiltration of lymph, sometimes takes place, which renders the mucous lining more dense, and constitutes the true hypertrophy of this membrane. In almost all cases of follicular disease, however, there occurs, eventually, an opposite condition of things, from the above: for, after the affected glands have poured out their increased, and vitiated secretion, for a long time, not only are the surrounding, engorged membranes unloaded, and their increased thickness removed, but the sub-cellular tissues, and the pharyngeal muscles become atrophied ; in part, probably, from the increased absorption which has been set up; and we then have, on inspection, those enlarged, or cavernous 157 OF THE AIR PASSAGES. throats, so frequently observable in long-continued follicular disease, and to which, allusion has, more than once, been made. Connected with, and following this morbid condition of the throat, is an interesting physiological fact, which it may be proper here to mention. After the removal of the disease by a successful plan of treatment, a deposition of healthy, structural matter commences, and the calibre of the enlarged throat, is, in a short time, greatly reduced in its diameter. The filling up of the posterior pharynx, in these cases, usually commences, first, on the right side; so that, not unfrequently, the fleshy fibres of this side, will be, for a time, increased in thickness, to a considerable extent, beyond those of the left. The muscles of both sides become, at length, fully, and equally developed ; until this takes place, however, perfect, and natural vocalization will not be fully restored. CHAPTER VII. Causes of Follicular Disease of the Air-Passages, It is customary with writers to arrange the causes of disease, ordinarily, under three, separate heads; —the proximate, the predisposing, and the exciting. In a former chapter, I have stated that the disease which we have been considering, consists, primarily, and essentially, in a morbid condition of the glandular follicles, of the aerial, mucous membrane. Understanding the term, proximate cause, to be synonymous with the disease, itself, I shall refer the causes of follicular inflammation, to two distinct heads, only; —the remote, or predisposing, and the immediate, or exciting. Hereditary tendency. —One of the most important, among the remote causes of this affection, is a constitutional predisposition. That there exists, in some families, an hereditary tendency to follicular disease, is a well established fact. At this present time, I have under treatment, three brothers—clergymen, who have been compelled to relinquish their official, public duties, on account of follicular disease of the throat; and whose mother, now over eighty years of age, is laboring under the same affection. 159 OF THE AIR PASSAGES. In another instance, coming, also, under my observation, four members of the same family, with one of the parents, were the subjects of follicular disease; and, among my notes, a large number of cases are recorded, where two and three members, of the same families, have been treated for this affection. The presence of a strumous diathesis, awakened by any means, in individuals, who were born without any hereditary tendency to disease, may prove a remote cause of this affection. All those influences, in short, which tend to induce a cachectic state of the system, predispose the individual to follicular disease ; and, among these influences, no one stands more prominent, than that of impure air; —such an air, for example, as clergymen, teachers, lecturers, and other public speakers, are, frequently, compelled to breathe in crowded, and ill-ventilated churches, lecture-rooms, &c. Every observant individual, has often been made sensible of a morbid alteration in the secretions of the mucous membrane of the mouth, fauces, and throat, when he has been compelled to breathe, even for a short period, the pent-up, and vitiated air of a crowded room. When we reflect on the extensive mucous surface, of the respiratory apparatus, thus deleteriously acted upon; and that, without a perfect performance of the functions of this membrane, those important alterations in the blood, so essential to the 160 CAUSES OF FOLLICULAR DISEASE health of the individual, cannot be properly effected, we wonder that, under these circumstances, changes still more pernicious than those ordinarily observed, are not more frequently produced. M. Boudeloque, an eminent and experienced practitioner, thus estimates the influence of impure air in the production of scrofulous disease. "Personal experience," says he, " reading, reflection on a great number of facts, and the analysis of many observations, have impressed me with the deep conviction, that there exists one principal cause of scrofulous disease, a cause which predominates over all others, and without which, perhaps, the disease would never, or at least very rarely, develope itself. This cause consists in particular conditions of the atmosphere in which the individual resides. However ill-chosen or unsubstantial his food may be—however much cleanliness may be neglected—whatever be the nature of his clothing and its adaptation to the temperature — whatever the climate in which he lives, —the exercise he takes, or the duration of his sleep and waking,—if the house in which he dwells be placed in a situation to which the fresh air and the sun's rays have free and direct access, and the house itself be sufficiently airy, light and well-proportioned to the number of its inmates, —scrofulous disease will never make its appearance. On the contrary, however well chosen and nutricious the food, however minute the attention paid to clean- 161 OF THE AIR PASSAGES. liness, with whatever care the clothing be adapted to the temperature, or the duration of exercise, sleep and waking be regulated,—if the houses are so placed that the sun's rays cannot reach them, or the fresh air cannot* be renewed without difficulty —if, in short, they are small, low, dark, and badly aired, scrofulous disease will, inevitably, supervene."* Climate. —The influence of climate in the production of a morbid condition of the mucous lining of the larynx, trachea, and bronchi, has been noticed by most writers, on diseases of these organs. In predisposing the mucous follicles of the investing membrane of the air-passages, to take on diseased action, the cold, and especially the cold, and moist atmosphere of a northern climate, operates as a powerful agent. In its more aggravated form, follicular disease of the pharyngo-laryngeal membrane, first made its appearance, in this country, in New England j and it has occurred most frequently, and has proved most severe, in the cold and Northerly States of the Union. For several years, after the attention of the profession, at the North, had been called to the frequent occurrence, and the severity of the disease, it was not admitted that the affection had any existence, at the South. But this exemption from the disease, does not obtain at the present day. Some of the severest * M&noire sur les Scrofules, Revue MeMicale, 1832, Vol. I. p. 10. 162 CAUSES OF FOLLICULAR DISEASE cases of follicular disease, which have come under my observation, during the last two, or three years, have been those of individuals, coming from some of the most Southern States; and I have been informed by intelligent patients from New Orleans, that cases of the "Throat Ail" are very rife in that city. Debility. —Debility has a marked influence in the production of disease of the follicular glands; constitutional debility, especially, if it be the result of severe and protracted mental labor, conjoined, as it not unfrequently is, with mental anxiety, may prove a fruitful source of follicular disease. Few causes tend more powerfully to depress the vital energies, to weaken the nervous system, and dispose the organs to take on the action of disease, than mental inquietude, united with intense application to study. To this cause of disease it is, that many of the clergy of our country are exposed; and it is for this reason, among others, that so large a proportion of clerical men, —in comparison with those of the other professions,—are affected with follicular laryngitis. In these remarks, I refer not to that portion of the clergy, who, located in our cities and larger towns, receive, many of them, ample remuneration, for their ministerial labors; —but to that more numerous class, who, settled in the towns, and villages of the country, are compelled to sustain themselves, and their families upon salaries which, with the practising of a most 163 OF THE AIR PASSAGES. rigid economy, are barely adequate to supply them with the necessaries of life ! Subjected, as such inevitably are, to constant, mental anxiety, about their own temporalities; and obliged, at the same time, to labor, week after week, that they may prepare suitable spiritual food, for their flocks, they become, themselves, so far as regards this life, like the "vessels of wrath" against whom they declaim, "fitted for destruction —the easy, and almost certain prey to disease! I speak not at random on this subject; for, there has come under my own observation, case after case, of individuals of this profession, who have broken down, under the combined influence of mental labor, and mental inquietude. I am not the advocate of "fat livings" for "spiritual drones;" but, the labourer is worthy of his hire ; and that people, or that community, who employ a spiritual labourer, whose time, and talents, and life, are consecrated to their service; and, yet, who withhold from him any part of that support which is necessary to place him above these temporal cares, rob him of his own, as truly, and, in the eye of heaven, as criminally, as the house-breaker who despoils him of his goods ! Sex.— Dependent upon a peculiarity of formation, or upon some other cause, there exists a greater predisposition to follicular, laryngeal disease, in males, than in females. 164 CAUSES OF FOLLICULAR DISEASE This peculiar susceptibility to disease in the male sex has been observed moreover, by writers, with regard to other affections, of the upper portion of the respiratory tube. Ryland* remarks that the opinion seems general, and well founded, that boys are more subject to croup than girls ; and he refers to statistical information, given on this subject by Jurine, Goelis, and Rumsey, who have recorded a great number of cases of croup, of which, by far, the largest proportion were boys. M. Louis, in his admirable work, to which we have before referred —" Researches on Phthisis;" has recorded fifty-three cases of ulceration of the epiglottis; of which thirty-nine occurred in men, and fourteen, only, in women ; likewise, eightysix cases, where lesions were found in the larynx, sixty of which were in men, and twenty-six in women; and of ulcerations of the trachea, one hundred and seven cases are given, by the same author; of these, thirty were in females, and seventy in men.j" In a former chapter I have shown, that there exists a difference equally marked, in the liability of the two sexes to follicular disease. Influence of age. —The influence which some particular period of life has, in imparting to the system an increased susceptibility to disease, has been acknowledged by most writers, on affections of the respiratory apparatus. With regard to * Op. Cit. p. 131. f Op- Cit. pp. 42-3. 165 OF THE AIR PASSAGES. phthisis, Hippocrates, the father of medicine, declared that the time of life most susceptible to the disease, is between the ages of eighteen and thirty-five —" Tabes Us maxime oztatibus jiunt qua a decirno-octavo anno sunt usque ad tricessimum-quintum"—and all subsequent experience has confirmed this opinion. Most cases of true phthisis laryngea, says Dr. Porter,* have appeared about the age of thirty-two, and varying from that to thirty-six. Altogether the largest number of cases of follicular laryngitis which have fallen under my observation, have occurred between the ages of twentyfive and thirty-five j very few have been the instances where the disease has been manifest before the first, above mentioned period. EXCITING CAUSES. Influenza. —With regard to some causes of disease, it is sometimes difficult to say whether they should be classed among the exciting, or the predisposing causes, as "the same agent may at one time be a predisposing, and at another, an exciting cause." An attack of influenza may become a predisposing cause, by imparting to the system a greater susceptibility to the disease, which, afterwards, * Observations on the Surgical Pathology of the Larynx and Trachea. By W. H. Porter, p. 130. 166 CAUSES OF FOLLICULAR DISEASE may be awakened by some other exciting cause. But, generally, influenza operates as a very prominent, exciting cause of follicular laryngitis. A large proportion of the cases, which have been observed by myself, have had their origin in a severe attack of cold, or influenza. I have elsewhere stated that, after the appearance of the epidemic influenza, of 1830; —which not only extended over Europe, and, so far as is known, over the whole civilized world j —cases of follicular disease became greatly increased, in numbers, and in severity. So, likewise, the occurrence of the epidemic of 1837; —which was almost equally pervasive with that several years before, and that which prevailed extensively, in this country, in June, 1843, —served, in each instance, to multiply, greatly, cases of follicular laryngitis; especially, in New England, and in the middle States. The nature, and the immediate effects, of this latter epidemic upon the system, are well described in the New York Journal of Medicine, by the late, lamented editor, of that periodical. In the city of New York, according to this writer, almost the whole population experienced an attack of the disease ; neither age, sex, nor any condition, in life, being exempt from its invasion. To the airy habitations of comfort and affluence, and to the hovels of wretchedness its visitations were equally made— " cequo pulsat pede pauperum tabernm Regumque turres." 167 OP THE AIR PASSACES. Individuals were attacked indiscriminately, without reference to any predisposition, to catarrhal affections, and the malady was attended with a much greater depression of the powers of life, both corporeally and mentally, and with more local pain, than were proportionate to the catarrhal symptoms. Indeed, many individuals, after forty-eight hours' confinement by this disorder, looked like convalescents from some severe and protracted disease."* Although the brain, and nervous system, generally, suffer severely, in most cases of an attack of epidemic influenza; as is evinced by the extraordinary prostration of the strength, and, usually, great depression of spirits; yet, it is upon the mucous membranes, that the violence of the morbid action falls, and especially, upon those with which the air-passages are lined. Hence, there often remains, in the aerial tissues, a greatly increased susceptibility to other diseases, of a character more dangerous than that of the primary malady. An augmented liability to pulmonary consumption, and chronic bronchitis, it has long been known, is the common sequent, of an attack of epidemic catarrh. Follicular disease, we have had abundant reason to believe, is not unfrequently called into existence by the same, exciting cause. Dyspepsia. —The frequency with which dyspepsia has been found to be complicated with throat- *New York Journal of Medicine, July, 1843—Art. VI. 168 CAUSES OF FOLLICULAR DISEASE ail, has led many practitioners to adopt the opinion, that indigestion is not only a frequent, but, the common, exciting cause, of chronic, laryngeal disease. But this opinion is altogether erroneous ; and it has originated in the, too common mistake, —in the diagnosing of disease—of giving to the sequent, the place of the antecedent. In a letter, received from an eminent clergyman, who, for several years, has suffered under an aggravated form, of follicular laryngitis, that gentleman writes : " In my own case it may be proper to remark, that I have always enjoyed uninterrupted health. Never, since my remembrance, have I lost my dinner for want of health and appetite to receive, and enjoy it; this is true up to this day. Whatever abstinence I have imposed upon myself, has been in accordance with prudential considerations." To an almost equal degree has the same exemption from dyspeptic symptoms obtained, in a large proportion of the cases, to which my attention has been directed. Where a predisposition to follicular disease exists, derangement of the digestive organs may awaken, and, unquestionably, sometimes, does call, the affection into action ; but, in a much larger number of cases, the gastric disorder, if present, is consequent upon, follicular derangement, and is, in fact, dependent upon this morbid condition of the glands. This will not appear surprising, when we reflect upon the amount of vitiated secretion, which, in 169 OF THE AIR PASSAGES. disease of the follicles of the fauces, and pharynx, must find its way into the stomach; conveyed there, by the food, and drinks of the individual. Not unfrequently, has it occurred to me, in the treatment of diseases of the throat, to meet with cases of indigestion, complicated with these disorders, which having proved obstinate, under all the ordinary modes of treatment, have yielded, readily, to appropriate medication, after the removal of the primary, follicular disease. Eruptive fevers. —The great degree of pharyngeal, and bronchial irritation, which, ordinarily, is present, in eruptive fevers, but more particularly, in scarlatina, and rubeola, tends, essentially, to excite disease in the aerial, mucous glandular. I have under treatment, at this present time, January, 1846, an intelligent medical gentleman, of this city, in whom, an attack of scarlatina, under which he suffered, eight months ago; was followed by a severe attack of follicular laryngitis. Children, and young persons, affected by any of the eruptive fevers, are very liable to have the follicles of the tonsils implicated, and these glands are, frequently, found, particularly, after scarlet fever, small pox, or measles, in an hypertrophic, and morbid condition; and unless great care is taken to remove this diseased state, the affection is very likely to become permanent, and ultimately, to be extended to the follicles of the pharyngolaryngeal, mucous membrane. 