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DF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE zi £— an wnoiivn 3Nma3w do Aavaan wnoiivn snioiosw do Aavaan wnoiivn DF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE an wnoiivn SNiDiasw do Aavaan wnoiivn 3nidio3w do Aavaan wnoiivn Q 0_ * £P^ S Z < ASK * D DF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE 311 IVNOIIVN 3NIDIQ3W dO Aavaail IVNOIIVN 3NIDIC33W dO AdVa9ll IVNOIIVN ^. I )F MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE / ' ^i, 'c , / *M« Plate I Plite 2 SORE THROAT; ITS „ NATURE, VARIETIES, j AND TREATMENT. INCLUDING THE CONNECTION BETWEEN AFFEC- TIONS OF THE THROAT AND OTHER DISEASES. IJY PROSSER JAMES, M.D., Physician to the Hospital fok I diseases of the Throat and Chest, FOURTH EDITION, ENLARGED. WITH COLORED PLATES AND WOOD ENGRAVINGS. PHILADELPHIA: P. BLAKISTON, SON & CO., io12 Walnit Street. 1SS2. WVB JX8s 682 A> / m P *6 3. !+"• PREFACE TO THE FOURTH EDITION. The third edition having been sold in a little more than three months, was reprinted in time for the opening of the last Winter Session. This reprint, in its turn, having been disposed of before the close of the academical year, the author has devoted his vacation to the revision of his work. Some alterations in arrangement have been made; the remarks on classification, omitted in the last edition, have been restored; many passages have been condensed, though many more expanded; several sections have been inserted, e. g., that on Stammering of the Vocal Cords; and fresh paragraphs have been interspersed throughout the work. Four entirely new chapters [XII, XVI, XVII, XVIII] have also been added. Thus the bulk of the book has been augmented, but it is hoped the greater completeness thereby obtained will be found associated with increased usefulness. The Plates are again new. The lithographic stones having been considerably worn by the two issues of the last edition, the author has selected a new series of cases for his illustrations. These have been now engraved on copper and colored by hand. A copious index has been compiled by Mr. Augustus Cox, the author's nephew and assistant. Prosser James, M.D. 3 Dean Street, Park Lane, October 31st, 1879. PREFACE TO THE THIRD EDITION. This little work originally appeared at the close of 1860, and in accordance with publishing custom, bore on its title-page the date of the approaching year. It was the first, and for about three years continued to be the only English book on the Laryngoscope—an instrument the value of which was recognized throughout. At the end of 1865 an illustrated edition was issued, in which five lithographic plates exhibited as many methods of employing the laryngoscope. These plates were copied from photographs, with which it was orig- inally intended to illustrate the work, but the photo- printing was attended with so many delays, that while passing the previous winter on the Continent, I had them transferred to stone by a foreign process. Those lithographic illustrations have served the pur- pose for which they were first designed, and, therefore, are not now reproduced. Instead of them I have added to this edition two much more costly colored plates, on which are depicted twelve examples of laryngeal diseases drawn and painted from life by the aid of the laryngo- scope. They are selected from cases occurring in my own practice, and some of them are of special interest not only as illustrations of diseases which can only be certainly detected and efficiently treated by the aid of the laryngoscope, but as additional demonstrations of the PREFACE. 7 accuracy of my former observations respecting eases of recovery from morbid conditions usually considered in- curable. In some "Clinical Illustrations of Diseases of the Throat and Lungs," contributed to The Medical Press in 1872, I recorded two examples of recovery from advanced laryngeal phthisis, having previously brought some be- fore the British Medical Association. A picture of one of these appears in my "Lessons in Laryngoscopy and Rhinoscopy," and another will be found in the present volume. These and other satisfactory instances of re- covery from advanced consumption, impel me to repeat my assertion that neither laryngeal nor pulmonary phthisis should be abandoned as hopeless. The delay in the appearance of this edition has been quite unavoidable. Seven years since, in compliance with the wishes of pupils and friends, I expressed a de- termination to revise the book. A little later an eminent foreign professor favored me with a visit, during which he preferred a similar request, urging that for several years he had used it as a textbook in his class. Stimu- lated by this, I readily undertook to set about the revision, but a series of acute rheumatic attacks interposed to pre- vent the execution of my purpose. At length, on re- suming practice after the rest enforced by a season of severe suffering, one of my first cares has been to redeem my promise by preparing a new edition. In-doing so it has been a gratification to find how little I have had to retract from the teaching laid down so long ago. Some of the doctrines then thought novel have been widely adopted, the remedies I recommended are now regularly prescribed, those I discountenanced have been gradually 8 PREFACE. abandoned, and the only statements I made which pro- voked opposition have become generally accepted. Considerable additions have, however, been made to the work, which is so far rewritten as to coincide with the further experience acquired in the years that have elapsed since the last edition, during which favorable opportu- nities for observation have been afforded me as Physician to the Hospital for Diseases of the Throat, as well as other public charities, one of them a Hospital for Consumption. Still, I am by no means unconscious of the shortcom- ings of my work, though I venture to hope it will again be found useful to my professional brethren, and not al- together unworthy of the position their confidence has conferred upon me, and which it has always been my en- deavor to deserve. No doubt the additions may be detected by their dif- ference in style, especially as in making them no circum- locution has been resorted to in order to avoid the use of the pronoun I. In extenuation of this I might plead that professorial labor seems naturally to produce a ten- dency to employ dogmatic modes of expression. But, indeed, I am ready to admit that, at this date, I feel en- titled to make assertions which twenty years ago it was natural to put in the modest form of suggestions. More- over, as the first English worker with the Laryngoscope, it seems to me as well thus to signify my acceptance of such responsibility as may attach to my teaching. Prosser James, M.D. 3 Dean Street, Park Lane, May, 1878. CONTENTS. PART I. PRELIMINARY SKETCH OF THE WHOLE SUBJECT. CHAPTER I. nature and varieties of sore throat. The Throat and the organs which enter into it: a passage for air and food : its parts, the soft palate, velum, uvula, arches, pillars of fauces, isthmus, tonsils, pharynx, larynx, trachea—Mucous membrane : its construction and use—Epithelium : its varieties —Follicles and glands; secretion—Congestion and Inflam- mation of mucous membrane: its stages : its tendency to spread —Catarrh : coryza, or rhinitis, influenza, angina, tonsillitis, pharyngitis, laryngitis, tracheitis, bronchitis, etc.—Aphtha— Thrush or Millet—Inflamed Sore Throat : acute, chronic —Relaxed Sore Throat—Dry Sore Throat : effects on ears and nose—Consequences of inflammation : effusion, ero- sion, abscess, quinsy, ulceration, gangrene, etc.—Clergymen's Granular, or Follicular Sore Throat—Phlegmonous Sore Throat : suppurative, parenchymatous, typhous, trau- matic—Gangrenous Sore Throat — Exudative Sore Throat : nature of exudation ; croup and diphtheria—Fun- gous Sore Throat : muguet and the oidium albicans—Glands —Cynanche parotidea—Metastasis—Tonsils in sympathy with ovaries — Non-inflammatory Affections : hyperemia, anaemia ; hypertrophy, atrophy ; degeneration ; spasm ; paresis, 10 CONTENTS. paralysis; nervous sore throat, hyperesthesia, neuralgia, anaes- thesia, paresthesia—External Influences ; entrance of for- eign bodies; pressure, wounds, injuries, etc.—Specific Sore Throat: tubercular, cancerous, syphilitic—Exanthematous Sore Throat—Relations between the skin and mucous mem- brane, displayed in eruptive fevers, in the haemorrhages, in ves- icular, in pustular, and other skin diseases, etc., . . .17 CHAPTER II. diagnosis of sore throat. Means of study—The history—General impression : Analysis of this in the several senses—Auscultation and percussion : Voice, cough, breathing—Palpation—Tenderness, hardness and soft- ness, roughness and smoothness, etc.—Changes of form and size, new growths, etc.—Inspection—Tongue depressors—Mirrors —Speculum—Art of Laryngoscopy : apparatus; the image seen in the laryngoscope ; its several parts ; the changes seen in disease; changes of form and color ; alterations of movements— Laryngostroboscopy—Rhinoscopy : the image seen in the rhi- noscope in health ; changes in disease—Anterior rhinoscopy— ffisophagoscopy, ......... 56 CHAPTER III. GENERAL TREATMENT OF SORE THROAT. General Therapeutics — Antiphlogistics—Bleeding— Leeches— Scarification—Emetics—Aconite—Iodine and its compounds— Nitrate of potass—Chlorate of potash—Chloride of sodium— Guaiacum—Throat Therapeutics—Astringents—Escharotics —Nitrate of silver — Caustics — Fomentations—Inhalations — Atomized sprays—Fumigations—Sternutatories and errhines— Gargles—Nasal douches—Pharyngeal douches—Irrigations- Insufflations—Lozenges — Laryngoscopal Therapeutics— Application to the larynx of liquids, solids, caustics—Operations within the larynx—Scarification, electrization, removal of growths —Tracheotomy,.........83 CONTENTS. 11 CHAPTER IV. Classification,....... 120 PART II. DIFFUSED AFFECTIONS. CHAPTER V. INFLAMED SORE THROAT. Acute : catarrhal, phlegmonous, traumatic—Erysipelatous, or Hospital sore throat—Chronic : relaxed sore throat—Consti- tutional Varieties : strumous, phthisical, rheumatic, gouty, syphilitic, diabetic,...... .122 CHAPTER VI. ulcerated sore throat. Simple, specific, tuberculous, scrofulous, herpetic—Lupus—Treat- ment, ...........136 CHAPTER VII. CLERGYMEN'S SORE THROAT—GRANULAR OR FOLLICULAR DISEASE. Inflammation of follicles, hypertrophy, ulceration—History—Diag- nosis—Treatment,........142 CHAPTER VIII. APHTHOUS SORE THROAT—MOUTH AFFECTIONS. Aphtha? in mouth and throat—Eolations to stomatitis and other dis- eases of the mouth—Stomacace—Sloughing ulcer—Gangrene of the mouth—Noma,........149 12 CONTENTS. CHAPTER IX. FUNGOUS SORE THROAT—THRUSH. Millet or Thrush—Oidium albicans in mouth and throat—Attacks only squamous epithelium—Symptoms and Treatment, . 153 CHAPTER X. CROUP AND DIPHTHERIA—EXUDATIVE SORE THROAT. The distinctions between croup and diphtheria — Croup — History, symptoms, varieties, laryngeal spasm, and paralysis—Complica- tions—Treatment—Antiphlogistics—Emetics—Mercury—Coun- ter-irritants—Fomentations—Cold—Tracheotomy— Inh alations —Hot vapor—Topical applications — False croup and allied spasmodic affections—Diphtheria—Character and symptoms— Varieties — Parasites—Contagion —Complications — Sequelae— Treatment,.........157 CHAPTER XI. EXANTHEMATOUS SORE THROAT. Lesions in the throat, in Small-pox, Measles, Scarlatina—Injuries to the ear—Course and consequences of exanthematous sore throat—Sequelae—Diagnosis—Treatment, .... 188 CHAPTER XII. SYPHILITIC SORE THROAT. Early and late manifestations—Ulceration—Association with affec- tions of mouth and nose—Lesions of the tongue__Ozaena__ Treatment,........ ^oq CONTENTS. 13 PART III. DISEASES OF INDIVIDUAL ORGANS. CHAPTER XIII. AFFECTIONS OF THE SOFT PALATE AND UVULA. Structure—Congestion—Tipplers' and smokers' sore throat—Haem- orrhage—Anaemia—Inflammation—(Edema—Ulceration—Gan- grene —Atrophy—Perforation—Cicatrices—Tumors —Cancer — Syphilis—Nervous diseases—Malformations—The Uvula—In- flammation— Oedema — Elongation and hypertrophy—Uvula cough and consumption—Ulceration—Polypus—Warts—Paral- ysis and spasm,.........202 CHAPTER XIV. AFFECTIONS OF THE TONSILS. Structure—Inflammation—Abscess—Quinsy—Ulceration—Chronic inflammation— Lacunal inflammation— Hypertrophy—Atro- phy—Cysts—Concretions, etc.—Syphilis—Cancer—Sympathy BETWEEN THE OVARIES AND THE TONSILS, . . .211 CHAPTER XV. AFFECTIONS OF THE PHARYNX. The membrane—Pharyngitis, catarrhal and phlegmonous—Chronic pharyngitis—Granular pharynx—Ulceration—Pharyngitis sicca —Dry sore throat—Hypertrophy—Polypi—Pharyngocele—Em- physema—(Edema—Syphilis—Retro-pharyngeal abscess—Ner- vous affections, . .......228 CHAPTER XVI. AFFECTIONS OF THE NASO-PHARYNX. Hyperemia—Inflammation—Ulceration—Cysts—Polypi—Hypertro- phy—Rhinoscopal therapeutics,.....238 14 CONTENTS. CHAPTER XVII. Connection of Sore Throat with Affections of the Nose and Ears—Throat Deafness,......~42 CHAPTER XVIII. affections of the oesophagus. Inflammation—Varieties and consequences—Ulceration—Hypertro- phy—Morbid growths—Stricture—Dilatation—Foreign bodies— Neuroses—Symptoms, course, and diagnosis of oesophageal dis- eases—Treatment, ........ 246 CHAPTER XIX. affections of the larynx and voice. Variations of color—Anaemia—Pigmentation—Haemorrhage—Hy- peremia—Congestion—Inflammation : Acute catarrhal laryn- gitis, oedema, phlegmonous laryngitis, treatment of laryngitis— Chronic inflammation—Chronic laryngitis, varieties, conse- quences, treatment—Perichondritis—Growths in the Larynx : Benign, malignant—Cancer—Sarcoma—Extirpa- tion of Larynx—Specific diseases — Syphilis—Glanders— Laryngotyphus—Lupus—Leprosy—Other lesions—Wounds— Injuries—Foreign bodies,....... 252 CHAPTER XX. laryngeal phthisis—throat constmption. Relations to pulmonary consumption—Course—Laryngoscopic ap- pearances and general symptoms ; not necessarily a fatal disease instances of recovery ; treatment, ..... 281 CONTENTS. 15 CHAPTER XXI. LARYNGEAL NEUROSES—AFFECTIONS OF THE VOICE. Affections of Motor Nerves—Forms of paralysis of vocal cords— Laryngeal spasm—Spasmodic cough—Stammering of the vocal cords—Affections of Sensory Nerves—Anaesthesia—Hyper- esthesia—Neuralgia—Paresthesia—Treatment, . . 288 CHAPTER XXII. affections of the trachea and bronchi. The tracheal image—Congestion—Inflammation and its consequences —Stenosis—Causes and course — Spasm — Foreign bodies — Treatment,..........301 CHAPTER XXIII. EXTERNAL SORE THROAT. Angina externa—Enlarged glands, tumors of the neck, mumps- Angina Ludovici—Goitre or bronchocele—Exophthalmic goitre —Thyroiditis—Cysts and other tumors—The thymus, . 308 Plates—Index, .... ^^, cleave, cut, or divide, this verb being but a changed form of the Sanscrit, phal, signifying a joint opening, or cleft. The throat is often described as the roadway from the mouth and nose to the stomach in one direction, and the lungs in the other. It would give a better idea, perhaps, to compare it to the junction of two curved roads which cross each other and then run a parallel course. One of these, the channel for food, goes from the mouth back- ANATOMY OF THE THROAT. 19 wards into the throat, crossing the other at the summit of the larynx, where the epiglottis falls like a drawbridge as the food passes over into the pharynx, whence it is dispatched along the gullet or oesophagus downwards to the stomach. The other road is for air, and may be said to start from the nose, taking its way along the posterior nares into the throat, where it bends rather abruptly for- wards, and having crossed to the front of the food chan- nel, continues its course downwards along the larynx, trachea, and bronchi, to the lungs. If further illustration were required, we might com- pare the throat to a narrow defile through which both air and nutriment must find access to the body, where accordingly two roads coming from the exterior converge, and from which two other roads lead to the interior,—to say nothing of smaller passages, such as that which leads to the ear, and thus brings that organ into intimate con- nection with the throat. From what has been stated it will be seen that the air has free access from the open mouth as well as through the nose. The respiratory passage is always open, except during the act of swallowing, when, as we have seen, the epiglottis closes it below, so that nutriment can pass over. At this moment it is also necessary to shut off the upper part of the air-tube in order to prevent the aliments from entering the nose. This is accomplished by the soft palate, which here playing the part of a swing-door or gate, closes the nares during deglutition, but immediately afterwards resumes its usual position, where, hanging like a loose curtain from the hard palate, and therefore ap- propriately named velum pendulum palati, it separates the mouth from the throat more or less completely, according 20 SORE THROAT. to the constantly varying degree to which it descends or is drawn up. The loose border of the velum is so shaped as to make it resemble a scalloped valance or looped-up curtain ; for this free edge in its course from one side to the other de- scribes two arcs, separated from each other by a conical prolongation, which descending between the two is com- mon to both, and is named the uvida. The two concave or retracted segments are called the arches of the fauces. From these the outer bounding folds are continued down- wards—one on each side—as low as the floor of the mouth, so as to form a pair of columns or piers from which the arches may be said to spring, and which are named the pillars of the fauces. Thus the uvula appears as one im- perfect division between the two arches which communi- cate below. When the velum is completely retracted, the central part is drawn up so much higher than the sides that the two concave segments seem thrown into each other, so that we have only a single arch spanning the dis- tance from side to side, supported on the two pillars, with the uvula looking like a mere ornament suspended from the keystone. Examining the parts a little more closely, we"see that there is a second pair of columns, one standing in front of the other; they are distinguished as the ante- rior and posterior pillars. At their summits both pairs converge, so that all four are lost in the base of the uvula; but tracing them in the opposite direction, we observe that the distance between the anterior and posterior pil- lars increases as they descend, since the former are pro- longed to the sides of the tongue, while the latter are directed backwards to the pharynx. Thus on each side there is inclosed a rather triangular ORGANS OF THE THROAT. 21 space in which lies the tonsil—an oval body, on the sur- face of which several lacunae are visible. The constricted aperture between the mouth and throat, bounded by the parts just mentioned, is called by anatomists the isthmus of the fauces. In resorting to geography for a name, it would have been better to have borrowed the word straits; for we have to do, not with a solid part, but with a channel, a mere empty space, bounded by the solid organs. This being so, it is obvious that a mere communication between two cavities can suffer no change except as to its size and shape; and even these are only altered indirectly, through changes in the boundaries. It is, therefore, with the organs which bound this channel —the shores of the straits (isthmus)—that we have to do in disease. Beyond the isthmus lies the cavity of the pharynx, of which the posterior wall, immediately in front of the ver- tebral column, faces the observer and bounds the view. How much of this wall can be seen depends on the ex- tent to which the velum is retracted and the tongue de- pressed. In some cases inspection also reveals the tip of the epiglottis, standing erect like a sentinel on guard at the opening into the larynx. But to see this valve satis- factorily we must employ a mirror and suitable illumi- nation. • The skilful disposal of these enables us to look behind the velum, so as to examine its posterior surface and explore the pharyngeal cavity, including the roof or vault above, the passages into the nose, the ends of the Eustachian tubes leading to the ears, and in fact the en- tire surface of the walls of the pharynx, which is contin- uous below with the oesophagus. Posing the mirror so as to reflect the rays into the larynx, we may also illu- 22 SORE THROAT. minate the interior of the organ of voice, and watch the intensely interesting movements of its several parts, be- sides which, with a little dexterity, we may trace the trachea in its course, and sometimes see the bifurcation of the bronchial tubes. How all these ends are to be attained will be shown when we come to speak of Laryn- goscopy and Rhinoscopy. If the reader will now be good enough to inspect some friend's throat, or his own by the aid of a mirror, he will have recalled to his mind a more vivid notion of the re- lations of the several parts we have mentioned than the most carefully detailed description could convey. Nothing more is necessary at this stage than to remind him that the mucous membrane which covers these parts is con- tinuous, is, in fact, a portion of the great gastro-pulmo- nary tract, which, commencing at the lips, eyelids, and nostrils, passes back through the mouth, throat, alimen- tary canal, and air-passages, thus lining the inside of the body, just as the skin does the outside, the former being always moist, the latter comparatively dry. The con- tinuity of these structures ought never to be lost sight of. Their analogy is closer still; in structure and function they are very similar, and indeed they appear to run into each other. A single glance at the lips suffices to show that it is not easy to tell where the external skin ends and the internal one begins. There, is no distinct line of demarcation between the skin and mucous membrane; they glide insensibly into each other; in a word, they are continuous. In certain circumstances, when the con- ditions of the one get imposed upon the other, they become readily transformed into each other, and so go far to show that in essence they are but one, the difference be- MUCOUS MEMBRANE. 23 tween them depending on the conditions to which they are subjected. This is a beautiful instance of Nature's simplicity, and we may well admire her handiwork when we contemplate this exquisitely fitting garment, woven without seam, adapted by a hundred variations to every office it has to fulfil, covering the body outside (skin), and lining it inside (mucous membrane), winding through every turn of the wondrous labyrinth, and inclosing in its folds the strange machinery of life. Reduced to its simplest form, mucous membrane may be described as consisting of a very fine lamina mounted on a network of bloodvessels, and covered by epithelium. In the same rough manner it may be stated that the blood is brought to the part by the vessels, that some of its constituents ooze through, and, together with cast-off epithelium-scales, form the secretion. We must, how- ever, be a little more definite. A mucous membrane consists of two distinct layers, the deeper corresponding with the true skin, cutis vera or corium, and the super- ficial corresponding with the scarf-skin, cuticle, or epi- dermis, and named epithelium. It should, however, be observed that this superficial layer is not merely protec- tive, but discharges a more important function in relation to secretion. Beginning with the deepest layer—the fibro-vascular oase—We find it composed of networks of bloodvessels and lymphatics supported and united by connective tissue, areolar and retiform. It is of various degrees of thick- ness, and arranged, sometimes in prominences, called papillse or villi; at others in depressions, called crypts, follicles, or lacuna?; and, again, in involutions called glands. The deepest layer of the corium is formed of 24 SORE THROAT. bundles of non-striated muscular tissue running either longitudinally or circularly, and often in both these di- rections. This layer is sometimes distinguished by the name muscularis mucosas, and lies immediately upon the areolar submucous tissue to which mucous membranes are attached. The superficial boundary of the corium may mostly be made out as a distinct layer dividing it from the epithelium, and called the primary or base- ment membrane (membrana propria), which is so delicate that it long defied all attempts to make out its structure, and was therefore called a simple, transparent, homoge- neous layer. But by treatment with nitrate of silver it has been shown to consist of flattened epithelioid con- nective tissue cells, more or less fused together by their edges. This basement membrane in some parts—e. g., the cavity of the tympanum and the nasal sinuses—is so fine, if indeed it exist, that it cannot be demonstrated. The epithelium is made up of nucleated cells arranged in one or more layers, adhering together by some inter- cellular substance, which, as it exists in only minute quan- tity, cannot be demonstrated. From the variety which occurs in the shape of the cells, epithelium has received different names. Where the cells are simply spherical or globular-shaped bodies the epithelium is called sphe- roidal ; when they are flattened out into scales or plates, it is variously termed squamous, scaly, tessellated, or pave- ment epithelium. Again, when the cells are lengthened out into a prismatic or pyramidal form, and set uprio-ht on the surface, it is columnar or cylindrical epithelium. When the cells assume intermediate forms between those above mentioned, the fact is sometimes expressed in the term transitional epithelium. Lastly, the cells may be EPITHELIUM. 25 furnished with minute hairlike filaments called cilia, which are in constant active movement in a definite di- rection, this movement continuing for some time after death. This variety, which is of great interest in relation to our subject, is termed ciliated epithelium. Ciliated cells are usually of the columnar form, and their cilia are placed on the free bases. It is the epithelium which gives the smooth surface to mucous membrane, and to its cells belongs the more intricate part of the act of secretion. These cells, as they grow, appropriate to them- selves their own proper nutriment. Having attained per- fection, they exist for a short time, and then, bursting or dissolving, give themselves and their contents to form the secretion. Each individual cell thus goes through the stages of life—arrives at maturity and passes away—an exact picture of the economy of which it forms so small a portion. In the submucous tissue the bloodvessels divide into numerous branches. These penetrate the corium, and there form a network of capillaries in immediate contact with the basement membrane, advancing with it into the papilla?, and receding with it to surround the tubular or glandular recesses. Similarly the lymphatics form net- works which communicate with plexuses in the submu- cous tissue. The nerves of mucous membrane are also freely dis- tributed in the fibro-vascular layer, into which it is com- paratively easy to trace them, but they are also found to penetrate the basement membrane. In the palate they have even been traced between and among the epithelial cells, and the most recent researches seem to indicate that filaments penetrate the cell walls. 26 SORE THROAT. Looking at mucous membrane as a secreting apparatus, had it simply covered the internal surface, it would not have sufficed for the purposes of animal life, and conse- quently some contrivance was needed to augment its ex- tent. That end is attained by making the surface irreg- ular ; sometimes this is done by protrusions, but much more frequently by recesses, as already mentioned. A simple culde sac of mucous membrane forms a crypt, fol- licle, lacuna, or glandule. Such a blind pouch may be lengthened out and coiled up; much more frequently it branches out or subdivides in various ways. Thus glands —so far as we have here to do with them—may be defined as dispositions of mucous membrane for the sake of providing a greater secreting surface. Their shape depends on the connective tissue which supports the ves- sels and unites the branches. They are often inclosed in a fibrous envelope, and are always supplied with nerves and lymphatics. The same contrivance is adopted in other cases. The intestines are coiled on each other, and the capillaries wind and flex into a most amazing net- work, just as these elevations, depressions, and involutions pack into a small compass many thousand inches of the secreting membrane. The portion of the mucous membrane with which we are now concerned is studded with innumerable depres- sions, commonly called the follicles of the throat. In them secretion goes on actively; possibly, too, its product may be somewhat different from that of the plane surface. The tonsils may be ranked between these and more per- fect glands. On their surface may be seen upwards of a dozen openings leading into recesses, from which in their turn other but smaller orifices lead into numerous follicles. FOLLICLES—GLANDS—SECRETION. 27 These are lined by mucous membrane, and surrounding their walls are a number^ of closed capsules; whether they discharge their contents by bursting is undecided. Very similar to these are a series of follicular recesses at the root of the tongue, forming a layer extending from the papillae vallate to the epiglottis, and from one tonsil to the other. The salivary glands are perfect secreting organs of their class, elaborating important fluids, and possessing ducts to convey them to their destination. The act of secretion is modified by many circumstances to which living beings are subjected. From what has preceded, it will be anticipated that an unusual flow of blood to a part will cause an extra amount of secretion, while a diminished supply of the vital fluid will give rise to an opposite effect. Yet the sequence is not so invari- able that diminution or excess may always be thus easily accounted for. Other disturbing and counteracting agencies are often at work. The tone of the capillary system seems to have a wonderful effect, for in a relaxed state more fluid escapes than in health, giving rise to hypersecretion or passive haemorrhage. An unusual quantity of the material secreted getting into the blood, has to be eliminated by an increased activity of the organ which usually secretes it. Again, the presiding nerves have considerable influence over the act, as proved by stimulants to them augmenting the flow. Through the nervous system certain mental states find expression by an increased or decreased secretion. The effects of joy, grief, anxiety, or contentment on the skin, kidneys, and bowels are familiar to all. In many instances emotion increases secretion, but sometimes a contrary effect is pro- duced. There must be few who have not seen diarrhoea 28 SORE THROAT. thus set up. It may in the same way be arrested. I have known the sudden death of a relative completely arrest a diarrhoea which had continued in spite of various remedies. The liability of the salivary glands to refuse to work from mental anxiety is probably the foundation of the Indian method of detecting a thief, in which the parties implicated are compelled to chew rice, and spit it out on a leaf. He who has not saliva enough to wet it is judgecTguilty. The preceding sketch of the anatomy and physiology of mucous membrane affords an advantageous standpoint for glancing at its pathology, to which we now turn. CONGESTION AND INFLAMMATION OF THE MUCOUS MEMBRANE. In entering on the diseased state of the lining of the throat and air-passages, the important part played by congestion and inflammation demands that these lesions occupy our attention first. Congestion is a word often used to imply a minor degree of inflammation. It is at other times, perhaps more properly, restricted to the state of hyperaemia or excess of blood in a part, producing in- crease of redness. If the hyperaemia be arterial, it is termed active. If the hue be more venous, it is passive. As soon as perversion of secretion or other interference of function, and especially increased cell development, occur, the congestion or hyperaemia has passed into in- flammation. A common cold or catarrh may serve for an example, and that kind called influenza is still more typical. The first impression frequently falls on the nose and eyes, very often it commences in the throat. Wherever CONGESTION AND INFLAMMATION. 