9 170 CAUSES OF FOLLICULAR DISEASE Exercise of the voice.-*- The exercise of the vocal organs, in public speaking, and singing, has been considered a prominent, exciting cause, of this disease. The frequent occurrence of the affection, among the members of the clerical profession, has led to the adoption of this opinion, an opinion which, so far as my experience goes, is not sustained by observation. Where a predisposition to the complaint, exists, an undue or irregular exercise of the organs of voice, will tend, undoubtedly, to develope the disease ; but, without the presence of this increased susceptibility, the regular use of the voice, in public speaking, singing, &c, is not more liable to excite the disease, than is the constant employment of this organ, in ordinary conversation. If public speaking, alone, is an exciting cause, of the malady, how happens it, that lawyers, who speak every day in the year, are, so seldom, the subjects of this affection ? I have made inquiry among the auctioneers of this city, many of whom are engaged, throughout the season, in "crying," for hours, at their daily sales; and I have not been able to find a single individual, of this fraternity, who has been, to any considerable degree, a subject of the throat-ail. The truth is, the vocal organs are strengthened, by the daily, and regular use of the voice, in precisely the same manner, as the arm of the smith is invigorated, and its muscles strengthened, and developed, by constant exercise^ 171 OF THE AIR PASSAGES. To some other source, therefore, rather than public speaking, must we look for the cause, or causes, of the frequent occurrence of laryngeal disease, among clerical men. These causes, so far as this class of persons are concerned, are to be found, both among the predisposing, and the exciting. To one of these, I have already alluded ) namely —the conjoined effects of intense study, and mental anxiety. Another cause may be found, in the sedentary habits of the clergy; but, one, which may be deemed pre-eminent, as the cause of follicular laryngitis, with the members of this profession, is referable to the great inequality, in the daily degree of exercise, which they give to their vocal organs. Remaining quiescent, or nearly so, during six days of the week, these organs, on the seventh, are required to perform, a more than double duty; and this too, when, from the fact of their having been so long at comparative rest, they are less capable of enduring the fatigue, than if the muscles, of which they are composed, had been subjected, to daily exercise, in public speaking. If the labors of clergymen, could be equally apportioned to all the days of the week; instead of being weakened, and diseased, by public speaking, the voice would become strengthened, and developed, by such employment, and the individual would be much less liable to be affected, by laryngeal disease. The attempt to use the voice, by public speak- 172 CAUSES OF FOLLICULAR DISEASE ing, when the individual is laboring under the effects of a severe cold, or an attack of influenza; or the sudden, and violent exercise of the voice, although the vocal apparatus, at the time, may have been, apparently, in a healthy condition, has, frequently, laid the foundation of laryngeal disease. Several years ago, a distinguished clergyman, from Boston, came under my care, who, for many months, had been unable to speak, above an ordinary whisper, from disease of the throat, which had been brought on, by delivering an address, when hoarse from a cold, on some interesting, public occasion; which required him to speak, as he thought, with more than ordinary energy. In September, 1845, an interesting case, of laryngeal disease, came under my observation, which will illustrate the proposition that the sudden, and violent exercise of the voice, will, sometimes, prove an exciting cause of the disease. A robust young man, in excellent health, who is connected with a mercantile house in this city, was engaged, nearly two years before the above period, in the hoisting of a quantity of merchandise, into the upper loft of a store-house; when, wishing to give some order, he called, several times, and with considerable effort, down through the hatchway, to the men below. At this moment, he experienced, as he states, a most unpleasant sensation within the larynx; "as if something there, had given way." He, immediately became hoarse; 173 OF THE AIR PASSAGES. and this hoarseness continued to increase, until, in a few weeks, from the occurrence of the accident, his voice was reduced to a rough whisper. At first no cough was present, but soon, this condition of the vocal organs, was followed by an increased irritation, in the laryngeal cavity; by a teasing cough, debility, and emaciation ; and, ultimately, by frequent attacks of haemoptysis; so that, when this patient came under my care, last September, his case presented many of the rational symptoms, of tubercular phthisis; and all these symptoms had originated, apparently, in the injury w hich had been done to the vocal apparatus, nearly two years before this period. This opinion of its origin, and of the primary seat of the disease, is sustained, moreover, by the fact, that the patient, subsequently, recovered, under the use of topical medication, applied to the pharyngo-laryngeal, mucous membrane. In a similar manner, commenced the disease, in the case of H. S. (No. XIX.) This gentleman, in attempting to speak to a friend, who was standing at some distance from him, increased his voice, in order to be heard, when he was immediately seized with an irritation in his throat, which was soon followed by great hoarseness ; loss of voice ; and, subsequently, by a cough, and extensive laryngeal, and bronchial disease. In some instances, again, the attack is as sudden, without the presence of any appreciable cause. It 174 CAUSES OF FOLLICULAR DISEASE is stated by a gentleman, who has suffered, several years, from the disease, in a letter, received from him; and which now lies before me; that, in his case, "the attack was as sudden as a blow." " I was sitting," he writes, Cf very quietly in a church, listening to a brother [clergyman] who was preaching, when, suddenly, as I describe, I felt a tickling in my throat, which was just sufficient to excite my attention, and cause me to swallows" From this hour, the irritation, thus commenced, continued to increase, until a disease w as established, which for years, entirely incapacitated him, for public speaking. It is not to be doubted, that in all these cases, there was present, a strong predisposition to the complaint, which only required the occurrence of an exciting cause, to awaken the disease. Tobacco. —With regard to the effects which are produced on the human system by the habitual use of tobacco, different opinions are held, and have been expressed. That a deleterious influence is exerted on the animal o3conomy, by its use, most pathologists, of the present day, admit. Of this, after having watched for many years, in my practice, the effects of this narcotic, I entertain not a doubt; and I fully accord with the opinion expressed by Dr. Prout, who observes, in his work, " On the Nature and Treatment of Stomach and Urinary Diseases," that it [tobacco] disorders the assimilative func- 175 OF THE AIR PASSAGES. tions in general, but, particularly, as he believes, the assimilation of the saccharine principle, f I have never, indeed, been able, he adds, to trace the developement of oxalic acid to the use of tobacco; but, that some analogous, and equally poisonous principle, (probably of an acid nature) is generated in certain individuals, by its abuse, is evident, from their cachectic looks, and from the dark, and often greenish yellow tint of their blood." In the "Elements of Materia Medica," Dr. Pereira, in speaking upon the physiological effects of the moderate use of tobacco, on the human system, remarks : that he is not acquainted with any well-ascertained ill effects resulting from the habitual practice of smoking tobacco. He admits, however, that he is not so competent to speak of its effects when otherwise employed, as in England " the practice of chewing tobacco is principally confined to sailors;" and is, therefore, less frequently submitted to his observation.* As an exciting cause, the use of tobacco, in my experience, has proved a powerful agent, in the production of follicular disease of the throat. Acting as a stimulant, directly, and constantly, upon the mucous follicles of the fauces and throat; and greatly increasing, as it does, the secretion of * Op. Supra Citat. p. 318. 176 CAUSES OF FOLLICULAR DISEASE these glands, its employment, as we should conclude a priori, must have a direct tendency Jo develope the disease j especially, if a predisposition to the affection exists : hence it has occurred to me to notice, that of a great number of cases of throat-ail, which, during the last year or two, have come under my observation, a large proportion of them have taken place in individuals, who had been, or who were at the time, in the habitual use of tobacco. My attention has been called more particularly to this subject, from having noticed, several years ago, some observations on the use of tobacco in laryngeal and bronchial affections, by an eminent surgeon of this city. After having alluded to the almost universal use of tobacco in the countries of Northern Europe, he observes : —" In one very fatal and distressing form of disease, to wit, Laryngeal Phthisis, and Bronchitis, among public speakers, the fact is very clearly established, that the moderate habit of smoking, by the drain it accomplishes, and its anodyne qualities, has been eminently useful, at least as a preventive, of that peculiar malady so frequent in the United States, especially among the clergy."* From this opinion of my distinguished countryman and friend, I am compelled to differ, entirely, by the statistical facts, which I have obtained, on * Travels in Europe and the East. By Valentine Mott, M.D., pp. 83-4. 177 OP THE AIR PASSAGES. this subject. Not only has the use of tobacco in any and all its forms, proved, in my experience, an exciting cause of laryngeal disease ; but where its employment has been persisted in, during the treatment of any case, I have found it impossible to restore such, to perfect health. 9* CHAPTER VIII. Symptoms of Follicular Disease of the Air-Passages. Having, already, described the morbid appearances which are found in the forming stage, of follicular inflammation, and entered, quite fully, into the pathology of the disease, I shall now, only allude briefly, to the particular symptoms of the affection. It has been stated, in a former chapter, that the access of follicular laryngitis, is, in some instances, so insidious, and its progress so gradual, that, not unfrequently, it may continue many months, and make considerable advance, before the manifestations of disease shall be such, as to alarm the individual, or to call his attention, even, to the existence of the affection. Ordinarily, however, soon after the mucous glandular have taken on a morbid action, there is perceived in the region of the fauces, an increased mucous secretion ; and an uneasy sensation in the gullet or upper part of the throat is observed, attended by a frequent desire to swallow, as if some object, sticking in the passage, might be removed, by the act of deglutition ; or, more generally, re- 179 OF THE AIR PASSAGES. peated attempts are made, by hawking, to clear the throat, and allay the irritation; all which difficulties are considerably augmented, by every continued effort, made, to read aloud, to sing, or to speak, as in ordinary conversation. If the secretion from the mucous follicles of the throat be examined, at this period, it will be found to be altered in its character, —being adhesive, and, in some instances, of an alkaline quality, and proving to be, by its effect on the mucous membrane, of an irritating nature. About the same time, if the patient be accustomed to employ the voice, in public speaking, or in singing, there is apparent, to a greater or less extent, a loss of power, in the vocal organs j uneasiness in the larynx, with, sometimes, pain on pressure. Hoarseness, is also present, which may be light, in the morning, or altogether absent, but which is increased, towards evening, and after speaking longer, or louder than usual. On inspecting the throat, the fauces and the posterior wall of the pharynx will appear redder than natural; and the mucous membrane, covering these parts, will be deprived of its epithelium, injected, and studded over with enlarged mucous follicles. (See Plate I.) Sometimes, if the disease is recent, these glands will appear quite minute, and will be distinctly apparent, only, when the pharyngeal cavity is exposed to a full light. In other instances, they will have attained a size, sufficient 180 SYMPTOMS OF FOLLICULAR DISEASE to give a rough, or granular appearance, to the whole surface of the fauces ; while the viscid, tenacious mucous, which is poured out by these follicles, in their morbid state, may be seen, coating the membrane, or appearing in patches, or marking its surface with white, or yellowish white striae. In some cases, several of the enlarged and morbid crypta? will become confluent, and uniting, form angry looking tubercles, of the size of a split pea, which may be seen on the posterior wall of the pharynx. In others, again, a deposition of textural matter takes place, and the follicle becomes indurated, and permanently enlarged; or it may be distended with pus, or with a morbid secretion which will exhibit all the physical properties of tuberculous matter. If the affection has continued for some time, we shall frequently find some of the diseased follieles in an ulcerated state ; these are generally first observed about the palatine arch, the posterior wall of the pharynx, and along the border, and on the laryngeal face of the epiglottis. In the first stage, these ulcers are small and superficial,—appearing in the form of ash-colored patches, surrounded by an inflamed, and slightly elevated base. (See Plate II.) Continuing, they at length destroy the mucous follicles; and, sometimes, involve, not only the mucous, but the sub-cellular tissues, in their progress. 181 OF THE AIR PASSAGES. Accompanying the above symptoms there is often found oedema, and elongation of the uvula; and, in many instances, hypertrophy of the tonsils. If the patient be exempt from all hereditary, phthisical tendencies, these symptoms may continue, for years, without making any decided progress. At times, the unhealthy appearances, will be nearly, altogether absent, and will return again, whenever the individual is exposed to any of the ordinary, exciting causes. Some cases have come under my care, in which the disease, —its symptoms alternating in this way, —has continued for fifteen or twenty years j affecting only the follicles of the lining membrane of the air-passages; but, in other instances, where the disease had not been in progress, as many months, yet, where a strumous diathesis existed, I have found the lungs, in this period, irremediably affected; although the disorder was entirely local, in its origin, and had been limited, in its incipiency, to the pharyngolaryngeal crypta3. In the fall of 1844, I was desired to see, in consultation with my friend, Prof. C. A. Lee, a gentleman of this city, who, for several months, had labored under follicular laryngitis. The disease was decided and severe, but was limited altogether, to the pharyngo-laryngeal structure; for, by a careful examination of the chest at this time, no indications, whatever, of pulmonic, or bronchial lesions, could be detected. But the individual was, mani- 182 SYMPTOMS OF FOLLICULAR DISEASE festly, of a cachectic habit; and, for this consideration, particularly, he was advised to have prompt measures adopted, to arrest, the yet local disease, by topical medication. The plan proposed,—that of cauterizing the larynx, being objected to, by the patient, or by some of his friends, —was not carried into effect; and he, falling into the hands of another physician, soon after, was treated by means, addressed to the general system, only, while the local affection passed on, unchecked. I knew nothing more of this gentleman's case, until the May following,—nearly six months after the first consultation, —when I was requested to see him again, with Dr. Lee. We now found him greatly emaciated —having a severe cough, with hectic, and night perspirations, and, indeed, presenting all the more prominent symptoms of confirmed phthisis. His voice was reduced to a rough whisper; he complained of great soreness along the whole length of the laryngotracheal tube; there was dullness, on percussion, under both clavicles j and, on auscultating the chest, a large tuberculous excavation, was detected in the upper portion of the right lung. He was now quite solicitous to have the topical means employed, but, at this period, it had become too late, to have these measures prove remedial. At the patient's request, however, and by the advice of Dr. Lee, t now cauterized the larynx, freely, and this operation w 7 as repeated, twice, or 183 OF THE AIR PASSAGES. three times a week, for several weeks. By this measure, alone, the urgent symptoms were, —as they had been in other similar cases, —greatly relieved, and the life of the patient, evidently, considerably prolonged. In the incipient stage of follicular laryngitis, of the uncomplicated form, there is seldom much cough present. The irritation that is felt in the larynx, and which is caused by the increased, and vitiated secretion, from the diseased follicles, is generally relieved for the moment, by hawking, in this stage of the affection. As the disease advances, however, and the glandular of the larynx and trachea become involved in the morbid action, a cough will steal on, which, from being slight, at first, is at length, severe, and, in most cases, is attended by a free, tenacious expectoration. In this respect, the cough, which arises in follicular disease, differs from that which occurs in the early stages of tubercular affection of the lungs. In the latter, the cough will frequently continue for months, without any expectoration; or, if expectoration should occur, it will consist only of a trifling amount of transparent, frothy fluid. In another respect, these two diseases are essentially different. That peculiar, mental condition, incident to pulmonary disease; —by which the spirits of the patient are buoyed up, and hope, often, continues bright, to the last, —is well known. 184 SYMPTOMS OF FOLLICULAR DISEASE The reverse of this, obtains in follicular, laryngeal disease. In this latter affection, mental depression is, to some extent, so universally present; particularly, where the affection has been protracted, that I have been led, almost, to consider it, a characteristic of the disease. If the disease is not arrested, until ulceration of the follicles of the larynx and trachea, occurs, a manifest influence is exerted, by this lesion, on the nature of the cough; it becomes greatly aggravated, and is, more or less, paroxysmal. It has, if the structural change is extensive, a peculiar cracked, or whistling character ; and is attended, moreover, by considerable soreness, in the region of the os hyoides. The effects produced upon the intonation of the voice, are, likewise, very apparent; but they differ, materially, according to the seat, and extent of the disease. If the ulcerations are confined to the follicles about the tonsils, the veil of the palate, and the pharyngeal membrane, the timbre of the voice is not, ordinarily, much changed ; incomplete disphony sometimes exists ; or, in other words, the sounds are merely obscured, or imperfectly articulated. But let the ulcerations extend below the epiglottis, and the hoarseness is greatly increased ; the voice loses its power; and should the mucous glands within the ventricles, and around the vocal chords, become involved in the morbid alteration, it is reduced to a state of complete aphonia, and a harsh whisper,—which is 185 OF THE AIR PASSAGES. merely an articulation of the ordinary respiration, —alone remains. M. Louis has recorded several cases, where superficial ulcerations, seated within the ventricles of the larynx, had been accompanied, during life, by great hoarseness, and, ultimately, by more or less, aphonia; and still other instances, are mentioned by this author, where the ulcerations having extended to the thyro-arytenoid ligaments, were followed by the voice becoming completely extinct. Great difficulty of deglutition, w T ith pain, and, sometimes, dyspnoea, are symptoms which are ordinarily present, wiien the epiglottis, and, particularly, when its superior border, is extensively ulcerated. The existence of erosions, or superficial ulcerations about the epiglottis, in throat-ail, is a lesion, much more frequent, in its occurrence, than is generally supposed. In a large proportion of the cases of follicular laryngitis, which have come under my care, where the affection has been longcontinued, I have found more or less of ulcerations of the crypt&e of the epiglottis. These erosions are frequently found occupying the edge, or border of this fibro-cartilage ; and they may, often, be seen, distinctly, by pressing down the base of the tongue, with a broad crooked spatula. (See Plate IV. letter A.) By the same movement too, I have discovered, not unfrequently, deep and ragged ulcerations, burrowing in the fossae, which are situated 186 SYMPTOMS OF FOLLICULAR DISEASE below the lenticular papilla?, at the base, or roots of the tongue, where the attachments between this organ, and the epiglottis exist. Ulcerations, occupying the latter position, are productive of much mischief; and, from their peculiar position, are very likely to escape detection. Unless great pains are taken, to draw the whole mass of the tongue, downwards and forwards, their situation w r ill not be observed. Being protected by the abasement of the tongue, unless this organ is drawn forward, and depressed, in the manner just described, they are not, ordinarily, reached, by the topical application, in the attempt to cauterize the throat. The symptoms which characterize the presence of these lesions, do not differ, essentially, from those which indicate the existence of ulcers in the laryngeal cavity; they are, soreness, on one, or both sides of the throat, just under the cornua of the os hyoides; hoarseness, often, with more or less cough, and expectoration of an opaque secretion—sometimes free—which seems to come from the opening of the wind-pipe, or very top of the throat. This expectoration is, frequently, increased after eating, and is sometimes, tinged with blood ; or small masses of dark, almost coagulated blood, will be mingled with the sputum. Several eases have come under my notice, during the present year, where, topical measures having been employed, until the laryngeal affection had disap- 187 OP THE AIR PASSAGES. peared, these symptoms have remained, and have been found to depend upon the existence of old ulcerations, in the above described locality. The following case will illustrate the nature and symptoms of these lesions: A clergyman who had suffered several years from laryngeal disease, and whose official duties had been long interrupted, by the effect produced on his voice, came under my care, for medical treatment. The measures employed—which were such as have been enumerated in other cases—were so far successful, that his voice improved, and he was enabled to return to his official public duties. But still, this gentleman returned to my office, again and again, complaining of great soreness, in the upper part of the throat, back of the os hyoides j and yet, at this time, no disease, whatever, could be detected in the fauces, or laryngeal cavity; nor, were the above symptoms, in the least degree relieved, by applications to these parts. At length, with considerable difficulty, by placing the patient in a full light, and depressing the base of his tongue, I discovered, in the fossae, on both sides of the root of this organ, deep and ragged ulcerations, which, until this moment, had escaped my observation, altogether. These were, now, freely cauterized; and by repeating the topical measure, occasionally, were healed, at length; when the soreness, and irritation, which had been complained of, subsided, entirely. 188 SYMPTOMS OF FOLLICULAR DISEASE Since treating the above case, several others, of a similar nature, have come under my notice, where these occult lesions were found to exist in the same manner. In two of these instances, there was an occasional oozing of blood, from the ulcerated surfaces, which, commingling with the sputa, gave great alarm, to the individuals, and their friends. Topical medication arrested the morbid action, and the alarming symptoms disappeared. The effects produced on the appearance and position of the epiglottis by ulcerations of its follicles, and of those of the larynx, are so uniform, under similar circumstances, that I have been accustomed to view the different aspects, presented by this organ in disease, as in some degree, characteristic of the location and extent, of the internal organic lesions. The appearances consequent upon these ulcerations, differ according to their seat and extent; but my observations have not been sufficiently extended to enable me to arrange, and classify, the facts obtained, with that precision which I hope,—by calling the attention of the profession to this subject,—may yet be accomplished, when more materials shall have been collected. If the follicles, situated along the border, and on the laryngeal face of the epiglottis, become ulcerated, I have observed, that this organ ; which in its normal state is slightly crescentic, loses this form, and appears flattened like the tongue; it is 189 OF THE AIR PASSAGES. moreover, enlarged and thickened, and its border may be seen, frequently, serrated by the erosions. When that cluster of follicles, which constitutes the epiglottic gland, becomes the seat of ulceration, the epiglottis will assume nearly an erect form, and be found incurvated, or its crescentic shape considerably increased; and when this lesion has extended to the numerous glandular of the ventricles, and to those around the chordae vocales, the above alteration of the form of the epiglottis, will be still greater; its lateral edges, will then be found rolled in towards each other, so that the organ will present, nearly a tubular form, with its convexity towards the dorsum of the tongue. In October, 1845, a young gentleman from Springfield, Massachusetts, came to New York, to be treated for laryngeal disease, complicated with tubercular phthisis. The disease had progressed until the symptoms, which were present, indicated extensive ulceration of the laryngeal cavity, with pulmonary tubercular deposits. By pressing down the base of the tongue, of this patient, with the bent spatula, the epiglottis, red and hypertrophied, could be seen, erect, and rolled up like a scroll. On introducing a small sponge, into the larynx, for the purpose of cauterizing its cavity, it w T as found, when withdrawn, to be loaded with purulent matter. The local treatment was continued, several weeks, and was attended, so far as the laryngeal lesion was concerned, with much benefit. As the 190 SYMPTOMS OF FOLLICULAR DISEASE inflammation of the larynx subsided, the oedema of the epiglottis, diminished, and its contractions, in a good degree, became relaxed; but the tuberculous disease continued, and the patient died, at last, of confirmed phthisis. On examining this case, after death, both lungs were found extensively consolidated with tuberculous secretions; no large excavations were observed, but numerous, small cavities, extending throughout both lungs, w T ere found to exist. No lesion, whatever, was discovered in the trachea, but the surface of the larynx was granular, and uneven, and presented the appearance of having had extensive alterations of structure, in its cavity. Another aspect, indicative of organic changes, which the epiglottis presents, is that lesion which Dr. Stokes calls the "leaf-like expansion of the epiglottis." In one instance observed by this writer, the epiglottis was thinned, and singularly elongated, and its form so altered, as to present the shape of a battle-door, the narrow extremity being next the glottis. In this instance, the lesions of the epiglottis coincided with double perforating ulcers of the ventricles.* This singular alteration existed in case No. XX.; and I have observed the same lesion, in other instances, but it has always been, as in the above case, in connection with symptoms, which indi- * Op. citat. p. 217. 191 OF THE AIR PASSAGES. cated the presence of laryngeal disease, complicated with tubercular excavations. The symptoms which manifest themselves, when the laryngeal disease has extended into the bronchi and their ramifications, have been pointed out in a former chapter. When follicular disease becomes complicated with a catarrhal condition of the bronchial tubes, the cough, which is, ordinarily present, is attended by a free expectoration of transparent adherent mucus; and it is thisJieterogeneous discharge that indicates the existence of chronic inflammation of the lining membrane of the bronchial tubes. The symptoms which mark this complication of disease, are readily distinguished; as are those which are manifested, when follicular laryngitis exists with tubercular phthisis. In this latter complication the characteristic symptoms of consumption are, generally, greatly aggravated, by the presence of laryngeal disease; and the affection passes through its stages, and reaches a fatal termination much earlier, ordinarily, than when its progress is unattended by follicular disease, of the pharyngo-laryngeal membrane. Hence it is, that in these cases; namely, where ulcerations of the larynx co-exist with pulmonary disease ; —a lesion, which, according to Louis, is a frequent concomitant of tuberculous affection of the lungs,*—the * M. Louis found ulceration of the epiglottis and larynx to be present, in one-fifth of the cases of phthisis which he examined. Op. citat. 192 SYMPTOMS OF FOLLICULAR DISEASE lives of patients may, frequently, be prolonged, and their sufferings greatly mitigated, by the employment of such topical remedies, as will serve to allay the laryngeal irritation. CHAPTER IX. Of the Treatment of Follicular Disease. In the treatment of follicular disease, no difficulty will arise, ordinarily, in selecting such remedies as are appropriate to the early stage, of the simple, and uncomplicated form of this affection. Originating, as it does, in a morbid condition of the mucous glandulee of the faucial, and pharyngeal membrane, this affection, in its access, may be promptly arrested, generally, by an early application to the throat, of the proper topical, remedial agents It is, indeed, true, that a late learned writer, of this country, and, withal, a most excellent and experienced practitioner, exhibits a want of confidence in the means usually adopted, for the cure of chronic inflammation of the larynx, of the ordinary kind ; even when occurring in a sound constitution. The remedies enumerated by this writer, as those best calculated to meet the indications in the disease, are; —"bleeding, general and local; blisters, or other counter irritants, frictions with the emetic tartar ointment, or croton oil, till pustulation is induced, and setons, issues, &c," 10 194 OF THE TREATMENT OF together with " the application, once or twice a day, of burnt alum, over the entire surface of the fauces."* If this plan of treatment be perseveringly pursued, relief, he admits, is sometimes procured, "but it very often fails," and "in such an event, we are left," he declares, "nearly destitute of resources." Not having employed, to any extent, the means above enumerated, I cannot speak of their efficacy in the treatment of laryngeal disease. Of the depletory part of this plan, however, from having observed its effects, in some few cases that have come under my notice, I am prepared to say, with the writer in question, that, if " urged to any extent, it proves positively detrimental, by inducing weakness, without abating the force of the disease, or in any way making a favorable impression." On the other hand, it may be stated with confidence, that cases of this affection, occurring in sound constitutions, are treated, in their early stage, by means of appropriate, topical measures, with as much certainty of success, as we are accustomed to expect from the use of quinine, or arsenic, in the treatment of intermittent fevers. The attention of the physician, however, is seldom called to the disease, in its incipient stage : but at a period of the affection when, secondary symptoms having supervened upon the local dis- * Lectures on the more important diseases of the Thoracic and Abdominal Viscera. By N. Chapman, M.D. p. 122. 195 FOLLICULAR DISEASE. order, more efficient measures, in its treatment, are required. The plan to be adopted, for the purpose of meeting the indications, at this stage, must be varied, according to the seat and extent of the disease, the causes which have induced it, and the different complications with which it may be found to be associated. Embraced in this plan, are both the topical and the general remedies, which are required for the treatment of the disease; but it is to an examination of those of the former class, that I shall, for the present, confine my attention. Topical medication. —Although topical remedies have been employed from an early period, in the treatment of various affections of the air-passages —in the form of powdered substances, brought into immediate contact with the diseased surface, by means of insufflation, as recommended by Areteeus for angina maligna; and in the form of vapour of different volatile matters, by means of inhalation, as advised by many writers, —yet to MM. Trousseau and Belloc, belongs the honor of having been "the first to prescribe and employ topical medications in chronic diseases of the larynx."* Among the solid substances, which have been employed, as topical, therapeutic agents, are, sub- * Preface to A Practical Treatise on Laryngeal Phthisis, &c. &c. By A. Trousseau and H. Belloc, M.D. 196 OF THE TREATMENT OF nitrate of bismuth, pure ; calomel mixed with twelve times its weight of sugar, and rendered impalpably fine; sulphate of zinc, and sulphate of copper, each to be mixed with thirty-six times its weight of sugar; alum, with twice its weight; acetate of lead with seven times, and nitrate of silver with twenty-four, thirty-six, and seventytwo times its weight of sugar. The apparatus for insufflating any of these pulverulent remedies, is a small reed, or a glass tube, eight or ten inches long. A few grains of the powder being placed in one end of the tube, the other is conveyed back into the mouth, when the patient, after a strong expiration, closes his lips upon the tube, and by a sudden and forcible inspiration, through it, impels the powder into the larynx and upper part of the trachea.