29 it begins it displays a tendency to spread. The first in- dications that the membrane is inflamed arise from the preternatural condition in which it is placed. The afflux of blood is increased, and the nerves are disturbed; tumid- ity, heat, and dryness, with impairment or loss of func- tion, are thereby occasioned. Hence the prominent symp- toms are obstruction of the nose, redness, a feeling of stuffiness, heat, itching, it may be even pain; loss of smell, partial or entire, etc. The redness, heat, and swell- ing depend on the congestion, just as in inflammation of other structures. The pain is seldom intense, often only itching, as this tissue is not possessed of the same sensibility as others. Moreover, pressure from within is more easily yielded to than in tougher textures. We never observe that pain which characterizes parts highly congested and incapable of much distension, but we often meet with very great swelling. Then the itching or pain is often referred, not to the part irritated, but to its ex- tremity, where the membrane joins the skin; so itching of the nose is an every-day symptom of worms in the in- testinal canal. This state—the dry stage—soon ends in a moist one, when the prominent phenomenon is increased secretion. The debilitated vessels suffer a great deal of fluid to escape, which departs more or less from the normal char- acter of the secretion. We now have a running from the nose of a thin discharge, often so acrid that it excoriates the lip. After awhile this becomes thicker, yellowish, or even greenish, and returns gradually to the healthy state. As a rule these stages are to be observed in all inflam- mations of mucous membrane, which consist essentially of engorgement of the vessels, swelling of the tissues, 30 SORE THROAT. abundant production of cells, and an increased flow of perverted secretion; the variations which occur depend mostly on incidental circumstances, such as specific cause, constitution of the patient, severity or duration of the complaint, and above»all, on the position of the part attacked. Of such consequence is this last item in reference to the symptoms set up, the danger impending, and the treatment to be employed, that inflammation of mucous membrane receives different names according to the part attacked. In the lining of the nose it is coryza, or rhinitis, or a cold in the head; in the lining of the fauces it is sore throat, cynanche, or angina (the Greek and Latin words, cynanche and angina, being used in the same gen- eral sense as the English "sore throat"); if it affect the pharynx only it is pharyngitis; if the tonsils, tonsillitis, or cynanche tonsillaris; further down the air-passages, laryngitis, tracheitis, and bronchitis successively. The frequent origin of the disease in a chill, has given it the popular name of cold, and its prominent symptom, in- creased secretion, the scientific one of catarrh (xarappiw} pour down); and inasmuch as simple congestion or in- flammation, however caused, presents the same phenom- ena, it is not uncommon to designate it as catarrhal, without reference to its cause. A " cold in the head " is the popular term for a coryza or rhinitis. A " slight cough" or a "stuffed chest" are terms often used when congestion of the trachea and larger bronchi exist. A more exclusively bronchial congestion is often called only " a cough," or "severe cough," or more properly bronchial catarrh. When the lesser bronchi are involved the term bronchitis is more frequently used. When the local dis- CATARRHAL INFLAMMATION. 31 ease is accompanied by fever, the case is often designated febrile catarrh or catarrhal fever, and by the public "a feverish cold" or "feverish cough." Since the great epidemics of influenza it has also become common to speak of catarrhal fever as influenza, and inaccurate as this may be, the word has obtained such a foothold in the language that it is almost hopeless to attempt to displace it, and we are, therefore, frequently obliged to prefix the term epidemic to distinguish the influenza which should be known by the simple word. Thus we see how so many sore throats, coughs, and colds, resolve themselves into congestion, or simple, often called catarrhal, inflammation of some part of the mucous membrane. The term catarrh is also extended to all simple inflam- mation of mucous membrane, even that caused by mechan- ical injury ; thus entirely eliminating the idea of its causa- tion by cold, or, as it was termed, catarrh. The tendency of this lesion to spread has already been alluded to. In influenza this is particularly observed. Commencing in the nose and eyes, it soon involves the throat, and even runs along the Eustachian tubes, giving rise there to distressing singing or noises in the ear or deafness. The soft palate and tonsils almost invariably suffer. Then it travels down the larynx, trachea, and bronchi, sometimes to their minutest ramifications. And, although its chief force is thus expended on the respiratory tract, the digestive canal does not altogether escape. The pharynx is necessarily involved by its position in a disease so inclined to spread over the adjoining structure. From this it may spread along the continuous membrane of the oesophagus, and so find its way to the stomach, the disturbance of which is manifest in the symptoms to which it gives rise. Nev- 32 SORE THROAT. ertheless, the violence of influenza is for the most part spent on the respiratory tract. When it commences in the throat, we may watch its extension in both directions, downwards to the lungs and upwards to the nose. Not- withstanding this tendency to spread, we often see inflam- mation confined to a small portion of mucous membrane. The throat is the highway to both the lungs and the stomach, its lining forms part of both the respiratory and the alimentary tract taken separately, and on this account is a frequent sufferer. It has been seen to be embraced by influenza, which for the most part exhibits a predi- lection for the respiratory portion, as do many other dis- eases, and it is equally obnoxious to affections which have a strong inclination to run along the alimentary canal, leaving the respiratory membrane free, or nearly so. Of these aphtha is a familiar illustration. Usually com- mencing in and always attacking the mouth, thrush passes along the throat, the common highway to the lungs and stomach, choosing the oesophageal road, and by its not infrequent appearance at the other end it has given rise to the conjecture that it has travelled the whole length of the tube. Dissection shows, however, that its appearance at both terminations is not a proof of its extending through- out. The extremities are the most sensitive, they more readily take on diseased action than the intermediate por- tion, and seem to sympathize with each other. Hence we meet the disease in both these situations, where there is strong evidence that its extent is not so great as a care- less observer might conjecture. In muguet the coating does not spread to the larynx, but it takes the road of the oesophagus, which tube has been seen completely filled with thrush deposit. It is not seen in the stomach. In INFLAMMATION. 33 those who suffer from this affection, infants, and persons dying of chronic disease, diarrhoea is commonly present, and some have thought it is due to this; others think it only a symptom of the general derangement; certainly any irritant will cause diarrhoea in weak patients, and many suffer from both symptoms. On the other hand, many infants with thrush have no diarrhoea. It is now time to consider inflammation of the mucous membrane confined to the throat. The patient complains of heat and soreness in the part, difficulty or pain in swallowing, and yet he cannot refrain from the attempt, for the unusual fulness imparts a sensation of something to be got rid of by this process. The redness and swell- ing are very perceptible on looking into the fauces. The uvula is enlarged, its increase of size being most mani- fest by its elongation, which may be so excessive as to tickle the base of the tongue, the epiglottis, or even to fall into the larynx. It will thus aggravate the desire to swallow, produce nausea, even vomiting, or give rise to a very annoying cough, or set up paroxysms of spasmodic cough or dyspnoea. The tonsils may be much swollen, their hot, hard, congested state being easily perceptible to the touch. When they are the chief sufferers, the attack is called cynanche tonsillaris. The pillars of the fauces are very prone to attack, and then deglutition is difficult and painful. The lining of the rest of the pharynx in the same way is constantly attacked, and the symptoms vary with the part most affected. Details must be de- ferred to the chapter on the pharynx. So too, when the larynx is inflamed, according as the changes affect the breathing or voice, we have other symptoms which will be referred to in the chapters on the larynx. When the 3 34 SORE THROAT. moist stage comes on, the secretion, which is not so abun- dant as in other parts, is hawked up with pain and diffi- culty, being rather thick and extremely tenacious. Dif- ficult breathing will be present whenever the swelling or accumulation of secretion impedes the passage of air. The above form of disease is often brought on by cold, and is that to which the term inflamed sore throat, or catarrhal angina, or cynanche, is most applicable. When it is severe fever is set up, and even in subacute cases there is generally some constitutional disturbance. In connec- tion with the exanthemata, very intense fever is present, and the inflammation extends to the deeper tissues. So when it puts on the worst form, typhoid symptoms super- vene, and mortification may ensue, constituting malig- nant or putrid sore throat. In healthy constitutions catarrhal or inflamed sore throat rapidly resolves itself, or at most subsides into the chronic state. This, whether coming on gradually, or being the remnant of an acute attack, presents the same symptoms in a less degree, but is more obstinate. Congestion is no longer active; soreness is not intense, often it is not com- plained of; swallowing may be easy, or only unpleasant; a feeling of dryness or heat is present, and a continual hawking of tenacious phlegm or a tickling cough har- asses the patient. The throat is no longer fiery red—often it is pale, but there is evidently a want of tone, the ton- sils are perhaps large, the velum low down, the uvula a good deal elongated. The veins are sometimes seen of abnormal size, coursing over the membrane, as in the analogous condition of the conjunctiva called "bloodshot." Such is the state called " relaxed sore throat." The con- dition of the parts will explain the symptoms ; thus the CONSEQUENCES OF INFLAMMATION. 35 enlarged tonsils and the swollen pillars are the cause of the obstruction to the food, the elongated uvula tickling the epiglottis, gives rise to the cough, the thick and tena- cious secretion to the hawking, the combination of these to the desire to swallow, and so on. In other cases more chronic still, instead of increased, we meet with perma- nently diminished secretion; the membrane seems to be actually dryer than natural, sometimes glistening as if it had been varnished. In these cases there is general at- rophy of the tissues. This has been called pharyngitis sicca. It might as well be termed dry sore throat. It is very obstinate, though not incurable. When the dis- ease implicates the Eustachian tubes or tympanum, we have, on the one hand, deafness, on the other, earache. So if the nasal membrane be implicated, obstruction of the nose is produced, or a coryza, according to the prevail- ing condition, while the intense headache or browache so commonly seen in influenza, is perhaps produced by the extension of the inflammation to the frontal sinus. The consequences or terminations of inflammation in the throat do not differ from those of the same lesion else- where. Chronic induration or thickening is not uncom- mon in the velum and uvula, and is of great importance in the larynx. Effusion demands attention, for infiltra- tion of the uvula may cause an annoyance, the only dif- ficulty of curing which consists in discovering it; while oedema of the glottis may rapidly suffocate the patient, or necessitate an immediate operation to save life. Abscess is mostly met with in the tonsils, constituting quinsy. Gangrene is to be dreaded in the severer forms, especially in connection with eruptive fevers. Ulceration is a com- mon consequence when the constitution is originally un- 36 SORE THROAT. sound or has become contaminated; thus in scrofulous, tuberculous, and syphilitic patients it is most common. Erosion is to be distinguished from ulceration by its more superficial extent, but its character is precisely the same. The loss of epithelium caused by the rapid cell prolifera- tion is erosion; when the process extends into the deeper layer of the membrane, causing there also a loss of sub- stance, we have ulceration. If we bear this in mind we shall be able to reconcile some apparently contradictory statements respecting the prevalence of ulceration. In simple catarrhal cases in sound constitutions ulceration is rare, except at certain spots. In the nose this process is often the cause of obstinate ozaena; in the larynx it is intimately connected with consumption. The term ulcer- ated sore throat is frequently applied indifferently to all cases in which this process has taken place, although they are so very dissimilar that it is much better to distin- guish them. After a chronic inflammatory state, the mucous follicles are very apt to slowly ulcerate, and dis- ease is sometimes from the first confined to them, the intervening membrane being apparently healthy. In these cases the minute follicles become prominent, red or pale swollen points, which, after a time, ulcerate. This is the "follicular disease "of the late Dr. Horace Green,* of New York, the angine granuleuse of French authors, and may be called in English either follicular or granu- lar sore throat; it is often termed clergyman's sore throat, but the name is not a good one, and, like the Latin vox clericorum, it is, as shown elsewhere, frequently applied * Diseases of the Air-passages, New York, 1846 ; 2d edition, 1849. PHLEGMONOUS SORE THROAT. 37 to various forms of sore throat to which clergymen, in common with other public speakers, are liable. PHLEGMONOUS OR PARENCHYMATOUS SORE THROAT. We have seen that inflammation may be confined to a small extent, or involve a large tract of mucous surface. The position and extent of the part inflamed are of the first importance, because on these points hang the diag- nosis, prognosis, and treatment. From these circum- stances our classifications have been made. Local inflam- mations of the mucous membrane, therefore, get names which are intended to signify the entire ailment, or a set of symptoms; thus, as we have seen, the word coryza signifies an inflamed state of the pituitary membrane, which may be a separate attack, or only a part (a symp- tom, so to say) of a graver ailment. Cynanche, angina, and sore throat are terms applied in the same way. Cynanche is a compound Greek word derived from xuwv, dog, and «V/^? strangle, because dogs were believed to be subject to the disease. Synanche and parasynanche are forms of the word, also found in Greek authors. Aetius may be cited in favor of our mode of spelling the word, but Caelius Aurelianus and Paulus, following Celsus, wrote synanche. The Latins used angina, from ango, throttle, in exactly the same way. Deafness, again, or singing in the ears, tinnitus, may be equally localized dis- orders or symptoms of more extensive disease. The above complaints evidently depend on the attack involv- ing the lining of the nose, throat, or Eustachian tubes. The pharynx discovers its attacks by pain or difficulty in swallowing, without necessarily affecting respiration, 38 SORE THROAT. while the larynx and trachea give instant notice of their sufferings by disturbing that function; yet in these cases, too, it is seldom easy to swallow. If acute inflammation seize the tonsils, deglutition is extremely painful, and sometimes the breathing is considerably affected; yet all symptoms may be sometimes absent when the tonsils are very large and tender. In the several forms of sore throat described in the previous section, the inflammation, though very apt to spread over a large surface, does not display any tendency to extend beneath the mucous membrane. The morbid process is, in fact, chiefly confined to the epithelium, increased action of its cells being the characteristic phe- nomenon. When the deeper tissues are inflamed we have phleg- monous or parenchymatous sore throat, which may be either acute or chronic, primary or secondary, and which may be regarded as a much more serious disease, since it often gives rise to considerable destruction of tissue. The danger depends in primary cases on the part affected, for deep inflammation does not often involve a large area, and we shall therefore have occasion to refer to several variations when describing the diseases of different organs. When less limited in extent, but attended by a consider- able formation of pus, the phlegmonous form is some- times called suppurative or purulent sore throat, a term which is also applied to a localized abscess. Extensive deep inflammation may also be caused by injuries, such as result when hot water or caustic liquids are swallowed, or irritant vapors or gases inhaled, or foreign bodies get into the passages, or any kind of violence is inflicted on the parts. Such cases are sometimes classed together as EXUDATIVE SORE THROAT. 39 traumatic sore throat. Of secondary varieties, the sore throat of scarlet fever is so important as to demand dis- tinct description. In glanders we see an equally charac- teristic lesion. Typhous ulceration of the larynx con- stitutes another more-defined variety, and the ravages produced in the throat by cancer, consumption, syphilis, and other diseases naturally involve phlegmonous inflam- mation ; but such cases are properly discussed in separate chapters. GANGRENOUS SORE THROAT May be considered as only a consequence of the phleg- monous form, but inasmuch as mortification sometimes sets in without any previous inflammatory condition being perceptible—as occurs in noma—the claim to sep- arate classification may be admitted. EXUDATIVE SORE THROAT (CROUP, DIPHTHERIA). There is a form of inflammation to which the mucous membranes are liable which determines an exudation on the part, sometimes completely clothing it with an adven- titious membrane. In the throat this exudation is of infinite importance, forming, as it does, the characteristic of croup and diphtheria. The symptoms of this form of inflammation in the throat may not differ at first from the more usual variety. For a day or two simple catarrh exists, but soon the alarming nature of the malady is manifested. The danger arises in two directions ; first, from narrowing or closure of the glottis; second, from the constitutional condition existing. The characteristic of this variety of inflammation is 40 SORE THROAT. this,—instead of a trifling increase and depravation of the secretion in the second stage, a quantity of fibrinous matter is exuded, which rapidly coagulates, and adheres more or less closely to the surface. In the mildest cases it forms flakes, floating in the secretion; in the more severe ones it constitutes a solid, false membrane, adher- ing to or lining the part, so that perfect casts of the air- tubes are sometimes expectorated. Thus there is a far greater increase of secretion than in simple catarrhal inflammation, and that secretion departs much further from the normal state. This form of disease may attack any part of the mucous membrane, the position of the part giving it the distinctive features. We occasionally see an inflamed sore throat with a few patches of this kind hanging about the fauces, and giving rise to no general symptoms; but this is a rare circumstance, except during an epidemic, when many such cases arise, and are put down as diphtheria. The presence of the least par- ticle may well excite alarm, for it will rapidly increase and spread in all directions, and soon present a terrible aspect. In children it may run down the larynx and trachea, becoming croup, though this disease more com- monly begins lower down. In adults its energy is more often spent on the fauces in the form of diphtheria. This generalization will be objected to by those who hold that croup is altogether a distinct disease from diphtheria, but the discussions on this question have too often been barren disputes about words; the great fact remains, that both are alike the manifestations of an inflammatory condition tending to exudation. The inflammation may be either superficial or deep—catarrhal or phlegmonous. Further, it may be admitted that what we call in England EXUDATION. 41 croup is rare in France, where diphtheria is so common ; and since the latter ailment has been naturalized amongst us it has often presented marked differences from the French form of the disease—it is not unfrequently a kind of croupal diphtheria. Many of the varieties met with in practice seem to be due to differences in the con- stitution of the patient rather than in the type of the disease. Other modifying circumstances are also con- stantly brought into operation, of which by far the most important is epidemic influence. In studying the works of Nature we are everywhere met by analogies and sim- ilarities, and our clinical observations will become more lucid if we base them on these broad foundations. The most important exudative inflammations of mucous mem- brane possess properties in common, which are not to be lost sight of in endeavoring to distinguish them from each other. They may occupy any part of the surface, Justus a simple inflammation, so that we find the exuda- tion occurring on the pituitary surface, the pharynx, the oesophagus, and even, though very rarely, the stomach, as well as throughout the respiratory tract. More; the conjunctiva is singularly liable to it,* and sometimes it attacks the skin. Why in one case exudation occurs, while in another there is none, is as much one of Nature's secrets, as why one patient is particularly sensitive to catarrh, while similar circumstances in another develop rheumatism. The first appearance of the exudation is not always recognized. A coagulable liquid is effused on the in- flamed surface at the commencement of the moist stage. * Graefe, Archiv. fur Ophthal., 1854. 4 42 SORE THROAT. Soon some minute, solidified particles are discerned, and these run into each other as they spread. The exudation may stay here, or another layer may form beneath it, exactly in the same way, and as the false membrane is cast off, the process may be repeated again and again. In other cases the exudation is only partially adherent to the tissue, when blood may be effused and mixed with it, changing its color; it then rapidly putrefies, and in this state has, no doubt, been mistaken for gangrene. Much trouble has been taken to elucidate the nature of the exudation. Its toughness, its elasticity, its con- sistence, its extent, have all been dwelt upon; but these, we have seen, depend on accompanying circumstances. It may occupy a small portion of mucous membrane, and not last long, or it may extend to the minutest bronchial ramifications without varying its nature, and become, as it were, a chronic inflammatory habit. Niemeyer knew a young girl of fifteen years of age who, for several years, daily expectorated a complete cast of the left bronchial tree. Usually, moreover, it is tougher and denser in the larger tubes, and more fluid in the small ones. Here it covers the epiglottis like a glove, or casts of the tubes are coughed up. There it scarcely coagulates. On separating a tough and adherent speci- men, its under surface is seen to be studded with red points and streaks, which correspond to similar bleeding spots on the mucous membrane, and through these the connection of the two seems to be maintained. On placing a portion in water it is seen to float, and does not dissolve. Alkalies disorganize and partially dissolve it, as do some organic acids. Nitrate of silver and the mineral acids curl it up and harden it. Under the micro- EXUDATION. 43 scope this substance sometimes looks like a fibrinous net- work, of an irregular pattern, containing in its meshes leucocytes and epithelial cells, as well as the debris of the tissues. In other cases it is so disorganized that scarcely anything can be made out. Again, it seems at times to be composed entirely of cast-off epithelium cells. This seems to point to the true pathology of the disease; just as catarrhal inflammation consists of an excessive cell production, with active but purulent secretion, so ex- udative inflammation in its turn seems to be a still more active disease of epithelium, in which the cell formation is still more excessive. This view, however, is in oppo- sition to that of some able authorities. It is customary with many to speak of every exuda- tion as diphtherial, but this loose mode of using words is hardly justifiable in so momentous a case ; at any rate, it is best explained. A good deal of space is occupied in the present volume in insisting upon the analogies and resemblances of diseases; but the author has no wish, therefore, to confound all similarities with identities. Extremes are to be avoided, and care should be taken, while bringing one portion of a picture into full relief, not to throw another equally important too far into the shade. Exudation takes place in other states than those men- tioned. It is a common symptom of phlegmonous or deep inflammation of the throat. It is almost always present in that rare disease, acute glossitis. It is not at all uncommon in measles. It is this process which causes the sloughs of malignant scarlet fever and of putrid sore throat, and extending into the nares it is the malignant coryza of that exanthem. In the same disease 44 SORE THROAT. it may extend to the mouth and lips, but does not often attack the larynx. It is also seen in septicaemia and the later stages of continued fevers. It also appears in other conjunctions, especially during an epidemic. Thus a larger class of ailments are brought a link nearer each other by exceptional cases. FUNGOUS SORE THROAT. Instead of an exudation from, we may have a deposit upon, the mucous membrane. This is the case in thrush, or muguet, which attacks infants in the first weeks of life, and patients who are dying from exhausting diseases. The deposit is due to a vegetable parasite, the presence of which can be readily proved by the microscope. In muguet, the exudative stomatitis of children, a cryp- togamic vegetation, called oidium albicans, is invariably found. It was first discovered by M. Berg, of Stock- holm, whose observation has been abundantly corrobo- rated since then by M. Robin, who has very carefully investigated the productions of vegetations on mucous surfaces.* Where a vegetation is traced it may admit of doubt whether it is the essential part of the disease, or whether an exudation, otherwise determined, may not prove a favorable nidus for its development; and it is possible some truth may pertain to each of these views. In respect to muguet, or millet, the oidium albicans is constantly present, and the pellicle formed on the mucous surface is almost entirely composed of its sporules. This disease is infectious, is frequently communicated by chil- Histoire Naturelle des Veg^taux Parasites, etc. Paris. GLANDS—TONSILS. 45 dren using the same cups and spoons; it has been suc- cessfully inoculated. CYNANCHE PAROTIDEA. As the mucous membrane extends continuously along the ducts into the interior of the perfect glands, it is not surprising that the inflammatory process should some- times spread in this direction. Indeed one might antici- pate such a result of catarrh to be more frequent than we actually find it. Arising in this as well as in other ways, we, however, meet with inflammation, not only of the glandules of the throat and mouth, but of the salivary glands themselves. These are also obnoxious to other influences—e. g., their secretion may be changed, and a thick, vitiated, or cheesy, or creamy fluid may be exuded; the ducts may become obstructed, giving rise to abscess resulting in fistula; concretions may separate out, form- ing salivary calculi, and other conditions in the neighbor- hood may call for careful investigation. When inflammation attacks the glands, swelling and pain are the prominent symptoms. Suppuration is rare, though inflammation of the tissue around the gland is common, and frequently results in suppuration. Metas- tasis is common in mumps, or cynanche parotidea,or par- otitis. The parotid, being the largest and most import- ant of the salivary glands, is more often attacked than its fellows. In connection with the subject of metastasis, it may be proper to allude to a somewhat analogous sympathy between the tonsils and the ovaries, first pointed out by the author in the Medical Times and Gazette for Septem- ber, 1859, since when he has met with numerous cases, 46 SORE THROAT. some of which have been published. As the tonsils will again come under notice, the subject is only mentioned here for the sake of showing what mysterious relations subsist between diseases which, in other particulars, seem far removed from each other. NON-CONGESTIVE SORE THROAT. We have now passed in rapid review the majority of the ordinary forms of sore throat. It will have been observed that they are all accompanied by congestion or inflammation, and many of them are only manifestations of this process. They may be grouped together as sore throat in which there is disturbance of circulation lead- ing to excess of blood in the part affected. This local engorgement, or hyperaemia, as it is also called, leads to some other results; one example of these may be named —haemorrhage, though bleeding may occur without hyperaemia, and where we have spitting of blood, it becomes necessary to determine not only its origin, but the part from which the haemorrhage takes place; for such an occurrence may be the result of a slight local ail- ment, or the effect of serious disease either in the throat or lungs, or it may be the expression of a constitutional malady, such as purpura or consumption. There is another condition, the exact opposite of engorge- ment or hyperaemia, that is anaemia, or as it might more correctly be termed hypoaemia. In this we have decrease of blood manifested to the eye by pallor instead of red- ness. This is sometimes a most significant symptom, for it may give warning of the approach of consumption, or it may be only a local sign of a general anaemic condition. If local anaemia be extreme, it leads to death of the tissues. NERVOUS SORE THROAT. 47 In another series of cases the prominent change is in the function of nutrition. Here, too, increase or diminu- tion may either of them occur, constituting hypertrophy and atrophy, while perversion of nutrition gives rise to the several degenerations. Neoplasms, or new growths, take their place as forms of hypertrophy. Complete arrest of nutrition gives rise to death—necrosis, or gan- grene. Again, changes affecting the motor function, whether depending on local or distant disease, may derange the movements of the parts. Here excess of movement takes the form of spasm; impairment or loss of motor power is paresis or paralysis. As the muscles are governed by their nerve supply, so their power of movement may be affected either by disease in their own tissues; or in the nerves, either at the periphery, or in any part of their course; or, again, the central nervous system may be at fault. The desirability of distinguishing such derange- ments must be obvious. Not only motor but sensory nerves, or the parts they supply, may give rise to increase, decrease, or perversion of sensation, when we have hyperaesthesia and neuralgia, anaesthesia or paraesthesia. So, too, there are cases connected with the general con- dition of the nervous system in which little, if any, per- ceptible changes in function may be demonstrated, or, on the other hand, in which functional derangement is very evident. To all these the rather indefinite term of " ner- vous sore throat" is not unfrequently applied. It is well to restrict as much as possible the use of such a phrase, which is apt to lead to diminished ardor in the endeavor to trace out the nature of the case. 48 SORE THROAT. Lastly, besides the traumatic sore throat to which allu- sion has been made, the presence of foreign bodies in the parts may have to be recognized. Such bodies may ob- tain access by accident or intentionally. They are often drawn into the air-tubes by the breath, and children are apt to put all sorts of small things into their ears and noses. Then insects and parasites of a minute kind, both vegetable and animal, may effect a lodgment in any of the parts we have named. The consequences will depend much on the part the foreign bodies occupy. It will be seen that many of the disorders we have hitherto been considering may arise from influences acting on the parts involved, or operating indirectly. It must be added, that we have another set of local causes which act primarily on neighboring parts—for instance, tumors, from the pressure they exercise, often affect the throat. It is in this way that bronchocele or goitre, glandular or other enlargements, become of importance, and some of them thus maintain their claim to the name external sore throat. Further, in consequence of the nerve supply of the larynx, it-is common for thoracic tumors, including aneurism, to produce early symptoms in that organ. As the processes with which we have been dealing may affect the several organs composing or connected with the throat, further remarks about them are deferred to the second part of this volume, in which the diseases of each of these organs will be dealt with in detail. SPECIFIC SORE THROAT. The course of sore throat is greatly influenced by the cause which gives rise to it. The affections consequent SPECIFIC SORE THROAT. 49 on the inoculation of animal poisons are vivid illustra- tions of this. Glanders may be mentioned as such a poison. Besides, we have also to consider how far an ordinary inflammatory condition precedes, accompanies, or predisposes to certain constitutional varieties. Both tubercular and cancerous diseases of the throat necessitate a degree of inflammation, widely as they differ from it in other respects. The local ailment—the " sore throat," of which the patient complains most, and sometimes exclu- sively, reveals to the physician the existence of a grave constitutional disease. All constitutional states may inter- fere with the exact nature of the local manifestation. That specific sore throat which arises from absorption of the venereal virus presents such various appearances, that, to avoid mistakes, it is needful to be always on the alert. It may give rise, in its early stages, to excoriation, erosion, or even to mere congestion of the fauces. The parts look red and raw, and perhaps are also swollen. These qualities may be obscured by a dirty-white secre- tion, but are seen on gently wiping it off, or a thickening of epithelium may in like manner disguise the real appearance. Slight soreness, with or without swelling, will then, in certain cases, excite suspicion. A worse form of syphilitic sore throat begins as papules, patches, or gummata, and terminates in foul, deep, indolent ulcers. These may not cause much suffering ; in fact, no incon- venience may be felt, or only a change of voice, noises in the ears, or constant hawking, when inspection reveals a formidable loss of tissue. The history is extremely important in clearing up the diagnosis, but it is often impossible to obtain a correct one. A much more dan- gerous variety is the sloughing ulcer. It may begin as a 50 SORE THROAT. mere aphthous speck, but soon displays its formidable character. The sloughing may implicate the carotid artery, and so end in sudden death. The tonsils are the most constant seat of specific sore throat. The soft palate frequently suffers; then the palate and nose. The larynx is liable to become ulcer- ated, and sometimes the disease of this organ puts a period to the patient's career. EXANTHEMATOUS SORE THROAT. A form of sore throat apparently originating in an animal poison is that met with in the eruptive fevers. It is common to the whole class, but more frequent and severe in one variety than another. It constitutes the principal lesion of scarlet fever, and most practitioners have met with it in measles and small-pox. This specific inflammation of the fauces is of the gravest kind, very often proving fatal. Occasionally the rash may be watched extending itself to the mucous membrane, and giving rise to its disease. Probably this happens more frequently than is imagined. At any rate this sequence of events may teach us that appearances very unlike each other may be identical in nature, modified only by the tissues in which they are situated. The disease often first shows itself in the mucous membrane. Inflamed sore throat and smart pyrexia are the prominent facts. In the early stage, little else may be observed. The fauces are red and swollen perhaps, but not necessarily painful. In more severe cases the inflammation is deeper. Then exudation may occur, succeeded by ulceration and sloughing. Between the mildest and most malignant EXANTHEMATOUS SORE THROAT. " 51 forms every variety presents itself. The tonsils—always great sufferers—sometimes bear the whole brunt of the disease; and then they may be so swollen and tender that swallowing is impossible, fluids are returned through the nose, and even the passage of air into the lungs is impeded. The larynx is not often seriously implicated in scarlatina, but in measles the whole respiratory mucous tract is attacked by catarrhal and sometimes by exudative inflammation. When any disposition to the formation of false membrane coexists, the air-tube is more liable to suffer. Epidemics of the eruptive fevers differ very greatly, and it becomes the physician to make himself acquainted with the prevailing type, as well as to be on the watch for any change. In some epidemics a rapid recovery is the rule, in others convalescence is unusually protracted, in a third class the mortality is far more fearful. So much is this the case, that a confident and hopeful prog- nosis may be justifiable in one, while in another the gloomiest forebodings must be expressed. The appear- ance of the eruption is as various as that of the angina. Sometimes we have the sore throat without the eruption —a form, when well marked, I have been in the habit of calling cynanche exanthematosa, and of which I have studied several epidemics. Dr. R. Williams described such cases occurring in epidemics of scarlet fever as scarlatina sine eruptione.* Further, some degree of uncertainty may be occasioned by the rashes sometimes appearing to mingle with each other. This is especially the case with scarlet fever and measles, between which, On Morbid Poisons. 52 SORE THROAT. in their typical forms, are several links, in which the rashes partake somewhat of each other's characteristics, so that one physician might designate measles what another called scarlet fever, and yet the one would have as good reasons as the other for his classification. The two diseases were not differentiated until the beginning of the nineteenth century, though typical cases of each are very distinct. Perhaps, after all, there may be fewer fever poisons than has been conjectured. Is it possible that these exanthemata, so near to each other, are in essence but one, modified by the conditions under which it is developed ? The above description best fits the sore throat of measles and scarlatina, but a similar angina is liable to occur in every eruptive fever. In small-pox, pustules exactly similar to those on the skin attack the mucous membrane, and when they appear in the larynx may set up oedema glottidis. In erysipelas, too, infiltration of the submucous tissue occurs. Nor are the exanthems the only pyrexiae in which this occurs. HERPETIC SORE THROAT. This brings us again on the interesting relation which subsists between the skin and the mucous membrane. The structure and function of these tissues being so like, we might anticipate some similarity in their diseases, and the author has traced this in many instances. A chill, a suppressed perspiration, any interference with the cuta- neous function, is an every-day cause of bronchitis, cynanche, or some other catarrh of the mucous mem- brane. A hundred instances will occur to the reader. HERPETIC SORE THROAT. 53 Such things have been put down as sympathy. It is more probable that these similarities depend on textural likeness. The analogy between the skin and mucous membrane extends much further. The superficial or catarrhal inflammation we have described in mucous membrane has its counterpart in the skin in that trouble- some disease called eczema. This catarrh of the skin is a superficial diffuse dermatitis, which exhibits a tendency to spread as marked as the inflammations we have had to consider, and is provoked on the skin almost as easily as they are on the mucous surface. There is increased cell development, and more or less abundant transuda- tion of fluid, the degree of this and the change it under- goes accounting for many of the varieties.in the appear- ance of the eruption. Let us compare some other affections of the skin and mucous membrane. One example, herpes, so familiar on the skin, is often mistaken on mucous membrane. Herpes praeputialis ought to be known to every surgeon, or he will sometimes do his patient grievous injustice. It may present some difficulty, but more blunders hap- pen from forgetting its possible existence than from the absence of indications for diagnosis. This case is intro- duced because it is parallel to a form of sore throat— herpetic cynanche, I call it—which is sometimes very troublesome. Every one is acquainted with herpes la- bialis. Well, this often spreads to the mouth and throat, and, what is of more consequence, it may commence in the latter and not extend beyond it. It comes on with some severity, so far as the patient's sensations are con- cerned, and in weakly people sets up some degree of feverishness. A careful inspection discovers the vesicles 54 SORE THROAT. situated on red patches. A little later their contents are opaque, so that they are more easily discerned, but they are generally broken in their earliest stage by the passage of food, leaving small, deep ulcers. If any escape, they burst about the fourth day and give rise to the same ul- ceration, which is very irritable. French authors attach peculiar importance to the herpetic diathesis, and see herpetism where others fail to trace it. Many of them include under this name ulcerations which in this work are otherwise classified. It is important to distinguish this herpetic sore throat, because nitrate of silver or any caustic will be sure to aggravate it. The coexistence of herpes on the lips is an aid to diagnosis. The praeputial form may be cured in a few days by bits of cotton-wool, to absorb the secretion and keep the part dry. Herpes on mucous membrane produces small ulcers, and the chief obstacle to their cure is the moisture; all irritants, too, make them spread with great pain. The different appearances given to this ailment by the conditions in which it is placed—on the dry, external skin, or the moist, internal lining—is a great encouragement to pur- sue inquiry in this direction. Pemphigus, or vesicular fever, as it is often called, shows us similar appearances on the skin and raucous membrane, and often extends to a large surface of each. After all, can we point out much difference between herpes and pemphigus, except in severity or intensity? The remarks I made on pemphigus in my first edition have since been confirmed by Barenspriing. Psoriasis may be seen in the throat, accompanying its appearance on the skin, and in the absence of the cuta- SKIN DISEASES AND SORE THROAT. 55 neous disease a similar process may sometimes appear on the mucous membrane. Cutaneous haemorrhages have also their counterpart in the mucous membrane. We might, indeed, anticipate that the more vascular tissue would be most obnoxious to these affections, and such, I believe, is really the case. Purpura constantly affects the fauces. It also gives rise to epistaxis and haemorrhage from any of the mucous membranes. In one fever we see petechia? on the skin; in another a similar affection of the mucous membrane. Is not scurvy an additional example? Cejka saw cases of scurvy which began in the gums, these being very sore for some time before general symptoms set in. Scurvy is less liable to set up mucous haemorrhage than purpura. Another class of skin disease. Acne and sycosis con- sist in follicular suppuration, and so are intimately asso- ciated with an affection of mucous membrane before de- scribed. Barenspriing classes these diseases together now. Need the reader be asked whether he has ever seen a stye? Another class—does not pruritus torment both struc- tures alike? How often, too, is nettlerash associated with irritation of the lining of the stomach? Can a similar condition exist in the two parts? Lastly, to complete our analogy, either tissue may be- come the seat, not only of the various forms of inflam- mation we have considered, but of such morbid processes as we see in scrofula, tubercle, cancer, and lupus. The last disease is here of special interest, for it seems a neo- plasm peculiar to the skin and the mucous membrane of the nose, mouth, and throat. 56 SORE THROAT. CHAPTER II. DIAGNOSIS OF SORE THROAT. In every case brought under his notice, the physician's first care is to get a definite notion of its nature. The means of investigation at our disposal are the same as in all the natural sciences—the five senses, assisted by every device which can be of service. These it is our business to educate; not this, nor that, but all, so that one may check another,*and that we may pass judgment on the whole evidence we can elicit. We are able, too, to call in other witnesses, though these are much less trustwor- thy. The senses of the patient, and of those about him, will give their testimony. The history will, of course, depend on these alone. By them, too, we often com- plete wrhat would otherwise be fragmentary, and are able to draw distinctions and indications which we otherwise could not. They are, therefore, essential links in the chain of evidence. It is from others we obtain information about the patient before we see him. In this we must get a statement of facts, and not opinions. The notions of the friends are not only crude, but very often only suppositions, or fears without foundation in fact, and these ought never to influence the judgment. Well-attested facts are of the utmost value, but in elicit- ing them it is requisite to avoid all leading questions, DIAGNOSIS OF SORE THROAT. 57 discard all theories, and, if possible, conceal from the witness the exact bearing of his communication. For this purpose, some adopt the plan of making the patient, or a friend, or both, relate the history without any inter- ruption, and of questioning them afterwards with a view of settling points left doubtful, or filling up gaps in the narrative. Passing to the evidence of our own senses, let us first consider the general impression made upon us, and then separate this into its component parts. 1 n this general im- pression, produced as we enter the sick-room, or as the patient walks into our consulting room, sight is not the only sense employed. It is true we see much, but we hear too—the breathing and voice, for instance. Sight, too, gives us a notion of feeling, to be corroborated or cor- rected by actual touch. Smell must always be included, and this cannot but convey an idea of taste. It is clear, therefore, that a general impression may be conveyed to the mind as soon as the patient comes within the range of the senses. Much might be learned by prolonging this stage of the investigation. Before a word was spoken, I have sometimes pointed out to medical friends the nature of a case, which vigorous scrutiny corroborated. Not that such a diagnosis ought to be acted on. It merely shows how much may thus be learned. Posture, gait, aspect, expression, color, excitability, flushes, ema- ciation, manner of breathing, voice, physiognomy, and the many other points which may thus be studied, should all have a place in the physician's memory, for all are in turn to be more closely questioned. To gain all this information so quietly and unostentatiously is, to my thinking, the surest and best way. Standing thus at the 5 58 SORE THROAT. bedside of difficult and dangerous cases, in silent contem- plation of the phenomena presented, we may often gain a more accurate general impression, correct the errors of a momentary interview, analyze and compare our obser- vations, and so get a more perfect portrait of the disease. The reader who tries the experiment will be surprised to find how much can be learned by this systematic analysis of the various points which make up the physiognomy of disease. Having exhausted this source of knowledge, we may fairly draw from others, and now accordingly we turn to the individual senses. Smell is the sense which is perhaps least cultivated. The indications it affords are important, if few. *An unpleasant odor may proceed from various causes. Per- haps most frequently it occurs from diseases in some part of the nasal passages, producing offensive discharges, which have been lumped together under the term ozaena. In this case it is necessary to proceed to a rhinoscopic examination in order to determine the cause of the dis- charge. But unpleasant smells occur from other causes, for example, from offensive discharges in the follicles of the pharynx or the tonsils, and again from foul ulcers in any part, or even from decayed teeth. Hearing is often called into use, both as to voice and breath. Harsh, loud, or obstructed breathing; cough, whether dry, moist, barking, spasmodic, or whatever the quality; hoarseness, diminution or loss of voice, or change in its timbre, or want of purity in its tone, as well as imperfection of speech of any kind, at once excite atten- tion and demand an explanation. The morbid states of the throat and chest are so intimately connected, that it is absolutely necessary to train the ear to a skilful use of PALPATION. 59 the stethoscope. Often, indeed, throat cases entirely turn on the results obtained by this invaluable instrument. Feeling tells of sensations, both of the observer and observed. Thus, by touch we ascertain the presence of tenderness, hardness and softness, roughness and smooth- ness. To touch in connection with sight belong increase and diminution of size. To touch and hearing combined belong the phenomena of percussion. Palpation of the throat often reveals the presence of unsuspected symp- toms, and the physician should endeavor to gain from it the largest amount of information with the least possible pain or inconvenience. Enlargements of various kinds about the neck and throat are subject to careful examina- tion by the sense of touch, which may also be applied within the mouth, throat, and posterior nares. The pharynx is thus within the reach of this sense, both exter- nally and internally, and one finger can be within, while the other hand follows the movements from the exterior. The finger passed behind the velum may be also turned upwards, and thus we may rapidly explore the upper part of the pharynx as far as the posterior nares, satisfy- ing ourselves as to the condition of the velum at the pos- terior part, the septum, the orifices of the Eustachian tubes, the fossa of Rosenmuller—in fact, of all this important region that can be touched. Parts inaccessi- ble to the finger can be reached with a sound, of which I have had various forms constructed, but of course they are not so useful as the finger itself, but in using sounds we have the advantage of the sense of sight at the same time. Examination of the larynx externally by careful palpation is often most useful. We are, too, sometimes driven to introduce one finger internally, for an instant, 60 SORE THROAT. especially in young children. It seems almost unneces- sary to insist upon the need of gentleness in these explo- rations, but usually so little is learned by inefficient action, or else so much unnecessary pain is given, that I would strongly urge the avoidance of anything like violence. Sight is the most important sense of all. The proverb says, " seeing is believing," and pretty generally this is so. In all cases of sore throat inspection is to be had recourse to. It is often so carelessly done that nothing is gained by it. To see the parts well the tongue must lie flat on the floor of the mouth; so that if involun- FlG. 1. tarily arched or unusually thick it should be pressed down and drawn rather forwards. A spoon—so often INSPECTION. 61 employed—is not well adapted for the purpose; if the bowl be placed in the mouth it hides the fauces as effec- tually as the tongue itself, frequently more so, for many patients can display the throat very completely; if the handle be used, its sharp edges are apt to give pain. The common pocket tongue-depressors are useful, but their shape is not well adapted for more than cursory examinations, and for these a paper-knife is usually handy. My simplest tongue-depressor, designed before the discovery of the laryngoscope, and in constant use ever since by many of my pupils, is of such a shape (as seen in the engraving on page 60), that when introduced the base of the tongue is easily controlled by the broadest part of the blade. A second blade of a smaller size is required for children ; both screw into an ebony handle, and are thus very portable. For operative purposes the instrument depicted in the engraving, Fig. 2, will be foundmost valuable. It is based upon Tiirck's, which I have so modified as to make it much more generally useful. I have the hooked handle made much more slender than usual, and the blade fitted with a circular shoulder instead of a square one. My instrument can therefore be fixed in any position by a mere turn of the screw. The figure shows my depressor with three blades, but of course additional ones may be had if required. Another instrument, which I had constructed in the pre-laryngoscopic era, is a throat speculum of suitable size to be introduced into the mouth. It may be made of glass covered with caoutchouc, or of metal. The shape may be simply oval, or the under portion may be curved somewhat like the under blade of my tongue-depressor, 62 SORE THROAT. or it may be bivalvular. This speculum is not only useful for inspection, but is often of service in localizing topical applications in children and timid patients. It holds down the tongue and conducts the light to the Fig. 2. point desired. In order to use it without interfering with the light, I had a number of instruments made bent at a right angle. Having always used these, it was natural perhaps that I should on the discovery of the laryngoscope adopt the same angle rather than the conti- nental curve. In conjunction with my speculum I have long em- ployed a condensing lens or a concave mirror to illuminate the throat. The earliest concave mirror I employed was INSPECTION. 63 an old-fashioned traveller's shaving glass. Before then I had tried other methods of illuminating the fauces, one of these being to place the patient so that the stream of light from a large globe of water (such as seen in chem- ists' windows) might fall into the fauces; another, to use a convex or plano-convex lens, such as the microscope condenser. The concave reflector is by far the most convenient, and may be used in any position. The patient may be standing up or sitting down, or lying in bed, and yet a good view may be obtained either by day- light or with a lamp, or even a candle. The reflector used in laryngoscopy answers the purpose. The parts visible on inspection have already been men- tioned. It remains only to add that from this source of information we learn what deviations from the normal state have taken place. These may be changes in form, color, or function. As to form we have increase or decrease of size, new formations, and other abnormalities. The color in the same way may be heightened, as in hyperaemia, or the reverse condition may exist, or pig- mentation may have taken place. As to function, the secretions may be changed in quantity or quality; or the innervation may be at fault, so that we have motor derangement, spasm, or paralysis. The humidity and the lustre of the membrane, the presence or absence of erosion or ulceration, malformations, old cicatrices, and in fact any deviation from the healthy standard in the surface brought into view, can thus be studied. One caution may not be deemed amiss. The standard of health should be carefully sought by examination in the living body, and for this all opportunities should be seized by the inexperienced. There will then be fewer instances of 64 SORE THROAT. healthy throats being cauterized through mistaking, for proofs of disease, appearances which are not incompatible with a normal condition of the parts. So much can be seen by ordinary inspection through the open mouth; but of late years we have made great advances by the simple expedient of holding in the back of the throat a small mirror, upon which light is directed in such a way that we are able to observe the image of any parts reflected on its surface. This constitutes the art of LARYNGOSCOPY AND RHINOSCOPY. Just as we have taken the word pharynx for a single organ, although once it had a wider signification, so, anatomically, the word larynx is used for the organ of voice. The original Xdpuy^, doubtless more nearly means throat, but was also often used with special reference to the part to which we apply it, as is clear from the verb derived from it being used for scream, cry out, or shout. Larynx, then, with the assistance of the usual axtnziw, en- ables us to name our apparatus laryngoscope. But when we proceed in a similar manner to explore the posterior nares we call this plan rhinoscopy, from the Greek for nose, pis, genitive, phoq, or from the latter nominative f>iv, and trxoniw. When we employ the apparatus on our own persons the possessive pronoun, abro<;, self, enables us to distinguish the process as auto-laryngoscopy or auto-rhinoscopy. The word pharyngoscope, it is obvious, may be used in a similar way, but it has also been applied to the examination of the pharynx by reflected light without a mirror being introduced into the fauces. In LARYNGOSCOPY AND RHINOSCOPY. 65 the latter case, however brilliant the light, of course only that part of the pharynx can be seen which is visible on ordinary inspection as already described. To obtain a view of the interior of the larynx, we have only to hold in the fauces at a proper angle a small plane mirror, and illuminate it in such a way that we can see the parts reflected in it. In fact, we have only to look round a corner by means of a looking-glass, a riddle which, like all others, is easy enough when the solution Fig. 3. is known. No doubt many have endeavored to see these parts without success. Indeed, since the laryngoscope was perfected, numorous hints have been collected from previous authors who were near the discovery. Some 6 66 SORE THROAT. failed from one cause, some from another. Some could not get sufficient light. Some forgot to warm the faucial mirror, and so it was at once obscured by the breath condensing upon it. I related in the first edition of this work how I had myself succeeded in detecting and cur- ing disease by the aid of reflected light, and thus in reality applied the principle of the laryngoscope before the date of that invention. The case referred to was treated in 1856. But the rude instruments constructed for the purpose were laid aside without any effort to im- prove them, or any thought of making them of daily ser- vice, and yet a few years afterwards laryngoscopy was a recognized art. This case demonstrates that I was the first to employ reflected light to apply topical remedies. But it is unnecessary to refer further to the history of laryngoscopy, as I have elsewhere* treated it at length, and now pass on to the use of the instrument. The preceding engraving, Fig. 3, represents the sim- plest method of laryngoscopy by reflected artificial light, and has been copied from a photograph taken for me many years ago. It will be seen that the light from the lamp falls on the concave mirror beside or through an aperture in which the observer looks. From this it can be directed wherever it is desired. The patient opens the mouth, the tongue is protruded and steadied by the thumb and forefinger covered with a small napkin, the rays are brought to a focus in the fauces, the laryngeal mirror is warmed and at once placed in position, when on its sur- Lessons in Laryngoscopy, and Rhinoscopy. LARYNGOSCOPY AND RHINOSCOPY. 