* Inhalations of the vapour of hot water, impregnated with some of the essential oils, or with chlorine, iodine, cinnabar, or sulphurous acid, have also been employed; but, as a serious inconvenience arises from the impossibility of restricting these applications to the diseased larynx, their use, in uncomplicated laryngitis, has been abandoned, and liquid medications substituted, as capable of being applied, with more ease and certainty, and without any risk of injuring the trachea, or bronchi. These latter are composed of solutions of nitrate of silver, corrosive sublimate, sulphate of copper, * Op. supra citat. p. 125. 197 FOLLICULAR DISEASE. and nitrate of mercury; but after having made trial of them all, a decided preference was given, by Trousseau and Belloc, to a solution of the nitrate of silver, on account of its harmlessness, its efficacy, and its rapidity of action. A solution of the strength of two drachms of the nitrate, to an ounce, or, sometimes, to a half ounce of distilled water, was found most effectual as a topical remedial agent in laryngeal disease.* Two methods were employed, by the above writers, for applying the solution to the epiglottis, and upper part of the larynx. In one way, the object may be effected, by means of a small, round piece of sponge, attached to the bent end of a rod of whalebone. This sponge being dipped in the solution, is carried into the patient's mouth, and passed to the top of the pharynx, where its presence excites an effort of deglutition which causes the larynx to be elevated; at this moment the sponge may be brought forward to the opening of the glottis and the solution expressed into the larynx. Another mode of applying the solution, as advised, is by employing a small, silver syringe; having a long and curved tube. The instrument being filled to one fourth its capacity, is carried beyond the epiglottis, and the solution forcibly discharged into the opening of the larynx. Several years before the publication in this country, of the work of Trousseau and Belloc, and * Loc. cit. p. 125. 198 OF THE TREATMENT OF before possessing any knowledge of the interesting experiments which had been instituted by these gentlemen in the treatment of chronic laryngeal diseases, I had been prosecuting inquiries, in relation to the practicability of employing topical, remedial measures, for the treatment of chronic disease of the respiratory apparatus. After having tried many of the remedies, to which allusion has already been made, I became fully satisfied that, for safety, efficacy, and certainty of action, no know 7 n, local, therapeutic agent, can compare with the crystals of the nitrate of silver, in the treatment of laryngeal and bronchial affections. I speak of the crsytak of the nitrate; for, in preparing the solution, for topical applications, to the a?rial mucous membrane, the argenti nitras fusam, or the solid nitrate, should not be employed, as it is much more likely, than are the crystals, to contain the nitrate of potash, or copper, or lead, in combination. When pure, the crystals are transparent, white, or nearly colourless, and are completely soluble in distilled water. A solution of the strength of from two to four drachms of the salt, in an ounce of distilled water, when applied freely to the mucous membrane, does not act, as has been supposed, by burning, or by a destruction of textural matter: it forms, immediately, an union with the albumen, and other secretions of the mucous lining, and this compound, thus formed, defends the living tissue 199 FOLLICULAR DISEASE. from the action of the caustic; whilst it operates to produce a most favorable change, in the vital actions of the part.* Method of applying the solution. —In the treatment of laryngeal disease, by the direct application of the nitrate of silver, to the diseased surface, I have employed, ordinarily, a solution of this substance, of the strength of from two to four scruples of the nitrate, to an ounce of distilled water. When, however, there are found extensive ulcerations of the epiglottis, or, about the opening of the larynx —ulcerations which it is desirable to arrest at once, I have not hesitated to apply directly, to the diseased parts, a solution of double the strength of the last named. But, one or two applications, only, of a medicine of this power should be made, at one time ; ordinarily, however extensive the lesions may be, it will not be necessary to employ a solution of greater strength, than one composed of four scruples of the salt, to an ounce of water. On the other hand, it has been found, that one of less strength than of from forty to fifty grains of the nitrate to an ounce of fluid, will have but little effect upon a diseased mucous surface, where ulcerations exist. In cases in which it becomes necessary to cauterize the interior of the laryngeal cavity, the aperture of the glottis should not be passed at once ; the part should be educated, by applying the •The Elements of Mat. Medica, &c. By J. Pereira, M.D. Vol. I. p. 587. 200 OP THE TREATMENT OF solution daily, for several days, to the faucial and pharyngeal region ; to the epiglottis, and about the opening of the glottis. Proceeding in this manner, that exquisite sensibility which belongs to the lips of the glottis, is, in a good degree, overcome, and the instrument may then be passed into the larynx, without producing half the amount of that irritation which its introduction below the epiglottis would have awakened at first. The instrument which I have always employed for making direct, medicinal applications into the cavity of the larynx, is one composed of whalebone, about ten inches in length ; (with, or without the handle, as represented in the plate) curved at one end, to which is securely attached a small, round piece of fine sponge. The extent to which the rod is to be bent, must be varied according to circumstances; for the opening of the glottis is situated much deeper in some throats, than in others; but the curve which I have found, suited to the greatest number of cases, is one which will form the arc of one quarter of a circle, whose diameter is four inches. (See Plate VII. Fig. I.) The instrument being prepared, and the patient's mouth opened wide, and his tongue depressed; the sponge is dipped into the solution to be applied, and being carried over the top of the epiglottis, and on the laryngeal face of this cartilage, is sud- 201 FOLLICULAR DISEASE. denly pressed downwards and forwards, through the aperture of the glottis, into the laryngeal cavity. This operation is followed by a momentary spasm of the glottis, by which the fluid is discharged from the sponge, and is brought into immediate contact with the diseased surface. Every physician who has been present when this operation has been performed, (and a large number have witnessed it, from time to time,) has manifested much surprise on observing how little irritation has been produced, by the introduction of the sponge. If the patient, on opening his mouth, take a full inspiration, and then be directed to breathe gently out, at the moment in which the sponge is introduced, the irritation, caused by the application, will be much less, than when this caution is not observed. The fact, indeed, has been fully established, by repeated experiments, that the introduction into the larynx, of a sponge, saturated with a solution of the crystals of nitrate of silver, of the strength of forty, fifty, or even sixty grains of the salt, to the ounce of water, does not produce, ordinarily, as much disturbance as is caused by the accidental imbibition, into this cavity, of a few drops of tea, or even of pure water! In the topical treatment of the follicular disease, it will be found, that all larynges cannot be entered with the same facility. Indeed, in some 10* 202 OF THE TREATMENT OF instances, where oedema of the epiglottis, and of the arytenoid cartilages, has existed, I have found it very difficult, in making the first attempt, to pass the sponge of the probang through the aperture of the glottis. In May, 1845, an interesting young lady, the daughter of a member of Congress, from this State, was placed under my charge, to be treated for laryngeal disease. The affection had commenced nearly three years before, and with the exception of the occurrence of some degree of amelioration of the symptoms, during the summer months, it had steadily advanced until the period above named. At this time the symptoms were such as are ordinarily observed, and, by writers are enumerated, as belonging to laryngeal phthisis— namely : emaciation, hectic; pulse over a hundred, pain and soreness felt on pressing the thyroid cartilage ; cough, dyspnoea, and erratic pains in the chest. Inspection of the throat revealed numerous enlarged and diseased follicles, with hypertrophy and ulceration of the tonsils. The arytenoid and epiglottic cartilages, were greatly Gedematous; the border of the latter ulcerated, and the symptoms manifested, were indicative of ulcerations about the chordae vocales, —complete aphonia had existed for a period of more than four months. Indications of bronchial irritation were observed; but no decided symptoms of pulmonary lesions were detected, by auscultation. 203 FOLLICULAR DISEASE. Applications of a concentrated solution of the nitrate, soon improved the condition of the fauces and pharyngeal membrane ; but, by no effort, could an instrument, at first, be introduced through the opening of the glottis, on account of the partial closure of this aperture, by the oedema of the surrounding parts; and, until this latter operation was effected, the aphonic symptoms remained unchanged. At length, after cauterizing for several days, the lips of the glottis, the oedema subsided in a degree, and I succeeded in passing a small sponge into the glottis. An application to the cavity of the larynx was now made, every second day, and improvement rapidly took place. Two weeks from the time when the instrument was first carried below the epiglottis, she spoke aloud; and it was the first time any sound above a whisper, had been uttered by her, for a period of nearly five months. Her voice, and her general health, from this time, continued to improve, until both were fully restored. Eighteen months have since passed ; during which a matrimonial engagement, which had been suspended the year previous, on account of the unpromising state of her health, was renewed, and she married, and at this time she enjoys good health. Other physicians have observed the same difficulty in entering the larynx. 204 OF THE TREATMENT OF A few weeks since, a gentleman who had suffered, for more than a year, under an aggravated attack of laryngeal disease, and who had been completely aphonic, for several months, called on me with the following note, from one of our most distinguished surgeons : "Dear Doctor: —The bearer of this has suffered a long time with cough and hoarseness. Being advised to go to a warm climate, on his way thither, he called on me. I found his uvula elongated, and his fauces much inflamed. The uvula I cut off, and cauterized the fauces. Both these localities are now well; but his hoarseness and aphonia continue, as heretofore. The lungs are sound ; and to me the whole disease appears to be confined to the larynx, but there is great difficulty in passing the probang into it. Before he gives up local treatment, and departs for a warmer climate, I wish you to examine his fauces, and larynx, and try if you can enter the latter." On examining the throat of this gentleman, the epiglottis and arytenoid cartilages, were found thickened, as in the case of the young lady, above described; but the cauterization of these parts for a few days reduced the oedema, and a small instrument was then passed through the aperture of the glottis, into the laryngeal cavity. Nothing will so speedily enlarge the opening of the glottis, when it has been contracted by oedema, as a few applications of the nitrate, to the lips 205 FOLLICULAR DISEASE. of the glottis, and the laryngeal face of the epiglottis. In the simple and uncomplicated form of follicular pharyngo-laryngeal disease, however severe the local affection may have been, this remedy, alone, namely: the crystals of nitrate of silver, topically applied, has proved, in my hands, a specific in a large number of cases. Its use, when the affection has been of long standing, should be continued for some time. Ordinarily, it is better to make the applications, at first, every other day, for two or three weeks; subsequently, twice or three times a week, until the granular, and vascular mucous surface, assumes a smooth, and healthy appearance, and impaired vocalization is fully restored. Instances will occur where several of the enlarged, and diseased follicles of the throat, will become confluent, and present angry-looking tubercles, which may be seen on the pharyngeal membrane, below the palatine arch. These should be touched, occasionally, at first, with the solid nitrate, and the solution subsequently be employed. Not unfrequently, will the mucous cryptae, in the posterior nares, become involved in the disease; and when this occurs there will be an almost incessant dropping down, into the throat, of unhealthy mucus, from this cavity. On several occasions I have found old ulcerations of the follicles of the fossae, from which a most offensive secretion was constantly percolating. 206 OF THE TREATMENT OF This diseased condition of the lining membrane of the fossa nasalis, is more certainly relieved by the topical application of the nitrate, to the affected parts, than by the employment of any other known treatment. Applications to the nasal cavity, are readily effected, by means of a small rod of whalebone, which, instead of being curved, should be bent at nearly a right angle, one and a half inches from the end, and be armed with a small thin piece of sponge. This, being dipped in the liquid, is carried up behind the velum, and the whole lining membrane of the posterior nares, in this way, may be sponged with the solution. Several months since, a gentleman of this city came under treatment for an affection of the larynx, which was complicated with disease of the nasal fossa?, and was of many years standing. The morbid secretion from the nasal cavity, which was, ordinarily, abundant, was greatly increased by eating; so that the patient was unable to take food without being compelled to clear the discharge from his throat, several times during a single meal. So constant and unavoidable, had the difficulty become, for many months before this gentleman came under my care, that he had taken his meals alone, refusing, on this account, to eat at the same table with his friends. The disease of the larynx was removed by the employment of the usual topical measures ; but FOLLICULAR DISEASE. 207 this was followed by no abatement of the catarrhal symptoms. Applications of a solution of the nitrate of silver, were now made into the fossae, which being repeated every second, or third day, and continued for several weeks, removed entirely this disagreeable affection. As this morbid condition of the follicles of the posterior nares is, not unfrequently, conjoined with laryngeal disease, many other cases, similar to the last, have, from time to time, been observed by me, which have been treated, by the above method, with equal success. Elongation, and enlargement of the uvula, is a frequent concomitant, of follicular disease of the throat. Few cases occur, indeed, where the affection has continued for any length of time, that we do not find the uvula relaxed, and elongated— either the result of a diseased condition of its follicles, causing a serous effusion; or of an infiltration of fibrinous matter into the cellular tissue of this organ. On some occasions, this lesion takes place to such an extent, as to cause great inconvenience, and irritation about the roots of the tongue, and opening of the glottis; and, even in some instance —as in the case of Captain V. (Case XIV.) to endanger the life of the individual. Not unfrequently, slight elongation, when conjoined with a morbid condition of the throat, and occurring in individuals of a delicate, or irritable habit, is pro- 208 OP THE TREATMENT OP ductive of much mischief, by proving the occasion of a prolonged and troublesome cough. In simple elongation of the uvula, dependent upon relaxation of the parts ; the use of stimulant, or astringent gargles, may, in some slight, and recent cases, be sufficient to overcome the difficulty. But where hypertrophy actually exists, and the uvula itself, is both thickened, and elongated, excision will prove the only, effectual remedy. So simple is this operation, and so entirely unattended with subsequent danger or inconvenience, that the removal of the uvula should not be omitted, or delayed, in cases of follicular disease, where its elongation serves to increase, and prolong the irritation. In treating of excision of the uvula, Mr. Yearsley remarks that, in order to gain all the advantage, and insure no disadvantage from this operation, it is necessary that the whole of the uvula should be removed, and not a part only, as has been the usual practice; and he lays it down as an axiom that the shortening of the uvula is a most objectionable operation ; inasmuch, as patients, by its partial removal, have, occasionally, been much inconvenienced by the irritation kept up by the food, in its passage through the isthmus, striking against the amputated surface j while, on the contrary, its entire removal, by which the palatine arches are thrown into one, is an operation which, in suitable cases, is to be commended, not only for 209 FOLLICULAR DISEASE. the comfort and advantage it confers, in many cases, but for the ease and safety with which it is performed. "The utmost pains," he adds, "have been taken to ascertain the results of the loss of the uvula, but in no one case, can I find that the slightest inconvenience has arisen from its removal."