67 face there will appear an image of the parts. A very simple diagram will show how this occurs. A ray of light from the reflector through which the observer looks falling upon the mirror M is reflected to the glottis G, of Fig. 4. \E which an image appears at M. Obviously a very slight inclination of the mirror may throw the light along either of the dotted lines, in which case the image of S will be replaced by another, A or E, as the case may be. If the mirror be turned in the right direction we may see the posterior nares instead of the larynx. The next engraving, which represents a section of the parts with the mirror held as in auto-laryngoscopy, may render the subject a little clearer. The laryngoscope being held in situ, a ray of light represented as a straight line (a), is seen to fall upon it, and be reflected behind the epiglottis (e), and so down the larynx (_L), impinging on the wall of the trachea (tr), when an image appears in the faucial mirror (k). Of course there are various difficulties and obstacles to overcome, but these must not detain us. For detailed instruction how to deal with them the reader is referred to the author's Lessons in Laryngoscopy and Rhinos- 68 SORE THROAT. copy, in which he will find instruction on these and other points, together with a description of the forms and uses of the instruments employed in connection with the laryngoscope. We pass, then, to a consideration of the laryngeal image as brought into view in the living body. If the mirror be properly held, with the full light directed upon Fig. 5. Section of parts with mirror held as in auto-laryngoscopy. 1 to 6, the cervical vertebrae ; u, uvula ; L, larynx ; e, epiglottis; Ir, trachea; A, hyoid bone; t, tongue; J, (lower) jaw ; m, (upper) maxilla; k, laryngoscope. it, and the conformation of the parts be normal, an image of the interior of the larynx appears on its surface, the vocal cords arresting attention by their movement, as well as by their white color, which is in striking contrast with the red of the surrounding parts. The positions and relations of all the parts likely to come into view in the attempt to see the interior of the larynx, may be studied in the following illustration, Fig. 6. The laryngeal image, as seen in a moderate-sized THE LARYNGEAL IMAGE. 69 mirror, is included in the dotted circle. This engraving is copied from Tiirck,* with the exception of the dotted circle, which was added by Dr. T. J. Walker, f Several Base of tongue and larynx, a d, epiglottis; a, its lip ; d, its anterior surface; 6, glosso-epiglottic ligament; c, vallecula; e, arytenoid cartilage surmounted by the cartilage of Santorini; /, cartilage of Wrisberg ; g, true vocal cord ; h, false vocal cord ; i, rima glottidis ; k, outer surface of arytseno-epiglottic folds; /, inner surface of wall of pharynx. parts, such as the base of the tongue, will at once be recognized. The letter g points to one of the true vocal cords, while h indicates one of the so-called false cords; i is the rima glottidis, or opening between the two cords; * Klinik der Krankheiten des Kehlkopfes, Wien, 1866. f The Laryngoscope in its Clinical Applications. 70 SORE THROAT. e the arytenoid cartilage surmounted by the capitulum Santorini, and close to this is the cartilage of Wrisberg,/. The epiglottis is marked a d, the glosso-epiglottic liga- ment b, and the vallecula c. The figure gives a fair idea of the relative position of the parts. By holding the page horizontally, it will be noticed that the tongue is the nearest the observer, the epiglottis comes next, and behind it is the glottis. This is the position of the parts as they actually exist in a patient seated in front of the observer, but in the laryngeal mirror the position of the parts is reversed—the nearest becoming the most distant. The last engraving should, therefore, be compared with the following smaller cut, Fig. 7, which represents the same parts except the base Fig. 7. a of the tongue, which it is not necessary to re-engrave. Here we have the position of the parts as they appear in the laryngoscope, and as they are represented in the colored illustrations of this volume. The lettering cor- responds with that of the previous engraving. There is no such thing as a lateral inversion of the image in the laryngeal mirror. The idea can only result from a confusion of terms. Right and left are words LARYNGOSCOPY. 71 that each speaker is apt to refer to himself as a standard, but almost every clinical clerk is aware of the necessity of discriminating between the right or left side of the patient and himself. Rather ludicrous mistakes do, how- ever, occur. For example, I have seen a gentleman listening on the right side of a patient's chest for the sounds of the heart. The same confusion lurks in the error about lateral inversion in laryngoscopy. The phy- sician sits opposite the patient, and looks at the image formed in the mirror held in the fauces. The right hand of the physician is therefore immediately opposite to the left hand of the patient. It is the same with every other part. The standard of right or left must therefore be referred to the patient, and then it will be manifest that as the left vocal cord of the patient is opposite the right of the physician, so it appears on what the observer calls the right side of the mirror, but what would be called by the patient its left side. The correctness of the fore- going statement respecting inversion admits of the easiest experimental proof at the hand of every reader. Stand- ing in front of a swing toilet-mirror, the upper part of which is inclined forwards, so as to represent the position of the laryngoscope in a patient's fauces, he has only to place this book on the stand, and examine the image of any of the figures as reflected in the glass. He will thus satisfy himself of the accuracy of what I have said. Nor is it necessary for the experiment to turn to the figures, though as they represent the parts to be seen they are more striking. The letters on any page are reflected in exactly the same way. They appear in the glass upside down, but they do not read from right to left. There is no lateral reflection. 72 SORE THROAT. The laryngoscope enables us to look into the living larynx and watch its many movements. Accordingly the image at which we gaze in the mirror differs consid- erably from anything met with in our anatomical studies. It is therefore desirable to describe a little more fully the parts of this image, and the variations in the appearances which may be observed in the healthy human larynx. The epiglottis occupies the highest part of the laryngeal image. Its shape varies much in different individuals, as may be seen in the figures on Plate II, Figs. 1, 2, 3, but such varieties of conformation must not be con- founded with changes caused by disease. The free border of the epiglottis may be watched alternately rising and falling during the examination. The attached border is connected to the receding angle between the two alae of the thyroid cartilage by a long narrow band, the thyro- epiglottic ligament, and a similar band, the hyo-epiglottic ligament, connects it with the posterior surface of the body of the hyoid bone. The lingual, upper or anterior surface of the epiglottis, usually curves forwards towards the tongue, and the mucous membrane by which it is covered forms a median and two lateral folds, called glosso-epiglottidean ligaments. The posterior or inferior or laryngeal surface curves in a reverse way. It is usu- ally convex from above downwards, and concave from side to side. To the sides are attached the glosso-epiglot- tidean folds or ligaments. Thus the epiglottis neces- sarily is not all visible at once. In most cases a part of the upper surface comes into view on each side, present- ing almost a scroll-like form, and in the middle we see the under surface turned up like a lip. Below and behind this another portion seems to bulge out, and has LARYNGOSCOPY. 73 been distinguished as the cushion, Plate II, Figs. 2, 4. The upper surface is of an obscure pinkish color. The lip looks like what it is, yellow cartilage with a vascu- lar mucous membrane clothing, and giving it a tinge of pink or red. The cushion is much brighter. Fur- ther, when we see the whole of the laryngeal surface of the epiglottis at once, the color is more distinct, and this hue has been taken for congestion. If only the edge appear in the mirror it looks, from the reflections of the light, like a pale or white line. The glosso-epiglottic ligaments have been already shown in the figure, as also have the outer surface of the arytaeno-epiglottidean folds and the inner surface of the wall of the pharynx. The true vocal cords, sometimes called from their posi- tion the inferior vocal cords, are the next most prominent objects in the image. They stretch from the front to the back of the larynx, and the moment its cavity is illumi- nated may be seen in the mirror as two smooth, white bands, standing out in remarkable contrast to the sur- rounding red structures, and alternately approaching and receding from each other as the patient breathes. These two moving bands once seen will never be forgotten. Their importance can scarcely be exaggerated; they are, as their name implies, the true vocal organ, the voice being the expression of their various vibrations. On deep inspiration they separate widely posteriorly, but are near each other anteriorly, as may be seen in Fig. 3, Plate II. On the emission of a sound they approach each other until in the median line they look like two white parallel bands, closing the glottis, as the fissure or chink between them is called. They are strong, fibrous bands, covered by a very thin layer of non-ciliated mucous membrane. 74 SORE THROAT. After the cords, the next most striking objects in the view are the prominences composed of the arytaenoid cartilages, surmounted by the cornicula laryngis. These arytaenoid cartilages are so called from their resemblance, when approximated, to the mouth of an ancient cup or ladle ('aporava another form for 'apurjp, a name applied to any small vessel for holding water). Their situation is at the back of the larynx, at the upper border of the cricoid cartilage, one on each side. They are, therefore, right and left; the form of each is somewhat pyramidal. The apex of each pyramid is pointed, and curved back- wards and inwards. Each apex is also surmounted by a small conical nodule, called the corniculum laryngis, or cartilage of Santorini (Fig. 6), to which is attached the arytaeno-epiglottidean fold. These parts are more prom- inent when the vocal cords are closed, and to see them the patient should be made to emit a vowel sound—eh, ah, etc. The mucous membrane is here of a redder hue than in the other portion of the larynx. In the folds of mucous membrane extending from these bodies to the sides of the epiglottis, already spoken of as the arytaeno-epiglottidean folds, we observe two other elevations, called the cuneiform cartilages, or carti- lages of Wrisberg. They are seen in both the open and closed larynx, in front of the prominences just described. The cartilages of Wrisberg vary somewhat in their ap- pearance. Occasionally, they seem triangular in shape, their apices pointing outwards; more frequently they appear nearly round. It is obvious that the variations partly depend upon the amount of submucous areolar tissue around them, and partly on the breadth of the folds in which they are located. There are also great differences THE LARYNGEAL IMAGE. 75 in the degree, to which these cuneiform cartilages are developed. Sometimes they are quite invisible; while occasionally another distinct elevation can be made out between them and the cornicula. These are probably caused by small additional cartilages. The arytaeno- epiglottidean folds bound the superior opening of the larynx, and can easily be observed in the mirror, extend- ing from the arytaenoid bodies upwards and forwards to the sides of the epiglottis. They are usually paler in color than the prominences mentioned. The false vocal cords, so called, as they do not assist in the formation of the voice, are in a lower plane than the arytaeno-epiglottidean folds, but above the true cords, and so sometimes called by anatomists superior. They are thickish bands, extending from the arytaenoids to the angle of the thyroid cartilage, and their color is rather deeper than the folds above them. The space between them is called the false glottis. Their lower edge borders the ven- tricle and looks a little paler from the light being fully reflected from it. The openings into the ventricles, or, as they are sometimes called, the sinuses, of the larynx, are seen as mere dark lines between the true and false cords. Each ventricle is described by anatomists as an oblong fossa, bounded above by the free, crescentic edge of the false vocal cord; below by the straight edge of the true cord; externally by the thyro-arytaenoideus muscle. The anterior part of the ventricle leads to a cul de sac of mucous membrane between the false cord and the inner surface of the thyroid cartilage. This recess or pouch, conical in form, has been compared to a Phrygian cap, and is named the sacculus laryngis. Its mucous surface 76 SORE THROAT. is studded with the openings of sixty or seventy follicu- lar glands, which lie in the areolar tissue beneath. Between the arytaenoid bodies there is a fold of mucous membrane, the inter-arytaenoid fold, or the posterior com- missure, the prominence of which depends on the posi- tion of the cords. When they are wide open its surface may be examined, but when they are closed it folds together. So much for the several parts of the laryngeal cavity, but we can see farther still with our mirrors. When the glottis is wide open we may see some of the rings of the trachea showing through their mucous membrane with great distinctness. This membrane is generally paler than that of the larynx, but this may partly depend on its being less brilliantly illuminated. The rings of the trachea, from the reflection of the light, often look quite white. Another point we may also bring into view is the cricoid (xptxos, a ring, eldoq, shape) cartilage. Lastly, we can sometimes also see the openings of the bronchi. These and the tracheal rings are clearly shown in Plate II, Fig. 3. Such being the natural form of the image, we are prepared for the changes caused by disease. Deviations may originate in loss of substance or in swelling, or in new formation; besides which, change of shape may be produced by external pressure. Loss of substance may be seen in ulceration—e. g,, the epiglottis may be serrated at the edge by this process; or it may be almost destroyed, as in Plate II, Fig. 6. Both true and false cords and other parts may also be ulcerated. Swelling changes the form in a remarkable manner; and examples may be seen in the plates. The enormous swelling about the THE LARYNGEAL IMAGE. 77 arytenoids in Plate II, Fig. 5, is so frequent in some forms of consumption that it has been spoken of as pathognomonic of that disease. The epiglottis is at the same time often altered in shape from a similar cause. In simple inflammation there may be considerable swell- ing, as in Plate II, Fig. 1. In oedema the change of form is still more remarkable; the glottis gradually be- coming obliterated, so that the patient is in imminent danger of suffocation. Instead of simple tumefaction, the mucous membrane may be covered with exudation, and this may encroach on the glottis, causing a narrow- ing. Again, new tissue may be formed, as in polypi (Plate II, Fig. 4) and cancer; or any of the natural tissues may be hypertrophied. We may, too, discover blood, pus, and other products of disease in the larynx. In the same way, variations of color are equally char- acteristic. There may be increase of color, as in con- gestive diseases, and this may extend over a large or small surface. In Fig. 1, Plate II, the red is seen at the arytaenoids and on the false cords. In Fig. 2 it is more marked on one side, and not so deep. In several the false cords are heightened in color. So the hues of active and passive congestion can be distinguished in the mirror, as, too, can diminution of color, local or more extensive. Pigmentation is a change of color, also readily recogniz- able. The author has often drawn attention to the dif- ferences between the color of consumptive and syphilitic cases. In addition to changes of color and form, the laryn- goscope reveals alterations in function. We have seen that the movements of the vocal cords can be watched in the mirror; these movements may be impaired or exag- gerated. Impairment may proceed to abolition, when we 78 SORE THROAT. have paralysis; so increased motion may produce slight symptoms or dangerous spasm. Moreover, defective co- ordination, as recently shown in the author's paper at the British Medical Association at Cork (August, 1879), may give rise to irregular motor derangements. Laryngostroboscopy is the name proposed by Oertel for the plan of studying the vibrations of the vocal cords by means of a powerful light rapidly interrupted. The most convenient mode of interruption is by a perforated revolving diaphragm placed between the lamp and the laryngoscope. Rhinoscopy.—The examples given suffice to show how numerous are the changes which can be detected by the Fig. 8. laryngoscope. If now we turn our attention to other parts, we can in the same way explore the posterior nares LARYNGOSCOPY AND RHINOSCOPY. 79 and the upper pharynx behind the velum. Some slight alteration of position may be needful. The engraving on p. 78, Fig. 8, shows the simplest method of rhinoscopy. The apparatus is managed as in laryngoscopy, but the mirror is held in a position varying with the part to be illuminated. Carrying it behind the uvula and velum, it is comparatively easy to make out their posterior sur- faces. They should then be traced upwards, and the roof or vault of the pharynx examined, where the surface is very irregular, and resembles so much the tonsils that some speak of the " pharyngeal tonsil." Sometimes the minute orifice of the bursa which exists here can be seen, and must not be mistaken for the result of disease. We now proceed to the rhinoscopical examination. The septum nasi (a), as seen in the engraving, Fig. 9, a, posterior border of the septum nasi; b,b, middle turbinated bones; e, e, inferior turbinated bones; d, d, orifices of the Eustachian tubes; e, superior turbinated bone; /, spatula ; g, soft palate. divides the rhinoscopic image into two halves, and forms a shining central ridge, narrow below, but increasing in breadth above. At its lowest narrow part, if well illu- minated, it may look quite white and bright from the bone shining through the thin mucous membrane. If the light be less brilliant, or the membrane not quite so 80 SORE THROAT. thin and tense, the hue may be pale pinkish or there may be a yellowish tinge. The color becomes deeper as the septum extends upwards, until at the highest, broad- est part it is lost in the red of the mucous membrane of the surrounding parts. The middle turbinated bones (6) occupy a large portion of the image on each side of the septum. They are cov- ered with thin mucous membrane of a pale-pinkish hue, and have been mistaken by beginners for nasal polypi. Just below, and much resembling them, at the base of the fossce nasi, are two other somewhat smaller roundish projections, looking like a pair of almost solid tumors. These are the inferior turbinated bones (c, c). They do not seem to approach so near to the septum as the middle ones, and moreover look more solid and duller in color, no doubt partly due to their being less brilliantly illu- minated. Just outside and behind each of the inferior turbinated bones we may easily discern the large irregular opening of the Eustachian tube (d), looking downwards and out- wards. From the lower edge running downwards and inwards there is a prominent ridge formed by the levator palati, while from the upper edge starts the fossa of Rosenmiiller, which extends upwards and inwards. The supenor turbinated bones (e) are not nearly so easy to find with the mirror, in which they are reflected only as narrow projections, in shape somewhat like a triangle, with the apex pointing downwards and inwards, and per- haps somewhat backwards. We have yet to mention the three passages between the turbinated bones. The superior meatus is the largest, but the easiest to discover is the middle one, which appears RHINOSCOPY. 81 towards the outer wall of the fossa. The inferior mea- tus is very indistinct, often appearing only as a dark line. The changes in form and color produced by disease may be arranged in a similar way to that which we have followed in the larynx. Anterior rhinoscopy is a term applied to the explora- tion of the nasal passages from the front, for which pur- pose various specula, dilators, and other contrivances are used. Fig. 10 shows one of the most convenient instru- Fig. 10. ments of this kind, made for the author by Messrs. Maw, Son, and Thompson, on the principle of the eyelid re- tractor. This method, sometimes of service in affections of the throat, is absolutely essential to a just appreciation of dis- eases of the nose ; for by it we can examine the entire anterior portion of the nasal passages. The natural ap- pearances are, however, so liable to vary with the state of the secretions, that it requires an experienced eye to 7 82 SORE THROAT. determine the difference between such changes and those due to disease. Zaufal has arranged a series of specula, by means of which he claims to be able to see portions of the upper pharynx from the front—a method which, though not intended to supersede the use of the rhinoscope, as pre- viously described, is sometimes of considerable use, as shown by Dr. Benno Baginsky in his paper,* reprinted from the Sammlung Klinischer Vortrdge. OEsophagoscopy is the term that has been proposed for the exploration of the gullet. Many attempts have been made to carry this out, but the difficulties are much greater than in the case of the air-tube. This is rigid and remains open, but the walls of the oesophagus are flaccid and fall together, so that it is necessary for the patient to be able to tolerate the presence of an apparatus for keeping them apart. This accounts for the little that has hitherto been accomplished in this direction, but for- tunately we are able to examine the oesophagus by other means, and thus bring its distressing diseases within the reach of our art. * Die Ehinoskopischen Untersuchungs- und Operationsmethoden. TREATMENT. 83 CHAPTER III. GENERAL TREATMENT OF SORE THROAT. Before proceeding to discuss the diseases of the dif- ferent organs of the throat, it is desirable to describe cer- tain details of treatment which are chiefly applicable in this locality; for as the manifestations of morbid pro- cesses vary according to the region involved, so our thera- peutical methods must be adapted to the exigencies thus brought about. Of course the modifications caused by other circumstances will be also carefully weighed by every judicious physician. In every case the age, sex, constitution, and family history of the patient, with other circumstances which make up his individuality, in refer- ence to disease, require consideration, but this is equally true in affections of other regions, and such points belong to the subject of general therapeutics. In this chapter, therefore, they will only be incidentally referred to, our attention being confined to points of interest in relation to the therapeutics of the throat. In diseases of this part it is often our first care to pre- vent disorganization, or even temporary change of form of only slight extent; for a degree of swelling which in other localities might be regarded as merely trivial may here prove rapidly fatal. Now changes of form so often originate in inflammation, that, whether we can arrest that process or prevent its results, is no mere philosophi- 84 SORE THROAT. cal speculation, but a practical question, on the answer to which hang the issues of life and death. Hence it is, that in this as in other localities we so often prescribe measures which are reputed to possess the power of con- trolling inflammation or its consequences. These and other remedies may act directly upon the part affected, or indirectly through the constitution—topical treatment assuming prominence in proportion as the morbid condi- tion is limited to a small area. In passing in review some of the remedies, we will begin with the general and proceed to the local, though it will be seen that some of them act in both ways. Bloodletting is now so rarely resorted to, that he who proposes it for disease in the throat need to be fully pre- pared with his reasons for doing so. In certain acute affections, however, the symptoms are so urgent, and time seems so important an element in the case, that, on account of the imminent danger to life, the practitioner may feel called upon to consider the propriety of phlebotomy as a possible means of relief. Leeches are frequently ordered, and many practitioners testify in their favor, but it has been questioned by others, whether the larger part of the benefit which seems to fol- low their use is not due to the fomentations by which they are usually succeeded. It is important to remem- ber that in children a few leeches are as potent as vene- section in adults. Scarification of the inflamed part may be often advan- tageously adopted. The engorgement is at once relieved, and the effect of the remedy, if judiciously employed, quite surprising. It is particularly adapted to some cases of tonsillitis. The gum lancet is so often used (and per- TREATMENT. 85 haps abused, too), that it is a wonder a similar proceed- ing should not have been more frequently carried out in other easily accessible parts. A single scarification will produce more effect than opening a vein, and this at almost no expense of the vital fluid. Even in infancy, if carefully done, it is safe as well as efficacious. The lancets I employ for the purpose are mounted on long slender handles, such as oculists use. They may also be bent at a right angle. My speculum will then be found of great assistance. In oedema of the larynx we are able, guided by the mirror, to give relief by scarifying the swollen part so as to allow the fluid to escape. This operation, as will be seen when treating of diseases of the larynx, is often able to save life. Emetics of all kinds are often employed, especially in the exudative forms of sore throat, in which their me- chanical effects are of great value. They often bring away a quantity of exudation or secretion which the patient could not get rid of without their aid. In this way they are often of the greatest use in freeing the air- tubes and relieving the embarrassed respiration. Some, indeed, imagine that they have a specific effect in restrain- ing the exudative process, and to obtain this they give smaller doses during the intervals between those which provoke vomiting. Others look upon emetics as a class of antiphlogistics, just as they regard purgatives as revul- sants, or as a means of reducing the system. It will be found, we believe, that emetics should be confined in diseases of the throat to the important role of their me- chanical action, by which they often render invaluable services. Aco7iite.—I have long been in the habit of prescribing 86 SORE THROAT. this medicine in various complaints. As a local appli- cation in painful affections it is frequently used, and, since the work of the lamented Fleming, occasionally given internally. From the result of many hundred cases I ventured strongly to recommend it to the profes- sion in the first edition of this work, since which date it has grown in favor. Being an energetic poison, I then thought it well to offer a caution as to the dose, which in almost all books was overstated. I admitted it to be quite true that a singlevdose of five minims, or even more, might be administered with benefit; but urged that re- peated doses of a much smaller amount are most ad- visable. Two minims of the tincture could be repeated three or four times a day or more; but I stated that, as a rule, one minim would be enough. In rare cases three might be required, and occasionally I had exceeded this. But I pointed out that the effect of the larger doses would be gained by a repetition of the smaller ones. This is no trivial matter, and therefore, though others have since taught the same doctrine, I may be excused for repeating my former instructions. A cautious use of this medicine is unattended with any material risk; but, if recklessly pushed, it may undoubtedly destroy life, rapidly and unexpectedly, for its poisonous properties develop them- selves rather suddenly if the first indication of its action be unheeded. It is a cumulative poison, and, con- sequently, is not to be prescribed in increasing doses. All the good effect may be obtained by small quantities, repeated at longer or shorter intervals, according to the rapidity of the action desired. I stated in 1861 that, although I had used it in thousands of cases, I had never produced alarming symptoms of poisoning, and knew no TREATMENT. 87 medicine which less frequently disappointed my expec- tations. Further, I said I had given it once, twice, and thrice a day for a considerable time, every four, three, and two hours for a shorter time; and sometimes re- peated a dose every half hour, carefully watching the patient, Others have since claimed great credit for the discovery that a dose may be given every quarter of an hour! After a few doses, sometimes after a single one, the action of the drug is observed, the pulse is reduced in frequency and power; in some cases the power is in- creased, the frequency diminished. The skin becomes relaxed and bedewed with a gentle perspiration; ner- vous irritability and excitement are allayed, a calm comes over the patient, and often sound sleep returns after a long absence. The pain is relieved almost as certainly as when it is locally applied for neuralgia. Clearly, then, it is a valuable sedative, exercising a marked in- fluence over the heart. It was some appreciation of these properties which caused it to be recommended in heart- disease and acute rheumatism. If a drop of the tincture be placed on the tongue, it is found to be acrid and bitter, and this taste is soon followed by a numbness or tingling in the mouth and fauces. Now, when the full action is produced, in giving this medicine, a similar sensation to this is perceived in other parts. The patient will de- clare or complain that he feels " numbed," or that he has the "pins and needles," or that he feels "just as if his feet had been asleep." This sensation may be very local —confined to the toes, fingers, or eyelids ; or may extend up the extremities, almost over the whole body, accord- ing to the susceptibility of the individual. The remedy 88 SORE THROAT. must now be discontinued, or the dose diminished, and only given just often enough to keep the system under its influence. This sensation is to aconite what salivation is to mercury. By it we shall not be misled. Like sali- vation, it may sometimes seem to fail, at others the effect may follow a single dose, but, on the whole, it is a cer- tain measure of the patient's tolerance of the drug. The reader may easily produce the sensation on himself by taking a drop or two in water, two, three, or four times a day. The medicine is useful in all febrile ailments; in ner- vous excitement; indeed, whenever the heart's action is quickened or the temperature increased. There are few diseases in which I have not at some period exhibited it. I often make it serve the place of salines, and in many cases it is an excellent substitute for digitalis. When sufficiently diluted, tincture of aconite is tasteless—a rec- ommendation of no small value to some people. For children, a little syrup makes it as palatable as sweetmeats. If not diluted enough, it produces numbness of the fauces by its contact. This property of acting locally on the membrane may be utilized for medical purposes. I have given it in the form of lozenges, as well as powders, made by rubbing the tincture with a few grains of sugar in a warm mortar, which causes the spirit to evaporate. A gargle may also be carefully used; it should not be too strong. Besides these modes, we may paint the membrane with the tincture, diluted with glycerin and water. This arrests pain, and sometimes puts a stop to inflammation ; but, if carelessly done, is exceedingly unpleasant. It may paralyze the soft palate for hours. This is not de- sirable, because in such case the uvula falls on the epi- TREATMENT. 89 glottis, and causes a suffocative cough, or feeling of choking which, unless the patient understands the cause, and how to act, will alarm him terribly, nor without some reason. I have not thought it requisite to enter here into an ac- count of the uses to which aconite is every day put by the profession. Its active principle, aconitin, is best adapted for external use, since its strength is such when pure, that Dr. Headland* calculated the tenth part of a grain would be certain death to an adult man. I formerly remarked that this alkaloid might be diluted for internal use; but though such a solution might be expected to be more cer- tain in its effects than the cruder preparations, I observed that the supposition did not coincide with my own expe- rience ; and more recent experimenters have adopted my conclusion that the alkaloid is not adapted for internal administration. It is true that various specimens of the root differ in the quantity of the active principle they con- tain ; and, therefore, that the tinctures are liable to differ in strength; but, on the other hand, the separation of aconitin is so difficult and expensive a process, that a pure specimen is rarely to be found. Moreover, its very potency necessitates greater accuracy in dispensing than can always be obtained. Iodine is a drug of great value. There are forms of throat disease which yield to its influence, and to nothing else. Its effect on enlarged glands is well known, and it is often applied locally. The tonsils are sometimes painted with it, but as the stimulating action of the drug on the surface often results in induration, fumigation is prefera- ble. In hypertrophy of these organs, as well as in bron- Action of Medicines. 8 90 SORE THROAT. chocele and other cases, it is used for interstitial injection. Iodide of potassium has a special value in syphilis, and cannot be dispensed with, though we may also use iodide of sodium or of calcium. These latter salts are specially useful in strumous cases. In anaemia, we may prefer the iodide of iron. Iodoform possesses peculiar advantages as a means of introducing iodine into the system, and as a most efficient topical remedy. The relative value of the several preparations of iodine was discussed in my paper "On Ozaena," at the Medical Society of London, in October, 1871, and their value again asserted in my articles on " Syphilitic Diseases of the Throat," in the fol- lowing January and February.* It is gratifying to find the views there expressed generally indorsed in a recent discussion on the subject.f Nitrate of potash is an excellent saline for throat cases, nor is it destitute of local efficacy. Mixed with sugar, and slowly dissolved on the tongue, or in the form of lozenges, it is a popular remedy, and for mild inflamed sore throat its ancient reputation is deserved. Chlorate of potash exercises great influence on mucous membrane. In some forms of stomatitis it is almost a specific, and since it has become generally employed, has been the means of saving many a life. It is useful both internally and as a topical application. For the intro- duction of this drug into modern practice we are indebted to Dr. Hunt.| Its influence is generally acdnowledged over thrush, but I find it of use in other conditions of the mucous membrane. From the influence it seemed * Medical Press and Circular, January 10th, February 28th, 1872. f British MedicalJournal, 1878. % Medico-Chirurgical Transactions, vol. xxvi. TREATMENT. 91 to exercise in restoring the health in such cases, it was conjectured that it also acted by supplying oxygen to the system, since it contains a large proportion of that element, but Pereira mentioned that it does not appear to undergo any chemical change in its passage through the system— a fact fatal to this hypothesis. It is a saline, and has a cooling diuretic action, but its chief use is for its local effect. It may be given in lozenges, and enters into many gargles, washes, douches, etc. Others, however, have attributed to it much more important powers, and pre- scribed it with confidence in diphtheria. Thus Seelig Miiller declares* that in five years a saturated solution of this salt has never failed to cure diphtheria ! When the patients were old enough he used gargles as well, but thinks the internal use of the remedy sufficient. Chloride of Sodium.—I have used this salt for some- what similar purposes as chlorate of potash, and with some success, but it appears more adapted for chronic cases of foul, indolent ulcerations in cachectic subjects where the chylopoietic functions are much deranged. As an emetic, I have great confidence in it, possessing as it does saline properties, with their beneficial action in the circulation, and it is itself a nominal constituent of the blood. A strong solution of it is also suited for topical application in exudative inflammation. Gucuacum is relied on by some in the early stages of quinsy. It was recommended by Sir Thomas Watson, and the late Mr. Harveyt much extended its use. Astringents.—Alum is one of the oldest of topical applications. At one time Velpeau highly extolled it in * Med. Times and Gazette, August 25th, 1877. f " The Ear in Health and Disease." 92 SORE THROAT. acute tonsillitis, but it has not answered the expectations inspired by that eminent authority's encomiums. As an ingredient of astringent gargles it is unexceptionable, and I have sometimes painted the fauces with a strong solution of this salt. Powdered burnt alum is also used by insufflation in some chronic diseases of the fauces, especially in the neighborhood of the Eustachian tubes. It has also been recommended in diphtheria. Zinc, iron, and copper sulphates, and other salts are, in like manner employed in several states of the mem- branes. Solutions of various strengths may be applied by means of cotton-wool, sponges, probangs, or camel- hair brushes. These salts are likewise useful ingredients in sprays, gargles, washes, etc. Tannin, the chief of vegetable astringents, is also extensively used as a topical remedy, especially in the form of gargles and sprays. Linimentum eeruginis is a very old stimulant, and slight escharotic for indolent ulcers, which still holds its ground with some practitioners. Nitrate of silver is, perhaps, the most constantly used topical remedy. It is employed both solid and in solu- tion ; the latter being conveyed to the part by camel-hair or glass brushes, by sponges mounted on whalebone, by cotton-wool held by a pair of forceps, and by specially constructed syringes, douches, and sprays. In the solid form it has been used by the insufflator, but this is not a good method. To cauterize by this agent the best way is to employ a small portion fused on a piece of silver or aluminium wire. There is no need to dilate on its prop- erties. It acts almost like a specific on some diseased conditions of the mucous membrane, and is certainly the sheet-anchor in many throat affections. Yet it ought TREATMENT—INHALATION. 93 not to exclude other remedies, and lead us into routine practice. Caustics.—Concentrated nitric acid and other strong; caustics are required in rapid sloughing and gangrene. They have also been employed in diphtheria. Their application is made on the same principles as to other parts, but the operation is one of great nicety. Fomentations are daily prescribed in all painful affec- tions, and are useful adjuncts in throat disease. In this category should be placed the use of hot moist sponges, which the late Dr. Graves so strongly urged in the early stage of croup. But, as a general rule, fomentations are quite secondary to InJialcdions.—The contact of watery vapor with in- flamed mucous membrane is very soothing. It cuts short the congestive stage of catarrh by a timeous supply of moisture, and so relieves the dryness, heat, and itching. In bronchitis, too, it is often of the greatest service, not only by supplying moisture to the inflamed mucous sur- face, but at a later stage by diluting and assisting to remove the secretion. As the warm vapor penetrates throughout the respiratory tract, it often produces more calm than powerful anodynes. Moreover, this vapor may be easily medicated. The same simple remedy ren- ders great service in croup and diphtheria. I formerly urged the application of steam to the inside of the air- tubes in a more thorough and systematic manner than had previously been recommended, since which several authors have learned to rely on the remedy, and some claim to have discovered its value. A very simple but effectual plan of inhalation, and one which even children willingly carry out, is to get the 94 SORE THROAT. patient to breathe through a large cup-sponge which has been dipped in hot water and rapidly squeezed. A less efficacious method is to lean over a jug or basin half-filled with boiling water. In this case the patient should not envelop the head in a towel, as many frequently do, for this practice is liable to produce headache and flushing, and so sometimes cast discredit on the remedy. It is easy enough to arrange a napkin or towel round the brim of a jug, so as to inclose only the mouth and nose. For simple steam inhalations these plans suffice, but when we wish to add medicinal agents—though an ordinary jug may be often made to do duty—some kind of inhaler is always more convenient and frequently necessary. Any volatile substance can be easily employed to medi- cate the vapor, and those herbs, the therapeutic value of which depends on an aromatic volatile principle, are often thus used ; or the active principle is previously extracted, as in the case of essential oils. The soothing properties of steam are thus increased by employing hops—the vapor of the freshly made infusion being charged with the sed- ative properties of the drug ; or the extract or tincture may be utilized, but the oil must not be substituted, as it is a stimulant. Chamomile flowers may be used in the same way. Another aromatic sedative is obtained by putting a teaspoonful of tinct. benz. com p. into the in- haler with hot water. The vapor coniae of the British Pharmacopoeia is more distinctly sedative—its efficacy depending on the conia being set free by the alkali, which for this reason should only be added at the time of use. The succus conii is to be preferred to the extract, as more reliable. The vapor acidi hydrocyanici is employed with cold water, but may be ranked among sedatives. The TREATMENT—INHALATION. 95 volatile parts of opium can be utilized by putting the tincture or the solid drug in the inhaler with hot water. Ether and chloroform may be used with water at a low temperature. It is, however, obvious that very volatile substances may be as well administered without the me- dium of water. A very simple inhaler, or a little cotton- wool in a cone of paper, will suffice for chloroform, ether, or nitrate of amyl, which I consider should be given under the superintendence of a medical man, as it is not well adapted for use when diluted as an inhalation, even at a low temperature. The late Dr. J. A. Symonds* rec- ommended solutions of balsams in ether or pyroacetic spirit, to be inhaled from an ordinary wide-mouthed bottle, the warmth of the hand holding it being quite suf- ficient to volatilize the liquid. I prefer ether to the pyro- acetic spirit. Spirit of chloroform may also be used by this method. Half an ounce of benzoic acid in an ounce of ether forms a standard solution, to which two drachms of balsam of Peru, or of Tolu, or of any similar substance, may be added. Turpentine has also been used in this way, but might then be made the menstruum. Besides anodyne inhalations, those possessing stimulat- ing properties are most important. In the British Phar- macopoeia there are only three—vapor chlori, creasoti, and iodi. The mode of using differs in each case, hot water being in neither instance employed, while each vapor is a special stimulant. Camphor is a good stimulant for in- halation. Ten drops of the spirit may be put into the inhaler to begin with. It is better to dilute it with more spirit. In like manner, many of the essential oils can * British Medical Journal, 1868. 96 SORE THROAT. be used as stimulants. They can be dissolved in spirit or diffused through water by means of magnesia, or pow- dered silex, in the manner often resorted to for making medicinal waters. The oils of aniseed, cajeput, cloves, cinnamon, marjoram, myrtle, rosemary, and others are adapted for this purpose. Ammonia is a general stimu- lant often resorted to. Atomized Fluids, or Sprays.—Liquids that are not vol- atile can be made available for inhalation by reducing them to a fine spray. So soluble solids can be dis- solved, and the solution used in the same manner. All the common atomizers and spray-producers consist essen- tially of a pair of Bergson's tubes, with an arrangement for driving air or steam through the upper one. The tubes are fixed at right angles to each other, one descending vertically into a bottle of the liquid to be atomized. The rush of air or steam through the horizontal tube exhausts the perpendicular one, the fluid rises, and is sent forward TREATMENT—SPRAYS. 97 in a fine spray. In Siegle's inhaler the force employed is steam generated in a boiler by means of a spirit-lamp. In the ordinary hand-ball atomizers the steam-boiler is replaced by a pair of bellows consisting of two india-rubber balls with proper valves. The bottle being held in the one hand, and the bellows worked with the other, the spray is inhaled as seen in the engraving, Fig. 11. I have contrived a more simple apparatus, which pro- duces an equally good spray, and is so inexpensive as to Fig. 12. place this mode of treatment within the reach of all. In my atomizer the tubes are placed parallel instead of at right angles to each other. The distal end of the upper tube is formed into a cup, which holds enough liquid for each occasion. The fluid finds its way by gravity to the 98 SORE THROAT. point, and the air is blown through the lower tube by the ordinary double bellows. This atomizer is much more simple in its construction than any other, as will be seen on reference to the engraving, Fig. 12. The bottle is dispensed with altogether. The tubes of glass can be replaced, if broken, at a small cost. They may be had of vulcanite or silver if preferred, but the cost is thereby in- creased. Maw & Co. are the makers. My atomizer is easier to use than more complicated in- struments at a much higher price, and will be found the most convenient apparatus wherever it is desired to use a spray. I find in practice that sprays are generally use- ful when it is an advantage to give them cold; while for warm applications I mostly resort to the common mode of inhaling steam impregnated with the remedy, but my atomizer can be adapted to Siegle's steam inhaler. It is mostly advisable to administer astringent sprays cold, though of course they may be used warm. Anodynes are applicable either way, but more frequently should be taken warm. The tubes of my atomizer can be held far enough in the mouth to prevent the spray spreading over the face. After warm inhalations it is often desirable for the patient not to go into the open air or into a cold room; but the cold spray is the best possible preparation for such sudden changes of temperature. The remedies most commonly used in the atomizer are solutions of metallic salts. As astringents, sulphate and chloride of zinc, alum, perchloride of zinc, and sulphate of iron. The strength of the solutions of these salts may vary from two to ten grains in the ounce, or more, ac- cording to circumstances. Permanganate of potash, five to ten grains per ounce, is disinfectant and stimulant, and TREATMENT—SPRAYS. 99 in some cases exercises a most happy influence on mucous membranes. In other cases chlorinated soda or lime, or liquor chlori, is more efficacious. Carbolic acid, three to five grains, is a good stimulant when the membrane is unusually dry. Lactic acid—already mentioned as a gargle—has been strongly recommended as a solvent of the false membrane of diphtheria. About half a drachm in the ounce will be strong enough. Nitrate of alumina was tried by Dr. Beigel,*who also used many other sub- stances, including acetate of lead, chloride of sodium, and even cod-liver oil. Demarquay recommends glycerin to soothe an irritated pharynx, and the late Dr. Scott Ali- son employed this fluid in laryngitis and tracheitis. Lau- danum and solution of the salts of morphia can be used in the form of spray, five to twenty minims at a time, properly diluted. Solutions of the bromides, the alka- line carbonates, and chloride of ammonium are also of use as sprays. In asthma success seems to have followed Fowler's solution, five minims at a time, administered in this manner, and in the same disease Professor See has recently introduced sprays of iodide of potassium. A spray of iodoform may also be used to obtain the good effect of this preparation. Sulphurous acid is generally pre- scribed too diluted ; it is important for the solution to be freshly prepared. Tannin, as an astringent, varies much in the dose, and is often prescribed in a solution too weak to be effectual. Many mineral waters, particularly those containing sulphur or chloride of sodium, have also been largely used in the form of spray. In conclusion, the atomizer has been used to fill the patient's room with * On Inhalation, London, 1866. 100 SORE THROAT. aqueous vapor, either pure or charged with medicinal agents, or with sea-salt, so as to make an artificial sea- air. Though the plan has now been for some time be- fore the profession, it has probably even yet not received the extension to which it is destined. Fumigation is a term frequently applied to the plan of drawing the fumes of any substance into the nose, throat, or any part of the respiratory passages. This is accom- plished by burning the substance so as to fill the room with the fumes, or by igniting a small quantity in any convenient vessel, and inspiring the vapor as it rises. The former plan is commonly employed for sulphur and some other substances. As, however, the fume or gas is inspired, we might include these under the term inhala- tions. Unsized paper, saturated with nitre and other substances, when ignited, gives rise to fumes, which have been inspired with benefit, particularly in asthma. Trous- seau and Pidoux recommended balsamic substances to be heated over a lamp, or thrown upon live coals, so as to fill the room with the anodyne fumes. Iodine gives off its vapor at a low temperature, so that it can be used in a still simpler manner. A watch-glass containing a little iodine put in a saucer of hot water is a sufficient appa- ratus. The vapor chlori of the British Pharmacopoeia requires no apparatus (though it is convenient to have one), and may be called a fumigation. Sternutatories and errhines are rather old-fashioned, but in disease of the pituitary membrane they are valu- able means of cure. Snuff-takers will readily employ them. Certain other powders may also be taken in the form of snuff, for the purpose of acting on the nasal passages. TREATMENT—GARGLES. 101 Gargle* are both popular and time-honored. Their action, however, is not so extensive as many imagine. In most cases they come in contact only with the anterior surface of the velum and uvula, and perhaps a small por- tion of the tonsils; but in other persons, as we shall see, they may reach more distant parts. In diffused affec- tions they occasionally exercise a surprising effect; and when one portion of the membrane becomes better for their use, the improvement sometimes seems to extend further than the local application of the remedy, just as we see disease spreading by continuity of surface. In the act of gargling, air is usually expelled through the liquid with sufficient force to cause a bubbling noise as it escapes into the cavity of the mouth. It is the gurgling sound thus produced, and popularly supposed to be essential, which gives the name to the process; for gargle and gurgle were originally the same word, derived from the Latin gurgulio, which means throat, and in its turn may be traced to yapyapewv, an old Greek word with the same signification, and perhaps coined in imitation of the sound, since, notwithstanding Max Miiller's con- tempt for the " bow-wow theory," at any rate the same collocation of sounds serves a similar purpose in still older lauguages, e. g., in the ancient Hebrew word for throat we find the same reduplicated syllable, gargar. Nevertheless, we may derive the full benefit from gar- gling without making any noise at all, since the liquid may remain in the position as long as the breath can be held; besides which, expiration may be carried on so gently that no gurgle is produced. So long as the liquid thus remains quiescent it is in contact with the mucous membrane and may act upon it—the extent of surface 102 SORE THROAT. thus affected depending on the position of the parts. If now the patient attempt to swallow, he soon reaches a point beyond which he cannot arrest that action. If in the same way he try cautiously to inspire, he will become conscious that the liquid is approaching the point at which it will set up spasm. The question is, how far we can allow the liquid to penetrate and yet retain full control over it. In this respect we meet with the greatest di- versities, some individuals possessing great power over the parts, while others never learn to gargle properly. The majority of patients require some instruction respect- ing the end to be served in their own cases. In using a mouth-wash the soft palate descends so as to cut off all communication with the pharynx. In gargling, as fre- quently understood, the result may be almost the same, the liquid coming in contact with the anterior surface of the velum and uvula only. If, however, the patient should now raise the velum, as many can do, some of the liquid would flow into the pharynx. There it pro- duces a desire to swallow, and unless the patient can control this some of it will pass into the oesophagus and stomach. Some persons, however, instead of yielding to the desire to swallow, suddenly jerk the head forwards, and a quick forcible expiration taking place at the same moment, the liquid is expelled through the nose. What they do involuntarily can be accomplished by others de- liberately and without inconvenience. In persons pos- sessing this control over the parts, we may often obtain good results from a natural nasal douche thus employed. It is by no means so easy to let the liquid enter the larynx, and in spite of persistent efforts, many will totally fail in the attempt. Of course, the glottis must be kept TREATMENT--GARGLES. 103 closed if the liquid is to rest upon it, and therefore the duration can only be while the patient can hold his breath. M. Guinier, of Montpellier, has shown that it is possible to attain such complete command over the parts as to allow the liquid to flow into the larynx, and remain there for several seconds. This is what he calls* laryngeal gargling. The mouth should not be quite closed, and the head should not be thrown back, as the less it is raised the less urgent is the desire to swallow. With these precautions M. Guinier takes the liquid into the mouth, brings forward the lower jaw, and closes the glottis by the uncompleted act of emitting a vowel sound. The velum in this disposition of the parts is raised, and the base of the tongue perhaps falls a little, so that the liquid finds its way into the larynx, where, if the patient can completely control the sensibility, it may remain as long as the breath is held. The slightest attempt to inspire will bring on spasmodic cough. Only the few can expect to attain success in this method, and its use is therefore very restricted, especially when we remember that there are other modes of applying liquids to the laryngeal mucous membrane. It will be observed that it is more important to manage the respiration than deglutition. If compelled to swal- low, the patient only receives a small quantity of the liquid into his stomach, and unless that be noxious there is an end of the incident. But if he draw the liquid into the air-passage very distressing spasm may ensue. Almost every one has seen this at table, when a morsel of food or drop of liquid has by a sudden inspiration * Etude du Gargarisme Laryngien, Paris, 1868. 104 SORE THROAT. been drawn into the larynx, or as we say, has "gone wrong way." A similar spasm is sometimes induced by the application of remedies to the larynx. The best way to act in such a case is to rigidly hold the breath for a few seconds and then to speak ; the utterance of a single syllable will at once put an end to the spasm. Drinking a little water is often recommended, but can scarcely be accomplished until the spasm abates. The little accidents just alluded to generally occur through talking or laugh- ing while food is in the mouth. Expiration then becom- ing complete, and the need for inspiration being suddenly felt, air is drawn through the mouth and carries with it a liquid or solid particle beyond the raised velum, and over the epiglottis into the larynx, where its presence is instantly resented. Astringents, disinfectants, and antiseptics are the rem- edies most frequently required in the form of gargle, but anodynes and narcotics may also be utilized in this way. One of the best astringents is a solution of alum, the strength of, which may be varied according to the effect required; chloralum may be employed for the same pur- poses. Tannin, a powerful vegetable astringent, may be used with confidence ; one or two drachms in half a pint of water, to which a little rectified spirit or an ounce of glycerin may be added. It is to the tannin they contain that various liquids popularly used as gargles owe their repute. Borax and chlorate of potash are also useful as both gargles and mouth washes : the former is slightly alkaline as well as astringent; the latter possesses special value in an aphthous condition of the buccal and faucial mucous membrane.' As a disinfecting wash and gargle Condy's fluid is the best, but chlorinated liquids are also TREATMENT—NASAL DOUCHES. 105 useful. Carbolic acid is a good stimulant to the pharyn- geal mucous membrane, but its flavor is so disagreeable that when indicated, it is better to pencil the parts with the solution. I have had excellent results from lactic acid, both as a gargle and in the form of spray ; three or four drachms may be diluted with eight ounces or ten ounces of water. This remedy is of special value in diphtheria. The lactates may be used in the same disease, and lime-water has been recommended for the same pur- pose. Diluted mineral acids are sometimes prescribed as gargles; their action on the teeth should lead us to prefer other astringents. Gargles are generally used cold, but occasionally, es- pecially when containing anodynes, warm. It is in chronic cases they are most suitable. In acute inflam- mation of the fauces the movement of the parts causes so much pain that the patient cannot gargle. Further, it is not desirable to order gargles for children, unless we know they have learned to use them. Nasal Douches.—I have shown (p. 102) how a kind of natural nasal douche may be taken. To accomplish the same end, and to wash out the passages more thoroughly, we employ the apparatus sold under the name of the nasal douche, by which fluid is brought into contact with a portion of mucous membrane, which, in the majority of persons, is otherwise inaccessible to such local treat- ment as the patient can employ. The nasal douche is, of course, most serviceable where the disease is located in the posterior nares, as shown in my paper "On Ozaena," already cited, but it is also of value in some pharyngeal cases. The nasal passages, as well as the pharynx, may also be medicated by means of syringes and atomizers > 9 106 SORE THROAT. properly constructed, while the primitive plan of snuffing up the liquid by a series of short inspirations is occa- sionally preferred. Some persons have a trick of thus taking up fluids from the hollow of the hand, or from any shalloAV vessel—a sort of "drinking through the nose," which may be turned to account in the case of nasal disease. The liquids most serviceable for the nasal douche are weak alkaline and saline solutions. A drachm of chloride of sodium in a pint of water is constantly prescribed, but half a drachm of carbonate of soda in the same quantity is more efficacious and more agreeable. Moreover, I agree with Weber-Liel that it is not so likely to injure the ear. By this the mucous membrane may always be thoroughly freed from the discharges, and thus prepared for other remedies. Astringents may be resorted to in many cases, but only in very small quantity, the membrane here being exceeding sensitive. Many cases of headache, local irritation, or other unpleasantnesses, are caused by too strong a solution being ordered. The permanganates as deodorizers are most useful. In all cases the nasal douche should be used tepid at first. Occasionally it may be desirable to decrease the temper- ature, especially when astringents are employed. The Pharyngeal Douche.