* In a large number of cases where I have found it necessary to amputate the uvula, I have not been made aware, in any instance, of the occurrence of inconvenience, either from its partial, or entire removal. Ordinarily, however, I have not considered it advisable, in the operation, to practice total excision ; but have, generally, found it necessary, and quite sufficient, to remove the greater part of this organ. Various instruments have been employed for truncating the uvula. The most simple, and, altogether, the most convenient, for this operation, are the curved scissors, and a pair of long, and slender forceps, having finely serrated blades. (Plate VIII. Fig. 4 and 5.) With these forceps, the extremity of the uvula is seized, and being retained, the scissors are carried into the mouth, and excision of the organ, at any point, may be quickly performed. Hypertrophy of the tonsillary glands, although not, necessarily, a concomitant of follicular disease, is, nevertheless, frequently found to co-exist with * Op. cit. p. 54. 210 OP THE TREATMENT OF this affection. The nature of these enlargements have, already, been considered. When they are the result of a chronic inflammation of the lacunar, of which the tonsils are composed, the morbid growths will be found to depend, for their immediate cause, upon a deposition of fibrinous matter, which gradually becoming organized, is incorporated with the proper glandular substance, producing permanent enlargement, and induration of these organs. To disperse such enlargement of the tonsils, various local, and general agents have been employed ; such as astringent and stimulant gargles; the different preparations of iodine ; and the repeated applications to the morbid growths, of the solid nitrate of silver. But, when this lesion is the result of a fibrinous deposite, these measures, however long or perseveringly they may be pursued, fail, almost universally, to remove the cause. Hypertrophy, and induration of the tonsils occur, frequently, in young persons and children, independently, of follicular disease of the throat. In some instances, the affection appears to be congenital, or is hereditary ; in others, it is the result of repeated attacks of chronic inflammation of the tonsillary glands. When the hypertrophy is accompanied by induration; whether this condition co-exists with follicular disease, or is the effect of chronic tonsilitis, excision of the enlarged gland, is, almost, the only method of treatment, by which 211 FOLLICULAR DISEASE. permanent and effectual relief can be obtained. This fact ought to be better understood by the profession, than it seems to be ; for the practice of painting these morbid growths with the tincture of iodine, or of cauterizing them with the solid nitrate, is still continued, and patients are daily being subjected to this annoying and useless practice, often, month after month, with the apparent expectation on the part of their attendants, that enlarged and indurated tonsils may be discussed by these applications ! When the disease is recent, and the enlargement is soft, this treatment may prove serviceable, in some cases; but more frequently, even under these circumstances, the effect of the applications has been, in my experience, to increase, rather than to diminish the morbid growths; and when induration has occurred, as the result of a deposition of textural matter, the employment of any, or of all the ordinary topical measures, will prove entirely futile. Consequently, for a number of years, I have been accustomed to practice excision, in the treatment of enlarged, and indurated tonsils, whenever this operation could, with propriety, be performed. Several years ago, before experience had taught me the inefficacy of topical applications, in hypertrophy of the glands, I attended a young lady of this city, who had suffered for a long period, from 212 OF THE TREATMENT OF enlarged, and indurated tonsils. Objections to their removal, by excision, being made by her friends, I attempted to disperse them, by local measures; and, for nearly three months, I made almost daily applications, of the solid nitrate, to the diseased glands. No improvement, whatever, took place, in this time, and at the end of the above period, the consent of the patient, and that of her friends, to an operation, being obtained, the morbid growths were removed, by excision; and, as the young lady, herself, declared, with much less pain, and inconvenience, than she had previously experienced, at each application of the nitrate of silver. A distinguished physician of my acquaintance, employed, for nearly six months, the different discutient remedies, in the case of a young clergyman, formerly of this city —who was the subject of enlarged tonsils—without any obvious effect, whatever, being produced. I was, afterwards, requested to remove these enlargements; which I did, by excision; when I found that they presented, on cutting them, almost, a cartilaginous consistence ; they had, doubtless, become still more indurated, by the topical applications, which had been made to them. Even Homoeopathy seems powerless, in these cases: a few weeks since, I removed from the throat of an eminent author, in this city, a pair of enormously enlarged, and indurated tonsils, 213 FOLLICULAR DISEASE. which, for a whole year, had resisted the effects, of a constant employment of some of the " highest Hahnemannic potencies!" In former years, it w 7 as customary to employ the ligature, or a flexible wire, for the removal of enlarged tonsils. This practice is now 7 , generally, and ought to be, universally abandoned ; for, —as the ligature, or wire, must, necessarily remain on, for many days, or, until the tumor sloughs away,— this practice, not unfrequently, produces extensive irritation of the mouth, and about the faucial region ; an irritation, which, generally, interferes much with respiration, and deglutition. This method of operating, for hypertrophied tonsils, was employed, to obviate the danger from hemorrhage, which, it was supposed, might follow the' use of the knife. In the numerous instances in w 7 hich I have operated, by excision, I have not met with a single case, where any serious inconvenience, resulted from the subsequent hemorrhage. Whenever, therefore, enlarged and indurated tonsils are found, in connection with follicular disease, these enlargements should be removed, at once ; and their excision followed, in the course of a few days, by topical applications to the throat, of the nitro-argentine solution. If the diseased growths are not removed, the subsequent treatment will prove, in a great degree, unavailing; for the irritation produced by their presence; and, 214 OF THE TREATMENT OF especially, by the morbid secretion, which is poured out by their disordered lacunae, will be sufficient to perpetuate the disease. Instruments of many forms, have been employed, by different authors, for the removal of enlarged tonsils. Those, that have obtained the most credit, among surgeons, are: the guillotine knife ; Cloquet's instrument, which is a pair of strong scissors, w ith crescentic-shaped blades ; the knife and ring, as recommended by Dr. A. L. Cox, of this city; the common bistoury, etc. etc. After having tried several of these instruments; to the use of all of which, some objection exists ; I procured to be made, and have used, for several years, a strong knife, having a long, slender blade, terminating in a blunt, or probe point; and a pair of crooked forceps, which have small claws, after the manner of the forceps of Muzeux. (See Plate VII. Fig. 2 and 3.) With this knife and forceps,—with which latter instrument the tonsil may be seized, drawn out from between the pillars of the fauces, and firmly held, —I have operated, in a large number of cases, with ease, and perfect success. Of the Topical treatment of Follicular Disease, wlien complicated with Chronic Laryngitis. Although this affection is, primarily, a disease, of the mucous cryptee, of the lining membrane of the air-passages j yet, as we have seen, in some 215 FOLLICULAR DISEASE. cases, after having continued, for a longer or shorter period, the intervening mucous tissue of the larynx, becomes involved with the diseased, glandular action; and we then have the original affection complicated with chronic laryngitis. The plans of treatment for chronic laryngeal inflammation, which have been proposed by different authors, coincide, very generally, with the measures recommended by a writer, in this country, to whom allusion has already been made.* The remedial measures proposed by Dr. Ryland,"}" consist, chiefly, of the abstraction of blood, generally and locally; —the latter by means of leeches applied in the neighborhood of the larynx; —counter irritation, by means of blisters, tartaremetic, issues, or the actual cautery; aided by internal medicines ; such, for example, as tartarised antimony and mercury; the former of these, given to the extent of producing nausea; and the latter, sufficient to cause some soreness of the gums; together with the inhalation of soothing vapours, and the rigid enforcement of absolute rest. In addition to many of the above remedies, Dr. CheyneJ advises, "the establishment of a discharge, from both sides of the larynx, by means of small caustic issues;" while Dr. Stokes allows, that a solution of the nitrate of silver, containing, according to circumstances, from ten to fifteen grs. to the ounce of * Chapman, ut supra. f Op. cit. pp. 111-12. X Cyclop, of Prat. Med. Art. Laryngitis. 216 OF THE TREATMENT OF water, may be employed; or the caustic solution of iodine, as recommended by Lugol; or the inhalation of the vapour of iodine, combined with a narcotic* Dr. Williams places his principal reliance, in the treatment of chronic-laryngeal disease, on local bleeding, followed by counter irritation, at the sides of the neck, or upper part of the chest, together with the adoption of a mild mercurial plan, which shall be varied to the extent of affecting the gums.f When these remedies fail relief, and symptoms of approaching sYrifocation present themselves, the above writers advise that, as a last resort, recourse should be had to tracheotomy. I have alluded thus briefly to the modes of treatment, employed by some of the principal writers on chronic laryngeal disease; in order to show that depletory measures, conjoined with counter irritants, constitute the principal, therapeutic means, employed by these authors; and that, in their opinion, if these measures fail, they are left, nearly destitute of resources; for, in such an event, recourse is advised to be had, to tracheotomy —an operation which, in these cases fails, almost invariably, of producing permanent relief. That we are not without resources, in the treat- * Op. citat. p. 228. f Diseases of the Respiratory Organs. By Chas. J. B. Williams, M.D. etc. pp. 132-3. 217 FOLLICULAR DISEASE. ment of chronic laryngeal disease, when the above measures fail; but, are in the possession of other, and most efficient remedial means, has been fully demonstrated, by the cases that have already been given. Many others have come under my observation, whose symptoms, and history, stamped them as marked cases of chronic laryngitis, complicated with follicular disease, where, other means having utterly failed, the long continued applications, of a concentrated solution of the nitrate of silver, was effectual in removing the disease, entirely. The following case is one of much interest, not only on account of the severity of the symptoms, and the happy effects that followed the employment of the local remedy, but for the reason, that the patient had been seen by several eminent physicians, during his illness, who had considered his case to be one of phthisis laryngea. In August, 1845, I was desired to see Mr. C. F., a young man who, before his sickness, had been occupied as a teacher, in one of the high schools, situated in the country, a short distance from New York. A cold that he had taken, more than a year before the above period, was followed by sore throat, hoarseness, and, ultimately, by complete extinction of the voice. During the winter, he was confined to his room ; and from the first of January, until the seventh of August; at which time he came under my care, he had not uttered a 11 218 OF THE TREATMENT OF sound, above a whisper. His attending physicians having considered his case to be one of chronic laryngitis, had employed, without avail, all the ordinary means—such as general and local depletion, counter irritation, &c. to remove it. When called to attend him, he was feeble and emaciated; his voice, for a period of more than seven months, had been completely extinct, his cough was almost inaudible, and he complained of much soreness, and irritation, behind the thyroid cartilage. The mucous membrane of the throat, was thickened, and the pharyngeal portion, was studded with hypertrophied follicles. Bronchial irritation, to some extent was present, but the parenchyma of the lungs, appeared unimpaired. Commencing at once, with a concentrated solution of the nitrate, I applied it, at first, to the faucial, and pharyngeal structure, and after a few days, introduced the sponge, every day, into the larynx, and cauterized its cavity freely—down to the inferior vocal ligaments. On the eighth day, after the first application, he spoke aloud; and from that time, his voice increased in strength, daily. His general health, also, improved, as rapidly as his voice; and, at the end of three weeks, he left the city, apparently, in good health, and with vocalization fully restored. In February, six months after, he left New York, I received from him a letter, in which he writes:—" Your treat- 219 FOLLICULAR DISEASE. ment of my throat, has been sufficiently successful, to restore my voice and health. My school now consists of thirty-eight scholars. I am able to attend to all the exercises of the school, without any assistance. I use my voice as much, and as freely, as I ever did, in any part of my life." So certain, and so salutary, are the effects of the nitrate of silver, upon the mucous membrane, and its cryptre, when affected by chronic inflammation, that I have, long since, considered the local employment of this remedy, a specific, in diseases of this character, and location. Of its effect, in acute inflammation of the mucous, and sub-mucous tissues, when locally employed, less is known. Having used it in several cases of acute uvalitis, where its free application, in a concentrated solution, to the uvula, velum, and whole faucial structure, arrested, at once, the inflammatory action, I ventured, a short time since, to resort to this remedy, in treating a disease, which has been remarkable, hitherto, for not yielding, in a large proportion of cases, to any plan of treatment employed. Mrs. B., a lady of rather a delicate constitution, who had been hoarse from a cold for several days, rode out from the city, a few miles, on the afternoon, of Friday, the 11th of June, of the present year. The day had been but on returning to the city, towards evening, the weather had become 220 OF THE TREATMENT OF cooler, and the carriage being open, she faced a current of air, all the way home. Some slight chills occurred during the evening, which being followed by a restless night, led her to suppose she had added to her cold ; and hoping that these symptoms would soon subside, she delayed through the following day, to call for medical aid. Her hoarseness the next morning, was greatly increased; slight chills were again felt, and in the course of the day, pain, and a sense of constriction about the larynx, came on, attended by a dry severe cough, and great difficulty of respiration. I was called to see her, late on the evening of the 12th of June, the next evening after her exposure, and found her labouring under strongly developed symptoms of acute laryngitis. She was sitting upright in bed, breathing with great difficulty, and uttering, at every inspiration, a croupal sound, which was followed by a short, convulsive cough. The face was flushed, the pulse frequent and full; and she complained constantly of a sense of suffocation, and of great distress in the laryngeal region. On inspecting the throat, the fauces, and the pharyngeal membrane, as far down as it could be seen, presented the appearance of a high degree of inflammation. As soon as it could be prepared, an emetic of tart. ant. with ipecac, was administered, the vein in her arm was opened, and about twenty ounces of blood withdrawn. 