—It is easy to direct a stream of liquid on the posterior wall of the pharynx. For this purpose I have arranged mouthpieces which can be used in place of the nosepiece of the nasal douche, or attached to a small Higginson's syringe. I have also had suitable tubes fitted to the atomizer to make it avail- able in the place of the nasal or pharyngeal douche. Patients soon learn to employ this method themselves. The liquids are such as have been recommended for the TREATMENT—LOZENGES. 107 nasal douche and for gargles, but their strength should be between these two. Irrigations.—I have contrived a pharyngeal and a nasal irrigator. By means of these the physician may irrigate the throat and nasal passages, both from the front and back, with fluids which he could not intrust to the patient. Insufflations.—Powders may be applied to the pha- ryngeal mucous membrane by means of any of the com- mon insufflators. They are often very useful as adjuncts to other treatment, particularly in diseases near the orifice of the Eustachian tube, and other conditions giving rise to deafness. Lozenges.—The local effect of some substances which are not too disagreeable to the taste, may be obtained from lozenges, which may be looked upon as the modern representatives of the ancient class of remedies termed, from the dose being placed under the tongue of the pa- tient, "hypoglottides," and which Galen, Dioscoridcs, and others were accustomed to prescribe. Lozenges should not be broken up by the teeth and hastily disposed of, but should always be allowed to dis- solve in the mouth, and should also be swallowed as slowly as practicable, so as to prolong their presence in the fauces as much as possible. It is further to be re- membered that as lozenges are swallowed their effect on the stomach is not to be forgotten ; their liability to in- terfere with digestion is one of their disadvantages. Some lozenges—for instance those containing morphia—are also used for their general effects. In the British Phar- macopoeia there are only ten formulae for lozenges—some, as those of tannin and chlorate of potash, most useful 108 SORE THROAT. locally; others, as those of iron and opium, for their ef- fects on the system. The hardness of these lozenges is sometimes an objection, to overcome which at the Hospi- tal for Diseases of the Throat the lozenges are made of fruit-paste, such as is used in the currant lozenges to be found everywhere. I have also had lozenges made like ordinary jujubes. The pate de guimauve, so common in France, is equally serviceable. The most useful additions to the lozenges of the British Pharmacopoeia are astrin- gents ; of these krameria is one of the best, as its remote effects are less marked than those of other astringents. In tonsillitis guaiacum has been strongly recommended by Sir T. Watson and others, and can be given in the form of lozenges. In the first edition of this book I also recommended aconite in that form, and continue to employ it. Each lozenge or jujube may be equal to half a drop of tincture of aconite, and prescribed accordingly. LARYNGOSCOPAL THERAPEUTICS. Most of the remedies we have been considering may be used by the patient, and are accordingly prescribed, but some of them, as certain sprays and douches, are sometimes—caustics always—applied by the medical man. We have yet to mention remedies which are only applied by the aid of the laryngoscope, and are therefore not ordered, but used by the physician himself. For topical applications to the larynx, as well as for more im- portant operations within that cavity, the mirror must always be employed, and the term laryngoscopal medica- tion or laryngoscopal therapeutics is used to designate the proceeding, but of course when the rhinoscopic mir- ror is used a corresponding distinction might be made. LARYNGOSCOPAL THERAPEUTICS. 109 There are other points to which the mirror will help us to apply remedies as surely as it aids to discover disease. It should be used whenever it is able to render assistance. Even in the most accessible parts of the throat topical remedies should be applied with care and only by skilled hands. Not seldom has considerable injury been done by the bungling application of a powerful agent. Firm- ness and steadiness are indeed required, but with these should be combined the utmost gentleness, and the more delicate the part treated the greater the skill and care demanded. Thus it is an easy thing to paint the fauces with a non-irritating fluid, while to apply caustic to a minute point in the larynx or nasal passages, and to this point only, is an operation demanding the greatest dex- terity. Liquids are perhaps the most frequently resorted to, to act on the mucous surface. We have already seen that douches and atomized sprays may thus be employed, as also may syringes. Throat probangs, consisting of whale- bone or other handles with suitable-sized sponges at the end, may be saturated in the liquids and applied to the fauces. In place of these, morsels of cotton-wool soaked in the fluid and held in specially contrived forceps can be used. Camel-hair brushes mounted on handles of various shapes and sizes are also employed for applica- tion within the larynx; brushes are so much superior to probangs that the latter are now seldom resorted to for this purpose, but they are much more employed in the fauces, where, however, a brush or cotton-wool is equally convenient and often preferable. When it is proposed to use a probang in the larynx it is necessary to have one properly constructed, those commonly sold being quite 110 SORE THROAT. unfit for the purpose. A variety of sizes and shapes of both brushes and probangs will be found desirable, so that any part may be reached with ease. The little in- convenience caused by the introduction of a brush charged with fluid into the larynx is a source of surprise to those who have not witnessed the operation. To take the larynx by surprise and bring the brush in contact with its lining with that combination of gentleness and firmness which characterizes the skilled hand, is by far less likely to pro- voke spasm than is the intrusion of a drop of water in the act of drinking. Still, even in the most skilled hands the brush may now and then cause distress; a choking sensation, a degree of pain or irritation, a contraction of the vestibule, or spasm of the glottis, may be provoked. Such symptoms are, however, very transient, as is also the change in the voice, that may surprise the patient. They give rise to alarm in the mind of the sufferer, who, if not forewarned, should be at once assured that there is no danger, and, if possible, induced to speak. The utter- ance of a single word gives complete relief, but as this may be difficult, the best plan is to hold the breath, when the spasm will at once subside. These inconveniences are the effects of the mechanical contact of the instrument and therefore temporary. We have next to consider the effects of the liquid with which the brush is charged; these, of course, differ with the nature of the liquid, whether astringent, stimulant, sedative, etc. The selec- tion of the liquid will be made in accordance with the principles that guide us in the local treatment of other diseased mucous surfaces, modified only by the conditions that are special to the organ under consideration. Liquids of an astringent, antiseptic, or anodyne char- LARYNGOSCOPAL THERAPEUTICS. Ill aetcr, may be used in this manner; perhaps the first are most frequently employed. Solutions of various metallic salts, of tannin, of iodine, or of any other substance that may be indicated can thus be applied to the diseased parts, and of course these solutions may be made of various strengths, according to the purposes they are intended to fulfil. These solutions may be made in simple distilled water, or a portion of glycerin may be added. It has been proposed to use the latter only as a solvent, but this is not desirable, as it is too irritating, glycerin being far from the bland liquid it is frequently called. When mixed with water, however, it loses much of its irritant quality, and the consistence of the liquid is increased. Its slowness to evaporate may also be regarded as some ad- vantage. Medicated liquids are sometimes injected into the larynx by means of a syringe. It is obvious that with the aid of the mirror there could be no more difficulty about this than about other instruments, provided the pipe of the syringe be of sufficient length and of a proper curve. So, too, we employ a laryngeal douche, in which the same form of pipe is furnished with a caoutchouc ball instead of a piston. The mode of injecting fluids into the larynx by these instruments needs no detailed observations. The only requirements on the part of the operator are steadi- ness and dexterity. The laryngoscope must always be employed so that the operator's hand is guided by his eye. This brings us to consider the special action of injec- tions. Sudden and forcible pressure evidently projects a douche or shower on the walls of the larynx, according as the instrument terminates in one or many apertures; 112 SORE THROAT. the feeblest possible compression will only cause a few drops to exude from the tiny apertures, and collect into one, which falls into the cavity. Between these two ex- tremes there are many degrees of pressure, and the effects will vary accordingly. Unless we intend to use sufficient force to drive the fluid as far as the walls of the larynx, there is no advantage in having the end of the syringe furnished with numerous minute perforations to break up the stream. If we use sufficient force to project the fluid on the membrane, clearly we administer a sort of shower- bath to the larynx, and the influence of this ought not to be overlooked. There is another difference between the use of syringes and brushes. In using the latter we touch the mucous membrane with a foreign body, a fact which has been urged against their employment, but I have shown that very little irritation is caused by the skilful use of well-made brushes. On the other hand, injections are in reality far more distressing. Whether a powerful douche be projected into the larynx, or only a drop or two slowly injected, violent spasm is very likely to be caused. In the former case many would naturally anticipate this result; but in the latter it is quite as frequent, and sometimes more severe. Part of the effect may be due to the shock of the stream on the walls of the larynx; but when only a drop or two is in- jected, we have just the inconvenience that is setup when in drinking or gargling, liquid is drawn into the air-tube by inspiration ("goes wrong way"). It is possible with a brush to localize the application of a fluid to a portion of the larynx. Though not so easily, this may also be accomplished with a syringe, if we take care to exert only just enough pressure to expel LARYNGOSCOPAL THERAPEUTICS. 113 a single drop of the fluid at a time. But neither of these instruments is well adapted for instilling fluids into the larynx drop by drop, and I have therefore adopted the principle of a pipette for this purpose. Guided by the laryngoscope, the operator can introduce my laryngeal pipette, and carry the point to the spot on which he wishes to act, when a drop of fluid is allowed to escape. The patient should emit a high note during the time. If the fluid pass the glottis, it will be likely to provoke spasm and cough. Solids are applied to the throat in the form of powder, by means of the insufflator, or the diseased spots may be touched with rapidly acting agents, like escharotics. We will first consider powders. To apply them to the fauces any of the common insufflators will suffice, but when we wish to localize the application in the upper pharynx, the posterior nares, or the larynx, special adaptations are re- quired. I have had these made of suitable curves for such purposes, and with openings for the exit of the pow- der in definite directions. Thus, I am able to localize the action of the powder on even a portion of the larynx. This I accomplish by having several tubes, each of which differs from its fellow in the position and shape of the opening. The most useful forms are three,—one with the usual termination, one with a slit on the right side, and a third with a slit on the left side. The idea of projecting a cloud of fine powder into the larynx will to some persons suggest a violent paroxysm of cough as the immediate result. They imagine, per- haps, that a solid, however finely powdered, must be more irritating than a liquid, but this is not the case, and soothing remedies are amongst those most frequently ap- 10 114 SORE THROAT. plied to the larynx by this method. In the pharynx we more often use astringents. The effects produced by a cloud of dust falling on the mucous membrane will differ with the nature of the particles of which the dust is com- posed. An insoluble powder thus applied to healthy membrane provokes some irritation and increase of secre- tion ; the mucus thus thrown out envelops the particles, and the whole is rapidly removed. Soluble powders will dissolve in the secretion, and be carried away. Whether soluble or not, powders may act as astringents, sedatives, stimulants, etc., and some influence is in every case to be attributed to the shock caused by the impact of the par- ticles on the parts. The powders most frequently insufflated into the larynx are anodynes, the salts of morphia being usually selected. Among astringents are tannin, gallic acid, acetate of lead, sulphate of zinc, etc. Nitrate of bismuth, oxide of zinc, and other powders have also been employed. Nitrate of silver has sometimes been used in this way, but I do not recommend it. Morphia may be ab- sorbed, and so act as a general narcotic. Insufflations of this drug often prove a great comfort in advanced laryn- geal phthisis and other diseases. Moreover, we may com- bine the morphia with astringents, antiseptics, or other remedies, in any proportion. The special effects of iodo- form may also be obtained by administering it in this way, either alone or in combination with other remedies. Evidently, then, there is a considerable sphere in which powders may be employed in the larynx, and it seems needless to add that this sphere is rendered much greater by the admirable results obtained from their use in dis- eases of the fauces. To regulate the strength of our reme- LARYNGOSCOPAL THERAPEUTICS. 115 dies we mix them with indifferent powders, such as sugar of milk, phosphate of lime, or talc. Cauterization.—Instead of medicating the general sur- face of the membrane, it may be requisite to apply solid caustics to small and defined portions of the larynx, and this can be done by the aid of the laryngoscope. Various forms of caustic-holders have been designed for the pur- pose of facilitating the procedure. Most of them conceal the caustic until the instrument is introduced to the spot to be cauterized, when it is propelled forwards by pres- sure on a spring; on removal of the pressure the caustic retreats within the sheath. Such a contrivance will give confidence to the beginner, and is constantly used by some larvngoscopists. I have, however, abandoned it in favor of the more simple naked conductor. Every one who intends to practice laryngoscopal manipulations of an operative kind should be able to apply caustic to any portions of the laryngeal surface, watching the proceed- ings all the time in the laryngoscope. The holder I employ closely resembles the laryngeal brushes already described without the termination. It consists of a handle of the same length, mounted with aluminium or silver wire of the same form; but the wire terminating in a blunt probe-point, or in a rough bulb, instead of having a camel-hair brush affixed. The nitrate of silver is fused in a small crucible, and the bulbous end of the wire dipped in. The bulb is thus covered with a thin coating of the caustic, aud the instrument is ready for use. In- stead of the bulb at the end, we may have depressions hollowed out on either side, into which the fused nitrate may be run; and other variations in the form of this simple instrument are occasionally seryiceable. Besides 116 SORE THROAT. only coating one side of the instrument, we may secure still further protection by covering the other with a paste containing some table salt. Should, then, some of the nitrate left on one cord come into contact with the other, it will be decomposed by the salt that is left upon the sound cord, and the silver chloride will produce no effect. The holder should be cleansed and recharged after each occasion on which it has been used. One of the greatest advantages of this simple instrument is, that it is impos- sible for a piece of caustic to break off and drop into the larynx. Nitrate of silver is so efficacious that the use of more potent caustics is seldom called for. They have, however, been employed. The caustic alkalies are not well adapted for use within the larynx, nor is the potassa c. calce. Objections also exist to sulphate of copper and bichro- mate of potash, as solid caustics. In rare cases chromic acid has proved very valuable, but is difficult to manage, and should only be used with the utmost caution. Caustics may be used for various purposes. They are of the utmost value in certain cases of deep ulceration. They are frequently applied to the pedicle of a polypus which has been removed by instruments, and they are also successfully used for the removal of hypertrophy of limited extent, as well as for the destruction of morbid growths in the larynx. Scarification.—In those cases of rapid oedema in which the patient is being suffocated, the laryngeal lancet is used to give exit to the fluid, and thus at once restore the power of breathing. The same instrument is also occa- sionally required to open an abscess, and it has been em- ployed as a scarificator in certain other conditions arising LARYNGOSCOPAL THERAPEUTICS. 117 in inflammation. It is, however, to be resorted to with reserve whenever there is not great urgency in the case. Various guarded lancets have been invented, the points of which can be pushed forward when they reach the spot, and which at once spring back within their sheath. I prefer the simpler form of unguarded lancets, mounted on handles like those of other laryngeal instruments. They give more power and precision. In skilled hands —and others ought never to touch them—they are not excessively dangerous. Interstitial Injection.—By means of a small pointed syringe of a proper form fluids have been injected be- neath the mucous membrane of the larynx, or into the substance of morbid growths in that organ. Some suc- cessful cases have been recorded ; but since a patient died in Vienna a few minutes after the operation, it has been less frequently resorted to. It is a method of treatment I do not recommend. Electrical Operations.—Faradization of the larynx has been found very successful in functional aphonia. It is accomplished by means of a properly insulated electrode of the form of a laryngeal sound, which having been attached to the wire of one pole, is carried into the larynx, the other pole having been previously applied to the neck, the circuit being completed by pressing the index finger on a spring. This operation is a simple one ; only a small battery is required, and the result is usually satis- factory. The galvano-cautery may be employed instead of the other methods of removing growths. This operation is one of great nicety, but has proved very successful. 118 SORE THROAT. One of the most delicate operations that have been per- formed is that of electrolysis within the larynx. Removal of Growths.—Some account of the morbid growths Avhich occur in the larynx will be found in a later chapter. In operations for the mechanical removal of such growths, various forms of forceps, guillotines, wire-loops, and ecraseurs, have been employed ; but hav- ing described these instruments in Lessons on Laryn- goscopy and Rhinoscopy, the reader who seeks further information on intralaryngeal operations may be referred to that work. I therefore content myself with repeating my preference for simplicity in the construction of all instruments, which can only be regarded as supplemen- tary to the fingers. Success depends not on the form of the instrument, but on the skill of the hand by which it is wielded. An artificial opening into the air-tube is to be made when suffocation is imminent. The principle involved is the same whether laryngotomy or tracheotomy be pre- ferred. The object is to enable a patient to carry on respiration, and in the case of foreign bodies being im- pacted, to remove them. The operation has been prac- ticed in acute and chronic laryngitis, in croup, oedema, ulceration, necrosis, exfoliation of the cartilages, in cer- tain states caused by syphilis, in consumption, in tumors, as well as in various injuries. It is indicated whenever there is an immovable impediment to inspiration situated high enough for the opening to be made below it. Tracheotomy has been further proposed as a palliative in general diseases, such as epilepsy and hydrophobia, but the experience of the profession is not at present LARYNGOSCOPAL THERAPEUTICS. 119 extensive enough to show how far it is useful for this purpose. Before proposing such a proceeding, we ought certainly to weigh most carefully the chances of the patient; but when once convinced that nothing else can save life, and that this measure holds out some prospect of doing so, it is criminal to conceal our opinion. In the first edition of this book I commented on the different results of this operation in the hands of English and French practi- tioners, and suggested that this was to a great extent caused by our so frequently postponing it till there is scarcely a chance of success, and urged that in this mat- ter the British profession should give a more candid consideration to the practice of their French neighbors. Since that tjime the growth of English opinion has been steady, if slow, in the direction then pointed out. Trous- seau has become better known in this country, and his enthusiasm for tracheotomy has produced a considerable effect. Some of our surgeons have taken up an attitude more favorable to the operation, and there can be little doubt that it has saved many lives. We now seldom hear the reproach, once so common on this side of the Channel, that the French perform tracheotomy when less severe measures would have terminated in recovery. The implied censure, if deserved, could easily be an- swered by a tu quoque ; for is it not just as culpable to delay a remedy until its employment is a mere saving of appearances ? True, no man of feeling likes to advise a serious surgical operation while he retains a hope that other means may give relief. On the other hand our feelings are not to be suffered so far to interfere with our judgment, as to omit even a dernier ressort. 120 SORE THROAT. CHAPTERIV. CLASSIFICATION. Diseases may be classified in various ways to serve different purposes, and a number of terms are conse- quently employed in describing or designating them, which apply to sore throat as well as other affections. Examples are acute, subacute, chronic, in relation to time or severity; strumous, gouty, cachectic, in relation to diathesis; catarrhal, exanthematous, specific, in reference to cause. From what has preceded, it will also be seen that inflammation of the mucous membrane of the throat might be further classified according to its result. We might, for instance, arrange part of our subject somewhat after this fashion: Inflammation of Mucous Membrane of Throat. Acute, as in inflamed sore throat. Subacute or chronic, as in relaxed sore throat. Terminating in ulceration, as in ulcerated, follicular, aphthous, clergyman's, tuberculous, syphilitic sore throat, etc. gangrene, as in malignant sore throat. effusion, as in oedema uvulae and oede- ma glottidis. suppuration, as in quinsy, abscess of the pharynx, etc. * induration, as in enlarged tonsils and elongated uvula. exudation, as in croup and diphtheria. CLASSIFICATION. 121 As, however, disease is sometimes confined to a por- tion of the membrane, another division suggests itself ac- cording to its position, and that an exceedingly useful one in practice, especially as in this we may group all the morbid processes affecting both the superficial and deeper structures of each organ together. It may be ex- hibited in the following manner: Sore Throat. Seated in the pharynx, as in pharyngitis, abscess, cancer, and aphtha. " tonsils, as in tonsillitis, quinsy, hypertrophy, ulcer, etc. " larynx, as in laryngitis, croup, cancer, hoarse- ness, aphonia, and other affections of the voice. " glands, as in parotitis, etc. Having already grouped the several forms of sore throat together, so as to exhibit their mutual relationship, we shall now, combining the two modes of classification presented above, proceed to describe the more important varieties of sore throat in detail. Thus, first we shall take inflammation and other morbid processes involving the several parts of the throat, and afterwards devote a chapter to the diseases of each of the several organs in- volved,—soft palate, uvula, tonsils, pharynx, larynx, trachea, etc. The slight repetition occasioned by this will be amply repaid by the convenience of such an ar- rangement. 122 SORE THROAT. CHAPTER V. INFLAMED SORE THROAT. Inflamed or inflammatory sore throat is a convenient term for an inflammation involving the entire faucial mucous membrane—uvula, velum, pharynx, pillars, ton- sils, etc., all being implicated. When one organ bears the brunt of the attack, the others suffering in a minor degree only, it is better to call it tonsillitis, pharyngitis, etc., as the case may be, reserving the expression " in- flamed sore throat" for the more diffused affection. In the former case, the inflammation more frequently ex- tends below the surface, is parenchymatous or phlegmo- nous ; in the latter, the attack mostly has a catarrhal origin, and is preceded by sneezing, coryza, or lachryma- tion. As already shown, however, even when catarrh is the exciting cause, the throat may be the part first at- tacked. In the same way I have often known the catarrh begin still further down, and gradually extend upwards. Then, instead of coryza, sore throat, and bronchial catarrh succeeding each other, the order is reversed. The point first attacked is frequently recog- nized by the patient as his weak spot, the one which always suffers with others, and usually before others, the locus minoris resistentke. Besides individual susceptibil- ities, we see others at work. Thus age has a great influ- ence in determining the liability of parts to suffer, as INFLAMED SORE THROAT. 123 witness the proneness of children to certain laryngeal affections. As soon as the throat is attacked by catarrh, it becomes sensibly sore. It feels dry, or itching, or hot, or even painful. Swallowing aggravates the pain or uneasiness. Respiration is seldom impeded, except from the stuffiness occasioned by the accompanying coryza. On looking into the fauces, evidences of the congested state are at once seen—the marked dry redness and more or less swelling. Occasionally the sympathetic fever runs high. It is important, therefore, to remember that more serious ailments commence in a very similar way, and that this, manageable as it usually is, sometimes gives the attendant anxiety as well as trouble. The consequences of a single attack may be grave, while a repetition of sore throat frequently lays the foundation of lengthened suffering, and one attack predisposes to such repetition. Moreover, an inflamed sore throat, instead of being produced by catarrh or local irritation, may be only a local manifes- tation of another general disease. It is, therefore, need- ful carefully to weigh the circumstances before pronounc- ing a positive opinion as to the nature or treatment of any case. It must be provoking for a practitioner, who has jauntily assured a patient that he has only a common cold, to find on his next visit unmistakable symptoms of scarlet fever. Besides, such an oversight would inevita- bly shake the confidence which had been previously reposed in his skill. When the diagnosis is determined, the chief point is not to overdose the patient. Confinement to the house for a day or two, or to bed even, with a milk or farina- ceous diet is to be advised ; but anything more debilitat- 124 SORE THROAT. ing is unwise. No loss of blood, even by leeches, is required. If, in the course of the diffuse form, a single point, such, e.g., as a tonsil, be attacked with phlegmonous inflammation, scarification of that part may occasionally be justifiable. Calomel, antimony, and other potent remedies, sometimes recommended on the score that the complaint is inflammatory, are best let alone: they weaken the patient and prolong convalescence. In all probability, left to his own choice, the patient will regu- late his diet with great propriety, choosing arrowroot, sago, tapioca, panada, gruel, or something equally innox- ious and soft to the throat. At the same time, it does occur that a sore throat affords us a good excuse for reducing a patient who really requires this with another view than curing his cold. The inhalation of steam affords much comfort, especially in the early dry stage. It often seems, indeed, to arrest the disease; and when it does not, it hastens on the moist stage. Instead of the simple vapor, anodyne, or aromatic inhalations, or fumi- gations should be tried when there is considerable suffer- ing. The act of inhalation encourages perspiration, which is an advantage. Fomentations, when there is pain, sometimes relieve. Gargling is painful in the acute stage. If the fever require it, a diaphoretic may be given, preceded or followed by a saline aperient. A combination of liq. amnion, acet. and spirit, aetheris nit., with, if the bronchi suffer, vin. ipecac, is very popular. In place of the last, antimonial wine is sometimes very efficacious ; but the doses should be small. Of all inter- nal medicines, however, aconite is the most universally beneficial. It acts on the local ailment, as well as on the sympathetic fever. It cures without debilitating; nor is PHLEGMONOUS SORE THROAT. 