221 FOLLICULAR DISEASE. The emetic operated freely, and although the pulse was reduced, and the patient experienced some degree of faintness, after the bleeding and emesis, yet the laboured breathing, the cough, and other distressing symptoms, remained, nearly the same. A mustard cataplasm was now applied to the upper part of the sternum, and another between the shoulders. Small doses of antimony, were given, every fifteen or twenty minutes; and, after remaining with her until two or three o'clock in the morning, I left her, to obtain other means of relief. On returning, an hour or two afterwards, I found but little alteration ; the oppressed respiration, the stridulous cough, and the distress in the throat remained about the same. She had vomited, several times, during my absence, but had obtained no rest. I had now brought with me the means of cauterizing the throat, and was determined to delay its employment, no longer. Indeed, had I had the means with me, at first, I should not have left the bed-side of the patient, without employing this invaluable local remedy. With a solution of the crystals of the nitrate of silver, of the strength of 45 grs. to the ounce of water, I cauterized freely, the fauces, the laryngeal face of the epiglottis, and, as thoroughly as I could, the cavity of the larynx. For a few minutes, the difficulty of breathing, and the cough were increased, by the application; a large amount of viscid, ropy mucus, was discharged; 222 OF THE TREATMENT OF and, along with it, a small quantity of blood. In the course of half an hour, after the application, the symptoms had improved. The laryngeal cough subsided ; the respiration became less laborious, and the patient, soon after, obtained some sleep. In short, from this hour, I had no farther trouble from the case. Occasional doses of expectorant medicines were administered during the day. On the following evening, a slight increase of the cough, and irritation, came on; but these, soon subsided, and were followed by a quiet night's rest. The next day, a considerable amount of a thick and yellow expectoration, was discharged;—such as occurs on the breaking up of a severe cold ; — and my patient has since continued daily to improve.* The power of this remedy, to restore a healthy action, where an altered condition of the mucous membrane exists, is well illustrated, in the following interesting case:— In April, 1845, a little daughter of Mr. R. F., of this city, about four years of age ; accidentally drank a quantity of sulphuric acid, from a cup, which had been left on the table, by a servant in the family. The tongue, pharynx, and the epiglottis were violently corroded, and inflamed by the poison. * The history of this case was read before the Medical and Surgical Society of New York, June 20, 1846; and is here given as reported. 223 FOLLICULAR DISEASE. Mr. Ryland relates the singular fact, that the larynx suffers injury, from the swallowing of any of the strong acids, only when they are taken accidentally, in mistake for some other liquid j —that a person bent on suicide, will swallow the corrosive acids well, and without pain. In these cases, the larynx is never injured ; the epiglottis, during the act of swallowing, completely covers the upper surface of the glottis, and the acid passes down the oesophagus to the stomach, without impairing, in any way, the organization of the larynx. But if the acid is taken accidentally, immediately that it reaches the gullet, the mistake is discovered, violent action of the muscles of the pharynx is excited, and the corrosive liquid is rejected through the mouth and nostrils.* In this manner, was the acid taken and rejected, by the little patient, above named ; but, besides the injury done to the back of the pharynx, and the root of the tongue ; the epiglottis, and the opening of the larynx were severely corroded, by the concentrated acid. Violent inflammation of these parts, attended with great difficulty of deglutition, followed. By the use of prompt, and active measures, under the treatment of the family physician, the,inflammation was subdued; but the injury done to the epiglottic cartilage, and the lips of the glottis, ended in ulceration of these parts; so that, at the end of two or three weeks, from the * Op. citat. p. 272. 224 OP THE TREATMENT OP occurrence of the accident, deglutition became nearly impossible, on account of the injured epiglottis failing to afford sufficient protection, to the opening into the wind-pipe. About five weeks, after taking the acid, I was called to see this patient, and found her nearly exhausted, for the want of nourishment- If a cup of gruel, or water, was presented to her, she would seize the vessel, with great eagerness, and attempt to drink; but the moment the fluid reached the gullet, a violent, spasmodic cough would take place, by which the liquid was instantly rejected. Solid food would be thrown out,in the same manner, as soon as it reached the pharynx; and this effect, for more than a week, had followed every attempt, made to administer nourishment; so that the child was, in reality, at this time, in a state of starvation. Convinced, from the symptoms present, and from an inspection of the throat, that ulceration of the epiglottis, and, probably, of the lips of the glottis, existed, I at once, determined to try the effect of a concentrated solution of the nitrate, upon this form of injury. Accordingly, I introduced a small sponge, saturated with the fluid, (35 grains to the oz.) and freely cauterized the epiglottis, and the opening of the larynx. On the following day, —after repeating the application —the patient swallowed a small cup-full of thin soup, —without exciting the suffocating cough,—which, as the attendants declared, was the 225 FOLLICULAR DISEASE. first food the child had taken for eight days. Some portion of the nourishment, however, must have reached the stomach, sufficient to have sustained life, during this period. On the third day, a small amount of solid food was taken, and, on several occasions during the day, a cup-full of gruel. After this period, no difficulty occurred, in administering a suitable amount of food, and the patient,—who had become much emaciated, — rapidly regained her health and flesh. As stated, in a foregoing chapter, follicular laryngeal disease is often found, co-existing with chronic inflammation, of the lining bronchial membrane. The presence of this complication, does not contraindicate the topical employment of the nitrate of silver. On the other hand, in making the applications, into the laryngeal cavity, a still more free use of the solution, should be employed, in order that some part of the fluid may find its way into the bronchial divisions. Among the patients who have come under my care, during the last eighteen months, are a number of intelligent physicians, who have been sufferers from laryngeal, and bronchial disease. Several of them have informed me, repeatedly, that after having a free application of the solution, into the larynx, they have felt, distinctly, the fluid extending down the bronchial tubes. Often, in these cases, no taste of the medicine would be observed, until matter, by coughing, was expectorated from the 11* 226 OF THE TREATMENT OF air-passages ; when the peculiar flavor of the nitrate of silver—a most acrid bitter —would be perceived; and this would continue to be observed, whenever the individual expectorated, for many hours after the operation. The following notes of his own case, were furnished me, by my friend, Dr. S. Conant Foster, whom I treated, in 1844, for follicular disease. The affection was complicated with some degree of bronchial irritation, as was manifested by the character of the expectoration. The case is interesting, not only because it is that of an intelligent physician, but, inasmuch, as the topical applications, were the only, remedial measures employed, in the treatment of the case. "In the spring of 1844," writes Dr. Foster, "I contracted a cold, the acute symptoms of which, subsided, after two or three weeks. After this, however, on first rising in the morning, I had a pretty severe paroxyism of coughing; lasting about five minutes, and terminating, after the expectoration —which was accomplished with some difficulty —of a viscid, tenacious mucus, of a deep slate color. Often, too, during the day, if I attempted to speak, or read, aloud, I was interrupted in the midst of a sentence, by coughing, inability to articulate, and the sensation of a spasmodic contraction, at the entrance of the glottis, which lasted a minute or two. This continued all summer, and became more frequent, and severe. There was, 227 FOLLICULAR DISEASE. also, a constant irritation in the throat, and a sense of dryness, at times, exceedingly annoying. On looking into the throat, I found the whole of the posterior fauces, in a highly congested state, and the glands beneath the mucous membrane of the throat, enlarged, and prominent. " In September, I requested you to apply the solution of caustic, which you did, some twelve or fifteen times, in the course of six weeks; at the end of which period, the difficulty was wholly removed." The importance of arresting disease of the bronchial mucous membrane, will be apparent, if we reflect, that it often proves a determining cause of tuberculous disease of the lungs. Dr. Clark, long ago, declared, that irritation of the mucous membrane of the larynx, trachea, and bronchi, is a frequent exciting cause of consumption ; especially, in persons, where the constitutional predisposition exists.* This has been well illustrated, in the history of several cases, which we have already recorded : the one noticed on pages 181-2 ; and that of Mrs. C. (No. XXIII.) are cases in point. Although, during the life-time of this latter individual, no symptoms were manifest, that indicated the existence of tubercles, yet, after death, several were found, developed in the very summit of that lung, which was penetrated by the ulcerated bronchus: some of these, located near the ulcerated opening, had suppurated; while * A Treatise on Pulmonary Consumption. By James Clark, M.D. p. 183. 228 OF THE TREATMENT OF the remainder of that lung, and the entire right one, were in a perfectly healthy condition. Among the cases of follicular disease, which have come under my notice, I have remarked a number of instances, where the affection was, in a good degree, confined to one side of the throat of the patient. Commencing, often, in the follicles of one tonsil, the disease would advance, until the larynx, and trachea, of that side, were affected by the morbid action; and, on several occasions, have I found the corresponding lung, affording evidence of tuberculous consolidation ; or, of the existence of a tuberculous cavity. Not long ago, I saw, in consultation with her attending physician, a lady of this city, who, one year before, had observed a slight degree of ulceration of the follicles of the left tonsil; which, together with the opposite gland, was moderately enlarged. Gradually, the disease extended, to the follicles of the larynx, and trachea; and, at length, reached the bronchus of the affected side. At no time had she observed any soreness of the other side of the throat; but, throughout the whole year, had the diseased action been confined to that side of the wind-pipe, where it first originated. A few months, after the commencement of the disease, hoarseness, with pain, under the left clavicle, came on, and a cough supervened, which was attended, at first, with a scanty, viscid expectora- 229 FOLLICULAR DISEASE. tion, and, afterwards, by a free muco-purulent discharge. When seen, on the occasion, alluded to above, her case exhibited, the characteristic indications, of advanced phthisis. On exploring the chest of this patient, the right lung was found to be perfectly healthy j but symptoms, that could not be mistaken, were present, indicative of the existence of a tuberculous cavity, in the summit of the left lung. The tendency of the bronchial mucous membrane to take on sub-acute inflammatory action in connection with, and as a sequent of, other diseases both local and constitutional, is well known. We have seen that more or less of bronchial irritation has been found connected with a large proportion of those cases which have come under observation. When this complication exists, it will be found that the remedies, which are ordinarily successful, in the treatment of other forms of chronic bronchitis, will fail to exert their accustomed remedial influence upon the disease. Under these circumstances, I have frequently employed the topical application of a solution of the nitrate, to the pharyngo-laryngeal membrane—even when the indications of the presence of follicular disease were not fully apparent —with the most gratifying results. Should the bronchial symptoms remain, the topical applications in connection with constitutional measures should be continued —though at longer 230 OF THE TREATMENT OF intervals than at first—for some time after the disappearance of the laryngeal disease. Of the employment of Topical Measures in the Treat- ment of Follicular Disease, when complicated with Pulmonary Phthisis. When opportunities were first presented to my notice, for the employment of the nitrate of silver, as a topical remedy, in the above complication of disease, I hesitated to apply the solution to the laryngotracheal membrane, lest the bronchial irritation, that might follow, should increase the pulmonary lesions. But, after watching the effect of this remedy, in its application to the different morbid conditions of the mucous membrane, I became fully satisfied, that its influence would be salutary, if employed, even when tubercular lesions co-existed with follicular disease. Accordingly, during the last few years, I have used the nitrate of silver, as a local therapeutic agent, in a large number of cases of tubercular disease, where laryngeal symptoms have preceded, or accompanied the pulmonary affection. Among the cases of laryngeal, and bronchial affection, which, during the year 1845, came under my care, twenty-five presented decided symptoms of pulmonary phthisis, complicated with follicular disease. As the pulmonary symptoms, in a majority of the cases, had supervened upon the original glandular affection, topical measures were em- 231 FOLLICULAR DISEASE. ployed j —not with the expectation of their proving, ultimately remedial, but with the hope of deferring the pulmonary, by allaying the laryngeal disease ; and the success which has attended these efforts, in a majority of the above cases, —in mitigating the sufferings, and in prolonging the lives, of my patients,—has been to me a source of the highest gratification. To the history of a few of these cases, I shall briefly allude; inasmuch as they are marked with peculiar interest, and are those of persons well known to a number of my professional friends. In an early stage of treatment, these patients came under the observation of several eminent medical gentlemen, of this city, by whom they were examined, and pronounced, at the time, to be labouring under decided symptoms of pulmonary phthisis. The first of these cases was that of a gentleman from Connecticut, who came to New York in March, 1845. Some months before coming to the City, he lost his voice, entirely; but he was hoarse, and had had a cough, with laryngeal inflammation, several years before this occurrence. He had also had several attacks of haemoptysis ; was emaciated, and so feeble, when he arrived, that he was not able to walk the distance of a block, without aid. He was suffering from a most severe paroxysmal cough; had great dyspnoea, and a free expectoration of purulent matter. The throat was studded 232 OF THE TREATMENT OF with granulations, or enlarged follicles ; and it was with much difficulty that he could articulate, above a whisper. A dullness, on percussion, over the right lung, with an absence of the respiratory murmur, and pain and stricture, about the chest, with the above rational symptoms, marked the case as one of confirmed phthisis; and such it was admitted to be, after a critical exploration of the chest, by several experienced medical friends; among whom was one of the physicians of the New York Hospital, who is esteemed, —and justly so, —as a most accomplished auscultator. Applications of a concentrated solution of the nitrate, were made to the throat, and into the larynx of this patient, for about two weeks. At the end of this time, his cough and dyspnoea were so much relieved, and his strength increased, that, from not being able to walk any distance, without aid, as was the case when he first arrived, —he, on the twelfth day of treatment, went on foot, down to the boat in which he came to the city, and back again,—a distance of more than three miles, without suffering any inconvenience. After remaining several weeks under treatment, he returned to Connecticut, with augmented strength, and with his cough greatly relieved. Nearly three months after he left the city, his sister called on me in New York, and informed me that her brother had been able, after his return, to superintend his affairs ; which had not been the case 233 FOLLICULAR DISEASE. for nearly two years before ; and in this favourable condition he remained when last heard from— which was more than a year after he left New York. Another instance is that of Mr. A. L. Porter, a young gentleman of this city —about twenty-six years of age, —whose case was also examined by some medical friends, and in regard to whose lungs an opinion equally unfavourable with the one above, was pronounced. When I first visited Mr. P., at his house—about the first of September, 1845, —he w T as confined to his bed. He had been labouring under symptoms of phthisis, over two years; he was feeble and emaciated; had had several attacks of haemoptysis; and, on the day in which I first saw him, had bled more than a half-pint from his lungs. Of his throat, he had complained from the commencement; had hoarseness, and other symptoms of laryngeal, complicated with the pulmonary affection. I commenced the use of topical remedies to the larynx, and from that day, to the present, he has had no return of haemoptysis. In one week he visited me at my office ; and continued to do so, at intervals, whilst under my care. His cough, soon lost its paroxysmal character, became very light, and in three months, he had gained fourteen pounds of flesh, under this treatment. On the coming on of cold weather, he sailed for Havana, where he remained two or three months ; 234 OF THE TREATMENT OF but he returned to New York early in the spring of 1846; and from that time, to the present, a period of nearly eight months, he has enjoyed an amount of health, sufficient to enable him to be constantly engaged in business. John Hagan, of Essex street; —another patient who was examined by the medical gentleman, to whom I have alluded, came under my care, about the last of October, 1845; presenting the ordinary symptoms of confirmed phthisis. He was emaciated, very feeble, and was harassed by a severe spasmodic cough, which seemed to be, in a good degree, laryngeal, for he was hoarse, and complained of great soreness and irritation, in that region. So unequivocal, however, were the symptoms of the presence of pulmonary lesions, that the physicians, above alluded to, did not hesitate to consider the case, as one, complicated with extensive tubercular disease. The applications to the larynx, had not been made more than a week, in his case, when his cough was diminished, greatly, in severity and frequency. As soon as this was mitigated, he commenced gaining flesh, and strength; and, of the former, added about fifteen pounds, to his weight, in the succeding three months. At this period he resumed his ordinary occupation,—which is that of a cabinet-maker, —and, for more than six months, has been able to devote himself to his business. He has a cough, which although light, 235 FOLLICULAR DISEASE. still remains, and the only remedy, which he has employed for the last half-year, has been, an application, once in two or three weeks, of the nitrate of silver, to the laryngeal cavity. These cases have been adduced, not only on account of their individual interest; but more especially, because an opinion has obtained, among some of the profession, that topical applications, to the laryngotracheal membrane, were not appropriate, when tubercular lesions co-existed with follicular disease. Other instances of the same character, and of equal interest, with the above, have come under my care, but, I omit them, in order not to multiply observations. CHAPTER X. Of the Treatment of Follicular Disease. General Remedies. —In simple, or uncomplicated follicular disease, occurring in sound constitutions, topical medication alone, judiciously, and perseveringly employed, will prove efficacious in removing the local affection, in a large proportion of cases. When the disease is associated with other morbid derangements, and, particularly, when united with affections of the general system, constitutional means, in connection with topical remedies, will be required. Nitrate of Silver. —There is one kind of gastric derangement, which is found, not unfrequently, to co-exist with the milder forms of follicular disease. It is the estomac glaireuse, of the French; or the follicular gastric dyspepsia, of modern nosologists. In this, as well as in other forms of indigestion, I have found no remedy to compare, in value, with the nitrate of silver, when internally administered. It may be given, combined with the extract of conium, or the extract of hops, in the form of pills, in doses of from one sixth to one fourth of a grain of the salt; twice or three times a day. The incidental effect, —that of producing a dis- 237 FOLLICULAR DISEASE. coloration of the skin, —which has sometimes followed the administration of this remedy, is considered by some as an objection to its internal use. No evil of this kind need be apprehended, from continuing its employment, for one or two months, at a time. Dr. Johnson, indeeed, asserts, that there is not an instance on record, where the complexion has been affected by the medicine, when restricted to three months' administration.* Iodine. —In quite a large proportion of the cases of follicular disease, which have come under my notice, where the morbid affection of the mucous cryptse had been long continued, it has been found that there existed, more or less, of a diseased condition, of other parts of the glandular system. Symptoms, indicative of the presence of a derangement of the hepatic organs, have, frequently, been manifested in connection with follicular disease. Hence, iodine, or some of its preparations, have proved, in my hands, of essential service, in the treatment of this complicated form of the affection. It is the opinion of Dr. Clark, that the action of iodine, on the animal economy, resembles, in a great degree, that of mercury. The effects of the two remedies may be similar, in some respects. The action of the organs of excretion, it is true, is promoted by both medicines, but not in the same degree. Paleness, or blanching, it is well known, is frequently produced by a course of mercury ; an • Essay on the Morbid Sensibility of the Stomach and Bowels, p. 90. 238 OF THE TREATMENT OF effect which has been ascribed to the diminished number of the red globules of the blood ; while, on the other hand, an increased nutrition of the body, or embonpoint, is the frequent result of the employment of iodine. Under its influence, —Dr. Clark, himself remarks, —when it is judiciously employed, the patient recovers flesh, strength, and colour; hitherto pale, relaxed, and feeble, he becomes full, strong, and florid. From the influence which iodine has in causing the disappearance of visceral and glandular enlargements, it has been supposed, that its continued use would have the effect to produce general emaciation; but this has been denied by many. —Lugol asserts, that instead of producing emaciation, it encourages growth and increase of size, and Dr, Manson, also, in his Medical Researches on Iodine, states that it exerts no peculiar, or specific influence, on the absorbents. In the administration of iodine, in follicular disease, I have found, almost invariably, a specific effect produced upon the organs of secretion by the use of the medicine. For some time, after commencing the remedy, an increased quantity of viscid mucus, is thrown off, by the diseased glandular ; and the patient often complains, of a disagreeable taste, produced by the morbid secretions, from the faucial and pharyngeal membrane ; and, in some instances, the irritation of the throat is, at first, increased by this salt. After a while the secreted fluid is diminished in quantity, becomes FOLLICULAR DISEASE. 239 bland; and is of a healthier quality, while the lining membrane presents an improved condition. Equally salutary are the effects produced, ordinarily, on the secretions of the digestive organs, by the use of iodine. The iodide of potassium, I have generally considered, as the best preparation for administration, in disease of the mucous follicles. Although the constitutional effects of iodide of potassium are very analagous to those of iodine, yet, it may be given in larger doses, and for a longer period, without producing disorder of the system, than the free iodine. When indications of a scrofulous diathesis are present, in any case, it will be preferable, and will prove more efficacious, to exhibit the two preparations in combination. The protiodide of iron, after being employed, first by Dr. Thompson of London, in the treatment of phthisis, was for a time extensively used, both in England and in France, in this disease. Several years ago Dr. Dupasquier, of Lyons, published some interesting statements, with regard to the favourable effects, produced by the use of the protiodide of iron, in the treatment of pulmonic affections. Since his publication, it has been used, to some extent, in this country, in the treatment of these diseases, but its employment, as a therapeutic agent, has not been atttended with the equally encouraging results. I have frequently exhibited 240 OF THE TREATMENT OF this remedy, in affections of the pulmonary organs, hut, I confess, I have not been fortunate in observing any decidedly favourable effects, resulting from its administration. Mercury. —As the universal effect of mercury, upon the animal economy, is to produce increased activity, in the secretory and excretory organs ; its employment in some forms of follicular disease, is in a high degree beneficial. From the influence which mercury has on the secreting functions of the liver, Dr. Clark considers it, a most efficient and valuable remedy, in the tuberculous diathesis; more especially in torpid constitutions, but he advises it not to be carried beyond its alterative effect on the hepatic system.* When there exists, in connection with follicular disease, a deranged condition of the digestive organs; or a diseased, or congestive state of the hepatic system ; mercury in some of its forms, will prove an invaluable remedy. In the treatment of tuburcular affections, and in all forms of laryngeal disease, most writers consider calomel, as the most efficient and useful medicine, of all the preparations of mercury. In these cases of follicular disease, when the symptoms indicate the presence of a chronic thickening of the lining membrane, of the laryngeal cavity, calomel, administered to the extent of affecting the mouth, as recommended by Dr. Porter, f * Op. citat. p. 234. t °P- citat. 241 FOLLICULAR DISEASE. is, undoubtedly, under these circumstances, the most appropriate, for exhibition; but where the general glandular system is involved in the morbid action; or, even, when some forms of pulmonic lesions co-exist with the follicular disease, I have found, in these complications, the bi-chloride of mercury, the most efficient, and, altogether, the best preparation of this mineral. In hepatization of the lungs, says Dr. Pereira,* the solid matter, deposited in the air-cells, is often absorbed, and the cells rendered permeable to air, by the use of mercury. The bi-chloride of mercury, may be given in doses from one twelfth, to one sixth of a grain; and is best administered, in the form of pills f made with crumbs of bread, or combined with the extract of conium, or hyoscyamus; the best time for exhibiting which, is after meals. In irritable subjects, opiates should be conjoined with it. * Elements of Mat. Med. Vol. I. p. 194. f The following is the formula of Dzondi of Halle, who is a great advocate, for the use of the bichloride of mercury:—Hydrarg. chlo. corrosiv. gr. xii. Solve in aq. distil, q. s. adde Micae Panis Alba, Sacharis Alba aa q. s. ut fit pilulae numero ccxl. Of these pills,—each of which contains.the twentieth of a grain of the mercury —two may be given night and morning. I have been accustomed to prescribe the following formula:— g;. Hydrarg. chlorid. corros. gr. iv. Extract conii 3ij. Misce ; et in pilulas quadraginta divide. Should these pills,—one of which may be given night and morning— irritate the mucous membrane of the stomach or bowels, one fourth, or one half of a grain of opium may be combined with each pill. 12 242 ON THE TREATMENT OP Prussic Acid. —The hydrocyanic acid was first employed as a therapeutic agent, by the Italian physicians near the commencement of the present century. Soon after its introduction into the Materia Medica, it obtained some celebrity, as a remedy, in disease of the pulmonary organs ; and it has since been employed, with more or less repute, in this, as well as in other forms of morbid action. In the treatment of disease, of the air passages, I have, frequently, administered the hydrocyanic acid; and in some instances, its employment has been attended, apparently, with happy effects; such has not been the result, however, in all cases. As this acid is considered a contra-stimulant, by many, its use is most indicated in those cases, where the presence of some degree of inflammation, would seem to preclude the employment of more active remedies. When given to allay the cough in pulmonic disease, I have found its efficacy much increased, by combining with it, a small amount of the sulphate of morphine.* Sanguinaria. —In New England, and in some other parts of the United States, a decoction or tincture of the Sanguinaria Canadensis or Blood Root, is much used in bronchial and pulmonic affections. It is a stimulating expectorant; slightly * Emulsio Amygdalae Acid. Hydrocyanic gtt. xl. Morph. Sulph. gr. iij. Misce. Sumat cochleare minimum ter die—dosin sensim augendo. 243 FOLLICULAR DISEASE. narcotic ; and when combined with opiates, will often prove a valuable remedy, in allaying the cough, and irritation, in some forms of follicular inflammation, complicated, with bronchial or pulmonic disease. When inflammatory symptoms are not present, and the cough, which usually attends follicular bronchitis, is accompanied by a free expectoration, I am accustomed to administer, with much advantage, a saturated tincture of the root of the Sanguinaria. The common tincture of the shops, which is prepared by macerating four ounces of the root in two pints of diluted alcohol, is, ordinarily an inefficient preparation, and does not, I am confident, contain the active principle of the medicine : to obtain this, absolute alcohol should be employed, and a saturated tincture procured, by macerating in two pints of the liquid, double the above named amount of the bruised root of Sanguinaria. Combined with a small amount of the tincture of opium, or the sulphate of morphine, this medicine will often exert a powerful influence in diminishing the cough and expectoration, in some forms of bronchial irritation,* * ]J. Tinct Sanguinaria Tinct Opii. 01. Gaultheria gtt. x. JMisce; cujus capiat guttas viginti vel triginti, ter die. 244 OF THE TREATMENT OF Muriate of Ammonia. —Of the therapeutic effects of this remedy, when internally administered, hut little is known; as in this manner, it is but rarely employed in this country. Among the German physicians it has obtained a high reputation as a powerful alterative, and a promoter of healthy secretions, in chronic diseases of the mucous and serous tissues. It was employed by Dr. Cless, of Stuttgard, who speaks highly of it, as a remedy in the early stage of phthisis; and Dr. Sunderlin says that it not only promotes the mucous secretions but the cutaneous exhalations, and improves, also, nutrition and assimilation. In combination with other remedies, I have frequently administered the muriate of ammonia, in follicular disease, when this affection has been complicated with sub-acute inflammation of the mucous membrane of the air-passages. In this form of the disease, —namely, where the bronchial and pulmonic tissues are involved in the glandular affection ; and, when a troublesome cough is present —I have found the following combination prove valuable in allaying irritation, and in promoting expectoration i — Murias Amnion. 3ss, Scillse pulv. Digitalis pulv. au 3j Opii pulv. gr. x. Fiat massa, in pilulas trigmti dividenda; quanttni capiat unarm ter in die. 245 FOLLICULAR DISEASE. Climate. —The influence of climate on the animal economy, and as a remedial agent in the cure of disease, has ever been considered by the profession, as of great value. Of such importance have I been led to estimate the medical effects of certain localities, or conditions of the atmosphere, upon some of the diseases of the air passages, that I shall not hesitate to devote a few pages, to the consideration of this subject. In 1840, I communicated, to the New York Journal of Medieine and Surgery, some " Observations on the Influence of Malarious Atmosphere, in the prevention and cure of Phthisis Pulmonalis."* My object, in that communication, was to demonstrate by facts and observations, the non-existence of pulmonary cousumption, in those localities, in our country, where intermittent fevers prevail; and, to show that, while those places are exempt from the disease, the inhabitants of others, in their immediate vicinity, but where marsh exhalations do not exist, are affected with pulmonary diseases to an unusual extent; although subjected to the same influences of temperature, habits, occupations, &c. Several cases, which came under my own observation, were given, where persons, presenting marked symptoms of tubercular phthisis, had been restored to perfect health, apparently, by residing in malarious districts. * New York Journal of Medicine and Surgery, January, 1840. 