125 there any extra danger of ill-effects from a chill during its use. Is it possible to cut short an attack of sore throat ? In certain catarrhal cases, yes, just as in coryza. A full dose of morphia or opium at the very beginning will, in many patients, succeed, but not so often as in coryza. Many patients will tell us that the dose always stops a cold in the head, but not a sore throat. A free perspira- tion is equally efficacious, whether obtained from exercise, a Turkish bath, or diaphoretic drugs. " The dry method " is useless when the membrane of the throat is affected, though, for those who do not find the remedy worse than the disease, it succeeds in certain cases of inflammation of the pituitary membrane when profuse coryza is the chief symptom. Phlegmonous inflammation, arising from several causes, is of common occurrence in the fauces. We then have a more serious disease, characterized, when the attack is severe, by greater urgency in the symptoms. In mild cases these resemble those of catarrhal sore throat; in the most severe we may have gangrene, and between these two we witness every phase. The phlegmonous inflam- mations, which are secondary to other diseases, will come under notice in another chapter; but idiopathic cases occur, and may have a catarrhal origin. In phlegmonous sore throat there is usually higher fever, more pain, and greater swelling of the tissues, due chiefly to serous infil- tration, and perhaps to dilation of the lymphatics; yet the glands may not be perceptibly swollen ; oedema is common; haemorrhage also occurs, but less frequently, both these symptoms being more frequent in traumatic cases. Swallowing is often almost put a stop to, so pain- 126 SORE THROAT. ful does it become, and even the movements of the soft palate in talking cause so much pain as to impose silence on the sufferer. The tongue is coated with a thick fur, and often there is a copious discharge of mucus —perhaps tinged with blood—into the mouth. Head- ache, nausea, vomiting, and fever of various intensity will be present. As to diagnosis, the chief point is to distinguish cases of primary inflammation from those connected with other disease, such as scarlet fever, glanders, etc. The treat- ment of idiopathic phlegmonous eases does not differ from the preceding variety of inflamed sore throat, except in so far as the urgency of the disease demands more active remedies, which, too, are varied, according to symptoms. Thus pain may call for anodynes and fomentations, though, at an earlier stage, ice to suck and cold compresses to the neck may be advisable. Some will use calomel and an- timony, and these remedies seem more appropriate in the graver forms, but I have found aconite preferable. Con- stant hot anodyne inhalations are grateful and beneficial. Traumatic cases are a variety of the phlegmonous caused by injury, and differ in degree from mere trivial lesions to those of a most deadly kind. Sometimes the throat is scratched by fish-bones accidentally swallowed. The dangerous custom of some women to hold pins and needles in their mouths leads to accidents of a like kind. Other substances taken into the mouth, even hard food or hot drinks, may give rise to various forms of injury. In still worse cases there is more severe and deeper in- flammation ; the mucous membrane may indeed be com- pletely destroyed. Thus poor children attempt to drink from a kettle of boiling water, and are sadly scalded. ERYSIPELATOUS SORE THROAT. 127 This injury mostly involves the larynx, so that oedema of the glottis is to be expected, calling, perhaps, for laryn- gotomy. Doubtless this arises so often from some of the hot water being sucked into the air-passage by the effort to scream which instantly follows the pain. Another variety is caused by acids or other caustic liquids being swallowed, and in this the food-passage is the most con- stant sufferer. In attempted suicide, the liquid is usually completely swallowed, and the injury to the throat be- comes of secondary importance. In accidents it is at once rejected, and the chief mischief happens to the mouth, epiglottis, and pharynx. In all these cases prompt and appropriate treatment is needed. Our first indication is to neutralize the poison, stay its destructive action, and then to contend with the inflammation set up. In the mouth and fauces the na- ture and extent of the injury done can be seen, and the parts are within reach of our remedies. This is also true as to the larynx. In the stomach we cannot determine the local damage. In the oesophagus, in cases that re- cover, the contraction that ensues often sets up stricture. Injuries involving the external parts, accidental or in- tentional, such as cut-throats and crushing of the larynx and trachea, though belonging to the province of surgery, demand notice in passing, as they bring on subsequent conditions which the laryngoscope alone can determine. ERYSIPELATOUS SORE THROAT; HOSPITAL SORE THROAT. Erysipelas, as a rule, attacks the fauces only when it is also present on the cutaneous surface, though it may begin in the throat and extend to the larynx without any \ 128 SORE THROAT. other manifestation of the disease. This fact, though sometimes denied, was known to Ryland. Sydenham de- scribed erysipelas of the throat, and Hippocrates seems to have observed it. The disease may also chiefly affect the pharynx, but the tendency of erysipelas to spread is well known, and it usually involves several organs. Often it may be observed spreading from the skin, and sometimes it disappears in one place to appear in the other—a kind of metastasis, in fact, takes place. The junction of skin and mucous membrane seems a favorite spot with erysi- pelatous inflammation. Some sore throat is a common symptom also in erysipelas of the scalp. There is then always some danger that erysipelas of the face may ex- tend into the fauces and larynx. In connection with the views insisted on in this work, and which I have taught for nearly twenty years, it is interesting to find that M. Gallard* has recorded a case in which erysipelas was distinctly observed spreading from the throat along the lachrymal duct to the conjunc- tiva, and this has been confirmed by Rigal,f who saw a case in which the disease passed from the pharynx along the nasal passage and lachrymal duct to the face. During the prevalence of erysipelas in hospitals cases are likely to occur in which the fauces are affected, and indeed this low form of diffuse inflammation may attack the attendants whenever the wards become foul. It is to this that the term "hospital sore throat" is so often ap- plied, though the term is also used in respect to other conditions. In fact, any sore throat occurring in students, nurses, and others engaged in hospital work is apt to get * Gazette des H6pitaux, 1869, p. 47. t Ibid., 1869, p. 20. HOSPITAL SORE THROAT. 129 the name which should be reserved for the graver dis- ease. In erysipelatous sore throat the congested fauces are dark in color, and often seem drier—giving a purplish, lustrous look to the parts. There is not necessarily much swelling. Vesicles sometimes form, but not often. The stinging heat or feeling of dryness is marked, and there are general ly gastric symptoms and fever. Pseudo-mem- branous patches sometimes appear, and the glands of the neck may swell a little. The danger of erysipelas in the throat is lest it should involve the larynx. As soon as it does so the swelling of the parts exposes the patient to imminent suffocation. In fact, all the symptoms of laryngeal oedema occur, and the course of the disease is generally rapid, calling for immediate scarification; even when carefully done this is not always effectual, and laryngotomy becomes the only resource. Erysipelas happily does not always extend to the larynx, and when it does the attack is not always so severe. It may give rise only to subacute laryngitis with- out oedema, or without sufficient swelling to seriously impede respiration; but in the mildest cases the patient should be watched and assiduously treated. Until the ob- struction to the air-passage becomes urgent, the best local remedies are constant inhalations of a soothing character. Sometimes it may also be desirable to apply nitrate of silver to the mucous membrane of the fauces and larynx —more frequently the former. It should therefore be tried there, and the effect observed. If beneficial, it should be carefully applied within the larynx. General treatment should be carried out with energy; as in ery- sipelas affecting other parts, the patient must be supported 11 130 SORE THROAT. by nutriment frequently given, and large doses of quinine and solution of muriate of iron administered. RELAXED SORE THROAT. Chronic inflammation may follow the acute attack, or it may arise only as such, or at most in the subacute form. If this be suffered to continue without treatment it is liable to bring about the condition called relaxed sore throat. This last term is in every-day use to express different things. One means by it any of the forms of chronic inflammation, another intends merely a suscepti- bility to catarrhal attacks. It is better to restrict it to slight relaxed states consequent on repeated attacks, or to chronic inflammation. Here we have no feverishness, and the local symptoms are much milder though not more tractable. The congestion is passive. Instead of intense redness, the membrane is often paler than usual. Relaxation is, in fact, the state with which we are brought into contact. Our treatment is more various and difficult, though for the most part it is local. If there be much irritability, with dryness of the surface and an approach to conges- tion, the soothing effects of inhaling steam should be tried as a preliminary to other measures. It will often, however, merely supply moisture, the nervous irritation only yielding to a dose or two of aconite. As the local effect of this drug is as marked as the constitutional, and in these cases more so, it should be obtained. This may be done by getting the patient to gargle a moment with the mixture before swallowing it, or the medicine may be given in powders or lozenges, or a gargle too strong to RELAXED SORE THROAT. 131 swallow may be used, or the throat be painted with the tincture diluted with glycerin. When the mildest possi- ble stimulant is needed to get rid of the relaxation, astringent or stimulating lozenges or jujubes are both pleasant and effectual. Black currant jelly enjoys a pop- ular reputation, which it well deserves; for it is a mild astringent, and one of the most agreeable that can be suggested. The gargle is a more effectual application when a stronger agent is desirable; but as the liquid is not brought into contact with the whole surface, its value is most manifest in cases in which the anterior part of the velum, uvula, and pillars are inflamed. Lozenges medicate the surface during the act of deglutition. Far more effectual, however, than these is the application of medicated sprays. The modifications I have made in the apparatus make my atomizer so simple and so inexpen- sive, that this method of treatment is now within the reach of all subjects of relaxed throat. Any of the numerous forms of chronic or subacute inflammation may not only be treated for a time with it, but it may be used as a tonic to the mucous membrane. I have also had tubes fitted to the instrument, by which I can apply the spray to the anterior or posterior nares, or in fact any part of the surface. In the same way I use the pharyn- geal or nasal douche. The atomizer and the douches may be used by either patient or physician. The latter may have to resort to still more powerful methods. By means of the throat probang or camel-hair brushes, or in other modes we have described, it may be necessary to apply remedies to more or less extensive portions of the mucous membrane. This is an operation the delicacy of which depends on the part to be touched, but in all cases it must 132 SORE THROAT. be performed by the physician himself. How frequently it may have to be repeated depends on the condition of the parts and the chronicity of the case. There is a tendency to resort to it oftener than need be, and to ne- glect intermediate treatment. The regular use of the atomizer greatly lessens the need for these more powerful local applications. CONSTITUTIONAL VARIETIES --SCROFULOUS, TUBER- CULAR, RHEUMATIC, GOUTY, SYPHILITIC, DIABETIC SORE THROAT. Difference of diathesis gives rise to certain variations in the course of inflamed and relaxed sore throat. Such cases should be discriminated, and the patient treated accordingly. Local applications, although of value, will be found less efficacious than in simple inflammatory processes. Their influence is also temporary, so that we can only permanently benefit our patients by a course of treatment—dietetic, regimenal, and medicinal—adapted to their constitutions. Some of these varieties may be specified. In strumous constitutions, an inflamed or relaxed state of the mucous membrane of the throat is very frequent and apt to prove obstinate. There is the same want of intensity, the same sluggishness which the inflammatory process generally presents in the scrofulous diathesis. Not only does the affection tend to become chronic, but it is liable at intervals to take on a subacute form, and a succession of these attacks may lead to more serious lesions. Even when they are entirely removed there is a special liability to return, and it is in such patients RHEUMATIC SORE THROAT. 133 that scrofulous ulcers have been observed to develop in the throat. Local treatment alone is in such cases of little use; it may, indeed, remove the temporary incon- venience, but not the tendency to a recurrence. It is, therefore, important to distinguish these from the catar- rhal cases of sound constitutions, and direct our treat- ment to the diathesis. It is the patient more than the part that needs treatment. In phthisical persons we notice the same tendency to repeated attacks, but often there is more temporary inten- sity of inflammation, and less disposition to chronic con- gestion between them. In fact, anaemia of some parts is more commonly seen in the earliest stages of phthisis, but the tenderness of the membrane predisposes to con- gestive attacks, and it is quite probable these may lead to other changes to which the name tubercular sore throat may be more properly applied. The cases we are dis- tinguishing here belong to an earlier period of consump- tion, and are therefore more likely to come within the range of preventive treatment. Rheumatic persons are also liable to suffer from recur- ring attacks of sore throat, and a more active chronic con- gestion is in them more common than in the preceding varieties. The recurrence of the subacute or even acute attacks is greatly influenced by the weather, and rheu- matic patients of this kind are much more sensitive to atmospheric changes than the scrofulous or consumptive. There is also another form of sore throat to which the name of rtieumatic has been given, one in which the angina seems to alternate with muscular or articular rheumatism. This is a more acute affection, and pain is a prominent symptom. There is considerable swelling, and a con- 134 SORE THROAT. gested state similar to that seen in scarlatina, with dys- phagia, pain in the neck aggravated by moving the head, and rather high fever. These symptoms may disappear suddenly as rheumatism appears in another part. In the most acute condition, fomentations and inhalations may relieve the pain, though it may be a question whether cold compresses should not be applied and ice sucked. But any of these are mere measures for tempor- ary relief, and it is most desirable not to lose sight of the rheumatic character of the disease. Guaiacum is thought by many to relieve acute rheumatic cases. In the more chronic forms, or the recurrent, iodide of potassium will often afford speedy relief, and its careful use may be of lasting value. On the other hand, this drug occasionally seems to produce a subacute cynanche; that it produces coryza is well known, and, for this reason, some persons are unable to take it; we need not be surprised, then, that its effect may sometimes fall on the other portion of the mucous membrane. It may be well to mention, how- ever, that the coryza or cynanche occasioned by this drug may be readily controlled by morphia. A single dose of this anodyne will frequently arrest the catarrh caused by the iodide, which may be resumed the next day, if needful. I have used the iodides of sodium, lithium, and calcium with good effect, and the salicy- lates of these metals are also valuable additions to our Materia Medica. Other measures for the management of rheumatic patients will suggest themselves to the reader. The great point is to discriminate the cases. Gouty people are also prone to suffer from chronic inflammatory or congestive sore throat, which is greatly aggravated at intervals. It is generally recognized that CONSTITUTIONAL SORE THROAT. 135 the bronchial mucous membrane is disposed to take on inflammatory action in gouty people, and that to treat the bronchitis without reference to the diathesis is futile. So retrocedent gout is known to affect the bronchi. It might, therefore, be presumed that the other portions of the respiratory mucous tract may equally be the seat of a metastasis. But acute gout in the throat must be rare, though the chronic affection I have described may often be met with. The intercurrent subacute attacks are not so much influenced by weather as by dietetic errors. Some local measures for relieving the patient may have to be tried; and between the attacks it is also desirable to persevere in such applications as will give tone to the membrane, but suitable general treatment should be at the same time prescribed. In syphilitic patients we may have only an inflamed or relaxed sore throat as a prelude, unless properly treated, of most destructive changes; but this disease will be treated further on. Diabetic patients sometimes have a chronic relaxed sore throat with a sweetish taste in the mouth, which induced Gibb to speak of " saccharine throat" as a new disease. He thought follicular sore throat essential to this, but that is evidently not the case. Some think fol- licular disease is itself constitutional, but it is unneces- sary to allude to it here, or to other varieties of sore throat dependent on diathesis. 136 SORE THROAT. CHAPTER VI. ULCERATED SORE THROAT. This term is often applied indifferently to any case of sore throat in which the process of ulceration has taken place. This indefinite mode of expression is apt to lead to confusion, inasmuch as it associates cases which are most unlike each other. Thus ulceration is a frequent occurrence in the specific forms of sore throat. Then there are some cases of aphthous ulcers, as they are called, which Avill occupy us in another chapter. At present we have to remember that erosions or ulcers may appear on any part of the throat; the significance of their presence varying with the part in which they appear, the condi- tion which has preceded, their number, size, cause, and course. First, as to the most simple form. Erosion or ulceration, following inflammatory sore throat, gives rise to most of the symptoms of the relaxed form. The painful deglutition may not be well marked, but the hawking or coughing up of the secretion which accumulates, in consequence of the local irritation, is often distressing. Inspection displays a solution of continuity, large or small; it may be a mere breach of surface, or a deep, round, definite ulcer of any size. Cases which have for a long time passed as a relaxed sore throat, and have been treated as such, may be found, on careful examina- tion, to be ulcerated. A hasty glance may not reveal ULCERATED SORE THROAT. 137 this state, but if every care be taken to obtain a good view it will be detected. A mere glimpse at the fauces will not suffice, as ulcers may be situated where it is impos- sible to see them without artificial aid. A good light can be obtained by a reflector, and in children my speculum will assist, but the faucial mirror must be employed, as in laryngoscopy and rhinoscopy, before we can form a trustworthy diagnosis. No one would venture to diag- nose ulcer of the larynx without a laryngoscopical exam- ination, and yet it is too often forgotten that the same method of illuminating other parts may be just as ser- viceable. In the upper part of the pharynx, in the pos- terior nares, the mirror will enable us to see.such changes as may have taken place, and to apply such remedies as may be indicated. Rhinoscopy, though less practiced by many, is as important as laryngoscopy. To know the disease is often half the cure. The dexterous use of re- flected light enables us both to see and treat it, as I have often had occasion to demonstrate. Ulcerated sore throat is generally seen in cachectic patients. This cachexia may be either constitutional or acquired. We have seen how certain diathetic conditions give rise to inflammatory sore throat, and some of such cases are apt to terminate in ulceration. Tuberculous cases are, perhaps, less rare in the fauces than has been supposed. In advanced consumption we find tuberculous infiltration of the mucous membrane and submucous tissue bringing on ulceration, which is not usually extensive or deep. Small ulcers form, and when near each other may coalesce. In the pharynx they are apt to be larger and deeper, and the muscles may be in- 12 138 SORE THROAT. filtrated with tubercle. In the larynx, we not only see the disease at an earlier stage, but more frequently have an opportunity to watch it; it will be considered at length further on as a phase of laryngeal phthisis. Scrofxdous ulceration takes place in several parts, and the destruction of tissue which occurs is greater than in tuberculous. It is likely to be confounded with syphilis. Some, indeed, have attributed to that disease all the cases recorded as scrofulous ulceration. I admit, however, with Hamilton, Fougere, and Isambert, the existence of strumous ulceration, and, although the disease is rare, it deserves to be distinguished. Moreover, it is not improb- able that if this disease has been confounded with syph- ilis, some cases of the latter have been supposed to be scrofulous. The fact that some treatment may be appro- priate for both diseases has, perhaps, perpetuated the indisposition to discriminate them. Mercury will only aggravate scrofula, though this is true of some cases of syphilis also. Iodine or its salts are indicated, and cod- liver oil. Iodoform, both locally and internally, is the most valuable remedy. As we may have in the throat scrofulous, tuberculous, and syphilitic ulcerations which are not to be distin- guished without great care, so in the nasal cavity the same may occur. Tuberculous ulceration of the nose is, how- ever, so rare as to be almost unknown, while scrofulous ulcers are tolerably frequent. They give rise to one form of ozaena. They may penetrate deeply into the tissues, and are then likely to be mistaken for syphilis. This may not be familiar to all, but it is certain that even injury to bone is not sufficient to enable us to positively assert that syphilis is the cause. In the nose, too, foreign ULCERATED SORE THROAT. 139 bodies have been discovered by the rhinoscope as the source of ozaena when syphilis has been positively diag- nosed. Lupus of the throat is usually seen simultaneously with its appearance on the nose or face, but sometimes it invades the throat first. It may cicatrize without great loss of substance, or it may give rise to extensive de- struction of tissue, followed by contractions or adhesions. In the larynx lupus is not so common, but it is more fre- quent than many imagine. Herpetic ulcers should also be discriminated. Their history, or the coexistence of catarrh, often slight fever- ishness, will assist the diagnosis. Their appearance, too, is generally less indolent; in fact, they look irritable, as they are, and suggest soothing inhalations, which are appropriate. They come in clusters, and may occupy the pharynx, pillars, tonsils, velum, etc., but are most com- mon on the roof of the mouth. Little ulcers similar to these often occur on the tongue. The treatment of ulcerated sore throat must vary with its nature. In acute cases it will sometimes be necessary to adopt the most active measures; especially is this the case in sloughing ulcers, or in rapidly spreading syph- ilitic ulceration. In such cases the rapidity with which important structures may be destroyed makes it desirable not to lose a moment in bringing the most potent agents into play in order to avert the progress of the disease. In the most urgent cases, nitric acid or acid nitrate of mercury should be applied, and active general treatment pushed with vigor. In less urgent cases milder appli- cations, such as nitrate of silver, may suffice. After the 140 SORE THROAT. action of the caustic, soothing inhalations will comfort the patient. Chronic ulceration requires a course of treatment, gen- eral and local, of the most varied kind, according to the variations of the case. If there be much irritability, anodyne inhalation may be the first measure, and this will often cure herpes. In other chronic forms a topical stimulant may be needful. Solution of nitrate of silver is, perhaps, the most commonly used, but other sub- stances— astringent, stimulant, or escharotic—are often preferable. The applications may be made with brushes, probangs, or cotton-wool, according to the position of the ulcer. If few and large, it will be better to make the application to the ulcers only, and solid substances may be best for this purpose. If, for any reason, it be unde- sirable for a time to employ such treatment, fumigations of iodine, and occasionally of mercury, will be found very valuable, and in other cases a resort to them, be- tween the use of caustic, will materially hasten the cure. But, important as is topical treatment, other indications must not be overlooked. It is true, the ulcers may be healed over by local appliances, and the sore throat called cured; but there will be a great disposition to a return, and the patient is really little better for his cure. He may suffer less annoyance; he may fancy himself well; but he carries about a constitutional taint, which may on the slightest exposure renew all his symptoms, or put a period to his existence by inducing consumption or some allied disease. Of course the general treatment will vary with the prescriber's opinion of the constitution he has to deal with. A mistake here will frustrate all his in- tentions and disappoint all his hopes. Often, too, every ULCERATED SORE THROAT. 141 form of tonic he may think suitable will prove vain unless he prepare the system to receive them. Not only so, the patient will declare, and quite truthfully, that all his medicines " disagree;" mischief, rather than benefit, will accrue. 142 SORE THROAT. CHAPTER VII. GRANULAR OR FOLLICULAR SORE THROAT--CLERGY- MAN'S SORE THROAT. Inflammation often seems to affect most the lacunae or crypts, and sometimes it is confined to them from the beginning. These follicles appear to take on a low form of inflammation ; they gradually enlarge, become distinct red points, and in course of time ulcerate. But the prog- ress of the disease is exceedingly slow; the follicles may remain for months or years inflamed and hypertrophied before actual ulceration occurs. All this time the inter- vening membrane may be scarcely affected, generally it is relaxed, or a state of congestion of a venous character gives it a dark, unhealthy look, or the congestion may be more active, or erosion may take place over the surface. Thus we may have all the varied appearances dependent on chronic inflammation and its consequences. This, commonly called clergyman's sore throat or vox clericorum, is the follicular disease of the late Dr. Horace Green, who devoted a volume* to its elucidation, and the angine granuleuse or glanduleuse of Chomel and other French writers, who attributed it to herpetism. We em- ploy the word herpes in quite a different sense, and in this volume I have carefully discriminated between her- petic and follicular disease. To the praiseworthy zeal of Op. cit. granular sore throat. 143 Dr. Green, who bestowed almost unlimited labor on the subject, we are indebted for the first elaborate description of follicular disease in the several portions of the mem- brane. In devoting himself exclusively to the pathology of the follicles, he seems almost to ignore the rest, of the surface. Without for a moment wishing to disparage his labors, the author thinks it right to state that experience teaches us that the intervening membrane frequently is primarily attacked with inflammation, which involves the follicles secondarily—a lesson in pathology which anatomy and physiology might have taught us ct priori to expect. French writers assign the merit of first teaching the na- ture of follicular disease to Chomel, who, according to Noel de Mussy,* was accustomed to describe it in his clinique for several years before Dr. Green. He also seems to have publishedf an account of it some six months before Dr. Green. As those were not the days of rapid communication like these, the American physician could not have been indebted to the work of the Frenchman, but we must award them equal praise for having worked out the subject independently of each other. Granular or follicular sore throat being only the result of inflammation of the follicles, may attack any part of the membrane where such recesses exist. It is most com- mon in the pharynx, especially on the posterior wall, but often seen also on other portions of the faucial membrane. It is not so frequent in the larynx, and some—as Dr. Mandl—do not admit that it attacks that organ. On the other hand, Reinhard describes it as common in the * Traite de l'angine glanduleuse, Paris, 1857. f Gazette Mddicale de Paris, 1846. 144 SORE throat. bronchi, and says he has seen it on the minutest ramifi- cations when surrounded by tubercularized lung tissue, and he thinks that disintegration of tuberculous lungs proceeds from this kind of ulceration destroying the wall of the bronchus. Niemeyer indorses this view, so far as regards caseous pneumonia. Green describes the disease as extending not only to the bronchi, but to the oesophagus as well. I see no reason why it should not attack any part provided with follicles. All admit that it is most common in the pharynx, the posterior wall of which is very apt to exhibit this disease. It generally begins there ; only rarely will it commence on the soft palate or uvula. More frequently it occurs on the upper pharynx, but there we require the rhinoscope to see it. It may seem to take its start from an ordinary inflamed sore throat—acute or chronic—or it may arise independently. It is also apt to appear in the course of other diseases of the respiratory mucous membrane, from which circum- stance no doubt arose the supposition that follicular sore throat is a disease intimately associated with consumption. I have described follicular inflammation as chronic, because this form is so frequent that authors have scarcely noticed any other. It is right to add, however, that I recognize acute folliculitis, and subacute cases are scarcely rare. The morbid process proceeds more rapidly in acute cases. In place of indolent hypertrophy we often see suppuration. The small abscesses thus formed leave ulcers behind, and such cases, unless recognized and prop- erly treated from the first are apt to prove very obstinate. Even when ulceration is prevented by timely treatment, the acute is liable to end in the chronic form, hyper- trophy of the follicles remaining. As long as this lingers granular sore throat. 