246 OF THE TREATMENT OF From among the most interesting of these instances I shall record the following : — A young lady, aged 16, had been labouring, for several months, under symptoms of incipient phthisis. She was hereditarily predisposed to the disease. Her mother and an elder sister had died of consumption; and several near relations on her father's side. The prominent symptoms were, a shorty dry cough; pain in the left side; a burning in the palms of the hands—particularly at night; dyspnoea following the least exercise, lassitude, &c. Symptoms which were remarked by herself and the family as being the same with w T hich her elder sister, who died, had been affected. With the other members of the family, medication had had, apparently, no salutary effect. Indeed, it seemed to have hurried them with greater rapidity to the grave. Under these circumstances, I advised her father to send her into the vicinity of the lakes, where she might be subjected to the influence of an intermittent atmosphere. For this purpose she spent the summer of 1831 in Whitehall. She had not been there many months before there was an evident improvement in her symptoms. Before the close of summer she had an attack of intermittent fever. It was slight,—having ceased after one or two paroxysms. Her improvement, after this, was rapid; and before winter, she returned to her father with restored health. She is now married to a gentleman in New York, and, up 247 FOLLICULAR DISEASE. to the present time, has enjoyed uninterrupted health. The two following cases came under my observation in this city: A young gentleman, about 24 years old, of a consumptive family, suffered severely from an attack of the influenza, which prevailed to some extent in New York, in the winter of 1837. He came under my care the latter part of that winter ; at which time he exhibited the following symptoms : —A frequent, hard cough, unattended with much expectoration j constant pain in the chest; pulse 100; debility; loss of appetite ; tongue coated ; respiration a little accelerated ; skin hot and dry, during the latter part of the day, with some perspiration at night. The ordinary remedies were employed, which were followed with some abatement of the cough, and the pain in the chest. On the 10th day after 1 first saw him he commenced expectorating blood, which continued several days. At the end of three weeks, his strength had improved and his cough had considerably abated; but as these primary symptoms of a pulmonary affection still remained in a great degree, I advised his leaving the city and seeking a more genial clime. He went first to Ohio, where he remained several months; and from thence to Michigan, where, in the spring of 1838, he had an attack of intermit- 248 OF THE TREATMENT OF tent fever. He returned to this city, about six months ago, in perfect health; not a vestige of that affection remaining, which he carried away with him. In November, 1836, Dr. H., a practising physician of New York, caught a severe cold, which was followed by a cough, and, in a few weeks, with an expectoration of purulent matter. His cough continuing about three weeks from the attack, haemoptysis supervened, and this was followed for some time, with a bloody, and muco-purulent expectoration. These symptoms of phthisis becoming more alarming, as the winter advanced, he relinquished his practice, and sailed for Mobile, early in January, 1838. So unfavourably did his symptoms appear, at this time, that one of the oldest and most experienced physicians of this city remarked to me, after taking leave of him, that Ł the Doctor would never live to return to New York.' On the 4th of February, he arrived at Mobile, where he remained several months; but went to New Orleans, the June following, and from thence to Indiana; where, in August of the same year, he had an attack of ague, which continued for some time. About eight months after, he returned to New York in confirmed health, and renewed his practice, and up to the present day has had no return, whatever, of his pulmonary difficulty. I could enumerate other cases, which have 249 FOLLICULAR DISEASE. come under my own observation, but will only allude to one other; the history of which was communicated to me, by my friend Dr. Woodward, formerly professor of Surgery, in the Vermont Academy of Medicine. Some time since, a young woman labouring under consumption, —apparently in its confirmed, secondary stage, —was brought to Castleton, the residence of Professor Woodward, to die among her friends. Her mother resided upon the borders of a small marshy lake, in the westerly part of the town, —a neighbourhood where all new residents are sure to be affected with intermittent fever. Thither she was carried, and Dr. Woodward was called to attend upon her. He found her, as he informed me, exhibiting every symptom of ulcerated lungs. Indeed, so apparently hopeless was the case, that the medicines he prescribed, were merely palliative ; and he informed her friends, that no permanent benefit could be expected, in her case, from the adoption of any means. Several months after this, being in that neighbourhood, he learned with surprise, that his patient was recovering; and on calling to see her, he, in fact, found her nearly restored. Her cough, and every other unfavourable symptom, had left her. Her health since, has been permanently established. Dr. Woodward gave it as his opinion, that in this case —as well as in some other similar ones, 12* 250 OP THE TREATMENT OF with which he has been familiar —the persons were restored to health by breathing an intermittent atmosphere. If we examine into the past history of our own city, the same facts will be established. Cadwallader Colden, who wrote an account of the climate and diseases of New York, more than one hundred years ago, says, in speaking of the diseases of that day, ' we have few consumptions or diseases of the lungs. I never heard of a broken-winded horse in this country. People inclined to consumption in England, are often perfectly cured by our fine air.' * It would seem that the climate, at this early period of our country, when the winters were long and intensely cold, would have been much better calculated to induce pulmonary affections, than it is at the present day. According to the testimony of the same writer, the winter then, commenced about the middle of November, and continued severe, until March. During this period, the Hudson river was often ' frozen over at the town, where it is about two miles broad and the water very salt, so that people passed over upon the ice in crowds/ f At that time, and for many years subsequent to that period, New York was surrounded with lagoons, and marshy grounds, from whence, during the summer months, those malarious exhalations * American Medical and Philosophical Register, Jan. 1811, pp. 309-10. | Ut supra. 251 FOLLICULAR DISEASE. arose, which so often proved the exciting cause of 'intermitting fevers, cholera morbus, and fluxes,' which, as the above writer states, w T ere the prevailing diseases of that day. As improvements have progressed, these fenny grounds and stagnant waters have been drained off, the sunken places filled up, and intermittent fevers have as gradually declined. But with this declension of ague, phthisis pulmonalis has steadily and fearfully increased. Within a few years a work * has been published in Paris, by M. Baudin—a physician of some eminence in the French army, which contains some interesting statistics on this subject. M. Baudin, who has enjoyed—according to the British and Foreign Medical Review, in which his work is examined—many opportunities for observing the effects of marsh miasmata, in several parts of France, Germany, Spain, Greece, and the Algerine districts of Africa, has embodied in this work many important observations and facts, which go to establish the truth of this same doctrine; namely, —"the antagonism of the paludal poison to certain pathological conditions, and more especially, to the tubercular diathesis." Among the many confirmatory facts, which M. Baudin has adduced, are the following:— " The * Traite" des Fi6vres Intermittent, Remittent, et Continues des Pays Chauds, et des ContrSes MorŁcageuses, etc. Par J. C. M. Baudin. Paris, 1842. 8vo. pp. 336. 252 OP THE TREATMENT OP rarity of diseases of the chest, at Algiers, is such, that it has happened to me to visit many hundreds of fever patients without having occasion to practise, in a single instance, auscultation or percussion of the respiratory organs. Among a total of twelve thousand eight hundred and fifty patients, whom I have treated, either in the army of Africa, or at the Lazaretto of Marseilles, (after their return from Africa,) I have met with only thirty-one cases of consumption, of whom twenty-five had incontestably, been affected with tubercle, before having embarked for the Morea or Algeria." * " But, while consumption," M. Baudin adds, "is thus proved to be extremely rare in the essentially febriferous part of Algeria, the immunity from the tubercular diathesis appears to decrease, in proportion as the country becomes more healthful, in respect to marsh diseases; so that a district often further South, but less marshy than the coast, predisposes so much the more to consumption, the less it is subject to fevers." f * Op. citat. pp. 72-5. f This discovery of M. Baudin having been brought before the " Royale de MŁdecine de Marseille," that learned body declared that, 44 it is one of great importance, and our colleague has all the merit of it, for no one that we know of has made it before him." Now if any merit in this matter belongs to either of us, I shall lay claim to it, from priority of discovery, as my essay, on this subject, was published early in 1840, —more than two years before M. Baudin's work made its appearance ; and, moreover, it will be seen from that communication, that I was in the practice, —as early as in 1830, —" of advising my consumptive patients to visit places where an aguish atmosphere prevailed." But neither to M. B. nor to myself, belongs the merit of discovery, so far 253 FOLLICULAR DISEASE. Two years after the publication of M. Baudin's work, namely, in 1844, a communication was made to the Royal Academy of Medicine, of Paris, by M. Nepple, a French physician of eminent talent, on " The Antagonism of Phthisis and Intermittent Fever," in which are embodied many important, and most interesting observations, on this same subject. Among other facts recorded, M. Nepple states as follows:— During the eleven years that were comprised between the years 1818 and 1829, I practised in the canton of Montluel (Ain*), which is composed as this matter is concerned ; for, a knowledge of this exemption from pulmonary diseases of many parts of our country, where intermittents abound, and also of the fenny districts of England, has existed among the inhabitants of those regions for many years ; and the attention of the profession has been called to this subject from time to time, during the last thirty years, by writers who have remarked the phenomenon. Although, so far as I was acquainted, in this country, up to the period of the publication of my paper, the employment of miasmatic exhalations, as a therapeutic agent) in the treatment of pulmonary diseases, had not been recommended ; nor had cases been given, where its influence, in these affections, had been tested. Since the publication of that paper, however, I have received information from many physicians, who have sent their consumptive patients into that part of the country, where intermittents are rife, and who, after a time have returned, restored to health, or greatly benefited by the operation. Yet, we need still further observations on this subject. It is one, well worthy of a thorough investigation. Pulmonary Consumption is, of all other diseases, the opprobria medicorum of the present day; and, so long as one-fifth of the deaths in our country, as well as in almost all others, — occur from this disease, it becomes the duty of every medical man to investigate this subject, with an untiring assiduity, until a remedy be discovered. * The department of the Ain is bounded on the east by the Jura mountains, on the west by the Saone, on the south by the Rhone, and is crossed 254 OF THE TREATMENT OF of several districts, some of which are marshy, and some quite healthy. I was then much struck by the small proportion of cases of phthisis, scrofula, and goitre, which the marshy localities presented. The frequency of these diseases appeared to decrease as the elements of impaludation became more numerous and more general; so much so, indeed, that in the farms and villages situated in the most impaluded districts, I seldom discovered any traces of tuberculisation. On my mentioning these remarks to a fellowpractitioner, Dr. Duteche, whose district was much more marshy than mine, he answered that his attention had never been directed to the subject, but that what I said was a ray of light to him, and brought forcibly to his mind, the fact, that he had never seen any cases of phthisis or scrofula in various parishes which he named, Marlieux, Versailleux, Lachapelle, St. Nizier, all situated in that part of the country in which the ponds are the most numerous, and the population most debilitated by intermittents. He added, that so convinced was he that the atmosphere of this district must exercise a favourable influence upon the first stages of phthisis, that he would at once establish a sanatorium for tubercular diseases, in an old mansion from North to South by the river Ain. It is covered by ponds, lakes, and marshy swamps, and is, perhaps, of all France, the district in which intermittents are the most general, and exercise the most baneful influence on the population. 255 FOLLICULAR DISEASE. which had been abandoned by its proprietors on account of its insalubrity. This plan, however, was never realized. M. Nepple also addressed inquiries to many other well-informed medical men, who are practising physicians in the different marshy districts of France ; from all of whom he received answers, confirmatory of the results at which he had arrived. From having been engaged, for several years, in the early part of my professional life, in practising, in the vicinity of marshy districts, I had observed many facts on this subject, and was, long since, well convinced of the incompatibility of pulmonary phthisis and intermittent fever. Accordingly, for many years, I have been in the practice of advising my patients, who were labouring under phthisis, or follicular disease, complicated with phthisis, to visit places where an aguish atmosphere prevails. In many instances, the result has been decidedly beneficial. This subject,—the influence of climate upon diseases, —especially the varied climate of our own country, has not, I am confident, received that attention from medical men which its importance demands. If, indeed, it be true, as some naturalists assert, that the infinite variety of form, colour, constitution, and moral character, which the different nations, tribes, and races, present upon the surface of this globe, have been marked by the slow hand of time, through the instrumental!- 256 TREATMENT OF FOLLICULAR DISEASE. ty of climate, what may not he expected from the same agent, in the cure of diseases, when the physical properties of climates, in their different localities, shall he thoroughly investigated, and their influence upon the human constitution, and their modus operandi upon diseases, shall be distinctly understood ? APPENDIX. After the preceding" sheets of this work had gone to press, I had the honour of meeting in a neighbouring city, of another State, several highly intelligent medical gentlemen, in a case of laryngeal disease, of great interest. Among the number present, was one of the professors of the Medical School, of that city;—a gentleman of high attainments, in his profession, and, withal, an accomplished anatomist. This physician, never having seen medicinal agents introduced into the laryngeal cavity; declared, in my presence, on being asked his opinion, in the matter, that it was " physically, and anatomically impossible, to apply topical remedies, below the epiglottis." On making some inquiries, I ascertained that this opinion of Prof. , was entertained, almost universally, by the medical men of that city. Within a short period, I have been visited, by a large number of professional men, from different parts of this State, and from different States of the Union; many of whom have honoured me, by being present, from time to time, and witnessing my operations. From these gentlemen, I have also learned, that the same skepticism, on this subject, obtains, very generally, among the medical men, throughout the country. I have, therefore, deemed it advisable, to substantiate, by the testimony of others, what, in the preceding pages, I claim to have accomplished. Accordingly, I addressed a note of inquiry, to several medical gentlemen, many of whom, —when the question of intro- 258 APPENDIX. ducing medicinal agents into the cavity of the larynx, was first proposed to them, —were entirely incredulous as to its practicability; but whose opinions,—as will be seen from their communications, —have since undergone an entire change. From them, I received the following replies. Sustained by the opinions, and experience of such men —some of whom are well known to the profession throughout the country; and, who are as incapable of deceiving, as they are of rejecting any improvements, however humble their origin, whose tendency is to advance the cause of science, and humanity,—I shall allow myself to feel no particular anxiety, about the opinions of those members of the profession, who may still remain incredulous on this subject :—They are as fully entitled to their belief, as they are to all the benefits which may result from their skepticism ! No. I. From Dr. Charles A. Lee, Editor of the New York Journal of Medicine and Surgery. New York, July 10th, 1846. To Horace Green, M. D. My Dear Doctor, It is with great pleasure that I bear my testimony, not only to the practicability, but also the efficacy of caustic applications, made to the internal surfaces of the larynx. Soon after the practice of cauterizing this organ was first introduced into this city, by yourself, in 1839,1 was favoured with repeated opportunities of seeing you perform the operation of introducing a sponge below the glottis, wet with a strong solution of nitrate of silver, as well as of watching the immediate and ultimate results thereof. It is proper that I should remark, that my previous notions, as to the 259 APPENDIX. harmlessness and practicability of this operation, were altogether erroneous; —for, like many others, I did not believe it possible to introduce a foreign body below the epiglottis; or, if it could be done, that it would be attended with any benefit to the patient. Here, however, as in many other cases, experience upsets all a priori reasoning. The mistake arose from confounding the organic sensibility of the larynx, that sympathetically causes the cough, with the animal sensibility of this organ, which is extremely obtuse. It is now demonstrated, that the application of nitrate of silver to the pharynx, larynx, neck of the uterus, urethra,