145 subacute attacks are likely to occur, each one aggravating the case; therefore our utmost efforts must be directed to re-establish a healthy condition of the follicles and give tone to the intervening membrane, so as to prevent the case degenerating into the more tedious disease. The diagnosis is easy; we have only to look into the fauces and see the prominent follicles—red and angry- looking, or paler, or yellowish, according to the contents of the enlarged follicles, which may be mucous or puru- lent. The intervening membrane may be nearly healthy, or display the signs of inflammation and its results. It is no uncommon thing to see enlarged vessels coursing over it, amidst a surface either clogged with viscid secre- tion, or preternaturally dry. In other cases the whole membrane appears to be in a state of intense active con- gestion. In others again it is deprived of its epithelium and the surface resembles raw beef with numerous prom- inent points upon it. These may be, in some stages, of a deeper color—more commonly they appear paler, or whitish, or yellowish. They are, in fact, little pustules formed by suppuration of the inflamed follicles. Some of the appearances are well seen in Plate I, Fig. 1. The symptoms vary greatly. The patient may suffer no inconvenience, and the disease be discovered by acci- dent. On the other hand, he may be so distressed that his life may seem a burden. Between these extremes we have every variety. Generally, at the beginning a sen- sation of dryness or tickling is present, or there is a constant desire to " clear up," to hem, or even to cough, occasioned by a feeling as if a particle of secretion were lodged, and required an effort to get rid of. From the persistence of the sensation the patient may acquire the 146 SORE THROAT. habit of frequently clearing up before he is aware of it. Preachers are prone to this, and often the habit becomes established, to the discomfort of the congregation. In private life, too, a constant hemming may make a man a nuisance to his friends before he seeks advice. There may be very little expectoration, and scarcely any cough, but the patient is susceptible to atmospheric influences, and every fresh catarrh increases his troubles, as it in- volves fresh follicles. Sometimes, however, there is more expectoration, and this may be tinged with blood and alarm the patient. The voice is usually altered in tone, its purity lost, and its use becomes fatiguing. These points are marked in public singers, teachers, and others who use the voice much, but where that is not the case, may be overlooked, or the patient will attribute his state to repeated attacks of hoarseness, the voice being more affected each time he takes a cold. There is no doubt that the constant " hemming " irritates the mucous mem- brane, and aggravates the case. Seeing how different are the conditions comprised un- der the term follicular sore throat, it is not surprising that the remedies required are very various, and that those most useful in one case may be injurious in another. While we must modify our measures with the constitu- tion of the patient, we must not neglect the distinct local lesion, even though it may be limited in extent, and in an early stage. Some physicians try to trust entirely to general treatment, others send their patients to a warm climate. Continental writers generally advocate mine- ral waters, especially those containing sulphur. It is not to be denied that many diseases may be shaken off when the patient is placed in the most favorable hygienic con- GRANULAR SORE THROAT. 147 ditions, for which reason no doubt relief is often obtained in this way, but it is seldom either complete or perma- nent. After the local disease has been cured the patient may be greatly invigorated by a visit to a suitable health- resort. Alterative, tonic, or other appropriate remedies, according to the indications, may be prescribed while the local lesion is being subjected to suitable topical treat- ment, This may embrace any of the measures recom- mended in inflamed, relaxed, or ulcerated sore throat, the selection depending on the condition of the membrane at the time. In the early stage the disease will be found under this plan more tractable than is generally supposed, but relapses are apt to occur, and therefore preventive measures should be enjoined on convalescents. Chlorate of potash, chloride of ammonium, bromide of potassium, the permanganates and many other sub- stances may be employed in various forms—the best perhaps being in spray. The persistent use of the atom- izer will, in fact, if the solution be judiciously selected, lengthen the intervals at which it is necessary to have recourse to stronger remedies. If the follicles continue to enlarge in spite of milder remedies, or if there be much granulation, perchloride of iron may be tried, and a solution of this salt as a spray is useful in other cases. If general hypertrophy or thickening have taken place, iodine may be more success- ful ; solution in glycerin is preferable to the tincture. Iodoform can be used solid or in solution. • Hypertrophied follicles will disappear under the per- sistent use of judiciously regulated treatment, and ulcer- ation may be removed, though it often leads to ulterior changes. Horace Green and others have relied almost 148 SORE THROAT. exclusively on nitrate of silver, and few agents have so wide a range of action, but its indiscriminate use is to be deprecated. The effect varies with the strength. Ac- cording to the indication it was intended to fulfil, and the condition of the part to which it was to be applied, I have employed solutions from 2 grs. to 60, and some- times 120 to the oz. The solid salt, fused on the end of a probe, may be used to touch individual follicles or ulcers. Strong caustics have been used in the same way, but it is to be feared have done more harm than good. At any rate, they should only be used with great circum- spection. To destroy tissue the galvano-cautery as used by Carl Michel, and the actual cautery, again proposed by Dr. Foulis,* may be resorted to, but I have not often found that destruction of tissue is desirable. Still less frequently would it be rjght to pass a cautery knife over the surface, as recommended by Riesenfeld.f It may sometimes be of use to scarify individual granulations, or to open small pustules, but this is not often the case. * Glasgow Medical Journal, October, 1877. f Lancet, August 11th, 1877. APHTHOUS SORE THROAT. 149 CHAPTER VIII. APHTHOUS SORE THROAT—MOUTH AFFECTIONS. The conditions which have been grouped together under the general name " aphtha " bear an intimate rela- tion to our subject, since not only may they involve the throat, but they form the connecting-link between its diseases and those of the mouth. The several kinds of stomatitis so common in children, are the exact counter- parts of forms of sore throat originating in inflammation ; and the one may therefore be made serviceable in ex- plaining the other. The simple catarrhal form of in- flammation of the mucous membrane of the mouth is not uncommon, and sometimes we see inflammation in this cavity put on the distinctly follicular form which has been described in connection with the throat: hence follicular cynanche has been called aphthous sore throat; but inasmuch as the word aphtha has been used in other senses, it is better not to apply it thus, but to distinguish this disease in the mouth as follicular stomatitis. When a crypt has suppurated, it presents just the same round ulcer, with all its varieties in appearance; and the treat- ment will be conducted on the same principles, whether the disease be in the mouth or throat. Ulceration in the mouth is more often aphthous than follicular; we see it involve considerable portions of the mucous membrane, both in children and adults, most frequently in the form of numerous small ulcers, more 150 SORE THROAT. or less inflammation occupying the surface between. Thus it would appear as if the ulceration were but a stage or result of catarrhal inflammation, but in other cases the latter process can scarcely be said to exist. It has indeed been denied, but perhaps the slightest degree has been overlooked. After some premonitory inflam- mation, or even before complaint of this has been made, little white patches surrounded by a red margin appear. They look like specks of exudation, which some believe them to be. They have been spoken of as vesicles, but should be distinguished from them. These aphthae, as they are called, produce erosion, which may soon heal over or leave deeper ulceration. A more serious aph- thous ulcer is seen at the junction of the hard with the soft palate. Here slight congestion is soon followed by ulcer- ation, which, though usually superficial, sometimes pene- trates to the bone, and in either case is apt to prove obstinate, often continuing until death. These cases are most frequently seen in foundling and lying-in hospitals. The effect of mercury in the mouth seems to be pro- duced by a process analogous to that which gives rise to aphtha, and the same may be said of the idiopathic stomacace. Sloughing may come on in these forms of aphtha, but is not often seen in sound constitutions. Gangrene may occur in the mouth as well as in the throat, but care should be taken not to confound with either sloughs or gangrene, aphthous ulcers, on which blood has been effused and decomposed. The treatment of aphthous sore throat is similar in principle to that of the same disease in the mouth. In mild cases cleanliness and the use of a mouth-wash and » AFFECTIONS OF THE MOUTH. 151 gargle of permanganate or chlorate of potash may suffice. In severe cases where ulceration has occurred, the aphthae are to be treated locally according to the indications, and the chlorate is to be freely administered internally. In mercurial stomatitis and in idiopathic stomacace 5 to 10 grains every three or two hours, or even more frequently, will soon overcome the fetor and produce a favorable local change. A child of two years of age may consume 20 or 30 grains daily properly diluted and at frequent intervals. It may relax the bowels, but that will do no harm. In follicular ulceration, or when ulcers succeed- ing aphthous specks seem to get sluggish, a mild stimu- lant may be required, such as a solution of nitrate of silver, and occasionally it may be as well to touch an ulcer or two with the solid substance, but these ulcers are seldom indolent; they are usually irritable, and such treatment is painful. Under the timely use of chlorate of potash aphthae generally only produce erosion, and the epithelium is rapidly replaced. This fact should deter us from one of the prevailing errors,—overtreatment of a topical kind. It is positively cruel to be too energetic with roughly applied irritants, and yet this is daily seen. Nurses, and mothers too, rub the tender and inflamed membrane of infancy with borax and honey; and rub it hard and frequently—a practice which few adults would suffer to be perpetrated on them ; and almost unneces- sarily, and for the most part mischievously. If stimulants be needed, there are others which are far better. In infants, careful management of the diet is all-powerful, and the local means must be the simplest, such as ablu- tion and the remedies mentioned. A mucilaginous decoction, with some chloride of lime, is highly prized 152 SORE THROAT. by M. Guersant,* who uses this remedy also in enemata in preference to lime-water, and topically instead of solu- tions of borax, or zinc, or alum. Sloughing ulcer and gangrene following aphthae, of course, require the most energetic treatment, both local and general. With every attention, they prove very fatal.f They should be distinguished from noma, a form of gangrene in the mouth which appears to come on with- out any inflammation preceding it. It attacks the inside of the cheek, which it often rapidly perforates. Rare in England, but more common in France and Holland, it is from French and Dutch observers we derive the best descriptions of it; Isnard is very graphic.^ It is mostly observed as an occasional sequel to the exanthemata; in strumous children it is often accompanied by a very seri- ous gastro-enteritis. In lieu of chemical caustics, M. Barron§ makes a crucial incision on the external surface of the cheek, and through this opening applies a wire at a white heat. * Diet, de Medecine, Muguet. f Billard, 'Traits des Maladies des Enfans. % Dissertation sur une affection gangreneuse particuliere aux enfans. § M6m. sur une affection gangreneuse de la bouche, Bulletin de la Faculte, 1816. FUNGOUS SORE THROAT. 153 CHAPTER IX. FUNGOUS SORE THROAT--THRUSH. Another most interesting disease in reference to our subject is also more common in the mouth, and chiefly affects children. This is thrush or millet, the muguet of the French, the soor of the Germans. It is essentially a parasitic disease, depending on the growth of the oidium albicans, and should be distinguished carefully from aph- tha, although that name has often been given to it. So aphthae have been called thrush, but it would be well to confine the word to this parasitic disease. Even this, however, often begins as a slight catarrhal inflammation of the mucous membrane, or there may be only slight congestion, or scarcely perceptible hyperaemia. It may indeed be impossible to state more than that there is un- usual dryness or a trifling soreness. When the mouth is parched and hot, either in early infancy or in adult patients who are sinking from chronic exhausting dis- eases, we may anticipate that the membrane is about to be invaded by the oidium albicans. There is always some deviation from the healthy condition of the mem- brane before the parasite appears—and the secretions of the mouth always give an acid reaction. Probably the fungus does not find a suitable nidus or appropriate nutri- ment in the ordinary moist membranes of health, besides which it may be removed too readily to allow it to grow. 13 154 sore throat. After the dryness and soreness have lasted an indefi- nite time small white points or patches appear on the membrane. These spread and coalesce until in severe cases a complete creamy deposit covers the mucous membrane. The deposit comes off in due time, and leaves the part beneath inflamed or perhaps eroded. Professor Berg* first proved the constant existence of this cryptogamic vegetation in the deposit. Whether the parasite consti- tuted the disease, or was merely developed in a sort of exudation caused by inflammation, was long in dispute, but it is now generally admitted that parasitic thrush is a distinct disease dependent on the presence of the oidium albicans—a kind of fungus which grows very rapidly in depraved secretions of an acid reaction or even on preter- naturally dry mucous membrane. The development of the fungus is also greatly favored by decomposing food, especially milk and sugar. It is not surprising that muguet is infectious, as proved by M. Berg, who transplanted the sporules of the fungus to healthy mucous membrane, thereby communicating the disease, an experiment repeated by others; and in a sense, often carried out on a large scale in foundling in- stitutions, where nurses are negligent as to cleanliness, and the promiscuous use of cups and feeding-bottles, and, above all, india-rubber teats propagates the disease. It is easy to understand from what has preceded why this fungus should find its first lodgment in the mouth. But now and then it begins in the throat. It spreads in all directions over the squamous mucous membrane, on which alone it appears to thrive. Hence in aggravated Ueber die Schwanimchen der Kinder. FUNGOUS SORE THROAT. 155 cases, though it does not descend into the larynx, it covers the whole pharynx and oesophagus as well as the mouth with a thick white deposit, which may acquire a yellow color, or may be stained with blood. The deposit may resemble a false membrane, but on microscopic examina- tion will be found almost entirely composed of the spor- ules of oidium albicans, or these may be mixed with de- praved secretion or with epithelium. In severe cases there is gastro-intestinal derangement; constant diar- rhoea, the stools being acid in reaction, green, and offen- sive. Under this the child soon wastes away. It used to be thought that this was due to the disease occupying the stomach and bowels; but although it appears some- times at the anus, the oidium, as we have said, only thrives on squamous epithelium, and therefore cannot extend beyond the oesophagus, which it sometimes quite fills. It is for the same reason that thrush does not in- vade the nose. Of course large quantities may be swal- lowed, and therefore found in the stomaeh, but that is very different from being formed there. The statements made respecting the nature of thrush, and the fact that it is a disease of the first weeks of in- fancy, or which attacks adults towards the close of ex- hausting diseases, go far to establish a rational mode of treatment. The first thing is to keep the mouth clean, and in infants this will suffice. If the baby be allowed to go to sleep as it is fed, the milk remaining in its mouth supplies fresh nourishment for the fungus. If the mouth be gently washed with water or a very feeble alkaline lotion, or a weak solution of permanganate, the fungus will soon disappear, and the mucous membrane put on a healthy appearance. I have repeated above my old pro- 156 SORE THROAT. test against borax and honey. It is true that in these cases the borax would be useful alone, because of its al- kaline reaction, but the saccharine element favors the de- velopment of the oidium, and should therefore be avoided, as I argued twenty years ago. A solution of this salt, or better still, of carbonate of soda or potash, from 10 to 20 grains to the ounce, is a much better preparation. In severe cases, where the enteric complication has begun, it is a common practice to apply a solution of nitrate of silver, sometimes the solid substance, to the part of the diseased membrane which is accessible. The value of the practice is by no means commensurate with its fre- quency—is perhaps altogether doubtful. It would be more rational to increase the strength of the alkaline washes or use chlorate of potash. But, indeed, when- ever spoon-fed children are thus attacked the one remedy is a healthy wet-nurse. When this can be obtained even desperate cases, carefully managed, will soon recover. The natural food and absolute cleanliness, and the avoidance of sugar and anything likely to undergo acid fermentation, will snatch many a child from the brink of the grave. The measures advised for infants will also be a com- fort to those dying invalids who are troubled with thrush. They will often be able to wash the mouth and gargle even when both are sore. As soon as dryness or sore- ness is complained of it is well to begin this treatment as a preventive. EXUDATIVE SORE THROAT. 157 CHAPTER X. CROUP AND DIPHTHERIA—EXUDATIVE SORE THROAT. We have now arrived at the exudative form of sore throat, some features of which have already been de- scribed. In the mildest cases a few flakes form on the fauces, without giving rise to very serious consequences; but such instances are exceptions, and the presence of a single flake must be regarded as of grave import, for this exudation is the characteristic of the two serious and fatal diseases treated of in this chapter. In croup, the exuda- tion endangers life, both by inducing spasmodic closure of the glottis and by mechanically impeding the entrance of air into the lungs; the patient dies suffocated; in diphtheria it is associated with intense depression of the vital powers, such as we see in malignant fevers, and speaks plainly of blood-poisoning; the patient dies ex- hausted. These distinctions are sufficiently marked in typical cases; but in others, as already shown (p. 39-44), there is a tendency for each group to run into the other, and no doubt this it is which has given rise to the nu- merous discussions as to the identity or non-identity of the two forms of exudative disease. The belief that croup is but a form of diphtheria, though not generally accepted in Germany and England, has long been a common tenet in France, and as such must be familiar to every one conversant with French 158 SORE THROAT. medical literature. Even in this country it is no new doctrine, for nearly twenty years ago, in the first edition of this work, as in the present, croup and diphtheria were grouped together under the head of exudative sore throat, in accordance with which, it was stated that " both are alike the manifestations of an inflammatory condition tending to exudation,"—exudation being regarded as the " characteristic of this variety of inflammation." The late Dr. Hillier soon afterwards adopted* the doctrine, which was subsequently embraced by Dr. G. Johnson,f M. Mackenzie,! and others. Dr. R. H. Semple, the translator of Bretonneau's Memoirs, has long maintained a similar view, and more recently Sir William Jenner§ has pronounced himself " inclined to think that the two diseases are really identical." This opinion he repeated and enforced at the debate on the subject which took place this year at the Royal Medical and Chirurgical Society. The report of the committee, which gave rise to that discussion, recommends that the word " croup be hence- forth used wholly as a clinical definition, implying laryn- geal obstruction, occurring with febrile symptoms in children." This definition corresponds with the manner in which the word is constantly employed; but it in- cludes conditions which it is desirable, though often diffi- cult, to discriminate. If any laryngeal obstruction, in a child, attended with fever, ought to be named croup, no wonder we are told that this disease " may be membran- ous or non-membranous," for signs of obstruction may be * Medical Times and Gazette, April 26th, 1862. f British Medical Journal, February 19th, 1870. % Ibid., March 5th, 1870. | Lancet, January 2d and 16th, 1875. EXUDATIVE SORE THROAT. 159 set up in children, and in adults too, though less readily, by any form of laryngitis; traumatic cases being specially remarkable. On the other hand, diphtheria may run its course without affecting the air-passage; or exudation may, at any period, invade the larynx and so bring about obstruction. The German school, following Virchow, restrict the term croup, or croupal inflammation, to cases in which the epithelium is alone involved; in these, where the membranous exudation is detached, the epithelium is rapidly reproduced and no loss of substance remains, con- sequently no scar. The term diphtheria, or diphtherial inflammation, is then to be understood as implying that the exudation extends deeper into the tissues, where it produces pressure, wdiich is intensified by the swollen state of the tissues, thus interrupting the blood supply, and bringing about sloughing of portions of the mucous membrane. These are thrown off on the surface with the exudation, and the consequent loss of substance leaves a scar. Now the former condition is most common in the air-tube, and seems to be set up in the trachea and larynx of children by causes which in adults produce catarrhal inflammation. The latter condition occurs in the fauces, but mostly only in connection with a profound general change in the system, and to the two are given the name diphtheria. If the exudation extend to the larynx, it is often croupous, but assuredly the distinction is not so great as has been represented by many of the German school, for in cases of undoubted diphtheria attended by the signs of malignancy and typhoid, and followed by paralysis and albuminuria, the fibrinous (croupous) exudation has been seen to lie on the surface 160 SORE THROAT. of the membrane, nowhere penetrating its epithelium. This distinction, therefore, must be given up, or it must be admitted that croupous inflammation may set up the constitutional symptoms of diphtheria; while, then, we cannot point to any anatomical differences between croup and diphtheria, the two affections form sufficiently clear clinical groups to warrant us in speaking of each sepa- rately. CROUP. The word croup, a popular term in Scotland for certain sudden seizures in children, was adopted by Dr. Francis Home in the first treatise on the disease,* and has passed into several languages to indicate acute exudative inflam- mation of the larynx and trachea. Cullen called it cynanche trachealis. Other names are—angina stridula, cynanche suffocativus, etc. Bretonneau uses the expres- sion, " diphtherite tracheale." The disease was not, how- ever, new in Home's time. It was mentioned as croops by Dr. Patrick Blair, in a letter to Dr. Mead in 1713, and that it had existed, and had even been recognized before, is clear, from the remarks of various authors, e. g., as Baillou, who, as early as 1576, indicated its pathology; Molloi, 1743; Malain, 1746; Ghisi, who called it an- gina strepitosa, 1747 ; Starz, who named it morbus stran- gulatorius, 1749; Middleton, 1752; Bergius, 1756; Rud- berg, 1755; Berghen, 1759; Wahlbom, 1761; Wilcke, 1764. Still, several affections of the throat were largely confounded with the acute exudative inflammation of * Inquiry into the Nature, Cause, and Cure of Croup, by Francis Home, M.D., 1765. CROUP. 161 the larynx and upper air-passages, accompanied by fever, occurring in children, to which it is desirable to restrict the word croup. The modern history of the disease dates from the epidemic of 1805-7, to which a nephew of the first Napoleon fell a victim. The emperor, thereupon, offered a prize for the best essay on the disease; to this incident we are indebted for many good works. The report* on the essays submitted will amply repay pe- rusal. Croup mostly commences as a catarrh, but often so slight as to be overlooked until the more urgent symp- toms excite alarm, and call to mind the cold the child had. Very commonly the severity of the attack occurs in the night; and, throughout the disease, nocturnal exacerbations are liable to take place. Cough and dysp- noea of a peculiar noisy character are the main features. The inspiration is very difficult and loud,—stridulous it has been called,—and compared to the sound a fowl makes when caught hold of. At first the cough is dry, but soon a viscid expectoration is brought up, containing films or flakes. The exudation is, of course, fluid at first, but its coagulability soon manifests itself. Some- times it is of creamy consistence, at others it forms solid tough patches or layers, which may extend over the membrane of the larynx, trachea, and bronchi. The little patient is in constant danger of suffocation. The expectoration will vary with the consistence of the exu- dation and the tenacity with which it adheres to the membrane. Sometimes it is only thick creamy stuff * Rapport de la Commission sur les ouvrages envoyes au Concours sur le Croup, Paris, 1812. 14 162 SORE THROAT. with shreds or flakes, at others larger layers come away, and not seldom complete casts of the tubes are brought up. The voice, as well as cough and breath, is croupy, and this often shows the first departure from health, and gives an early warning of the impending danger. There is sympathetic fever. The false membrane is formed in the larynx and trachea, and sometimes all along the smaller bronchi. It varies greatly in thickness. The thickest part is usually at the entrance, where, according to Hasse,* it never exceeds three lines, diminishing in density as it descends. Patches are seen now and then in the throat, and may descend into the oesophagus. The affection seems almost always to travel downwards, and consequently the morbid appearances are most constant in the larynx, then in the trachea, and lastly in the bronchi. Dr. Porter, f indeed, seems to have met with cases that took a contrary direction (ascending croup); but both Hasse! and Rokitansky§ support the view stated above. Climate and epidemic agencies influence the progress of croup greatly. In healthy country places it is mostly sthenic, and the exudation spreads over a larger surface, and is more dense, while in the asthenic form met with in large cities the opposite appearances are found. In favorable cases the exudation is cast off, and the mucous membrane beneath soon recovers—the epithelium being rapidly reproduced. In other cases new layers of * Anatomical Description of Diseases of the Organs of Circu- lation and Eespiration. (Sydenham Society's Edition.) f Su gical Pathology of Larynx and Trachea. X Op. cit. § Pathological Anatomy. CROUP. 163 false membrane succeed each other until the tendency is exhausted, or the patient succumbs to the incidental dan- gers. These are the consequences of the obstruction to the respiration. The symptoms, then, are first of all those of catarrhal inflammation in the air-passages, and chiefly in the larynx. Upon these are superimposed those caused by the process of exudation. When that obstructs the glottis we have the most terrible dyspnoea, and when there is yet suffi- cient space for the air to enter, we may have most violent attacks of glottic spasm, caused by the foreign body— the false membrane. The respiration is not only exces- sively laborious, it is carried on by engaging every muscle which can help to expand the chest in most violent con- traction. The noise, too, is characteristic, and the poor child's distress most piteous. Restless, terrified, haggard, it seeks first to be taken up, then put down; it feels the obstruction in the throat, and will sometimes try to tear it away in an agony for wrant of breath, which is truly heartrending. If no relief be obtained, a new set of symptoms—those depending on carbonization of the blood—will soon take the place of these. If the false membrane be removed, immediate calm will succeed the storm, and the child may fall into a tranquil sleep. Re- covery may begin here, or an exacerbation may awake the patient to a renewed struggle for breath. Sometimes inflammation, evidently of a croupy nature, produces only a small amount of exudation. The scanty exudation may be due to expectoration of the lymph as rapidly as it is exuded, yet such an explanation seems insufficient, as aphthous ulcers in the mouth are frequently associated with this variety. Another set of cases have 164 SORE THROAT. been distinguished as pseudo-membranous laryngitis, and the distinction is insisted on by Guersant,* as well as by Bouchutf The symptoms are more like those of laryn- gitis, and the expectoration contains at most but a few shreds, and these are never renewed. In true croup, according to these observers, the membrane reforms as soon as it is detached. Dr. John Ware,t of Boston, U. S., separated from membranous croup a form in which no exudation occurs, though the symptoms are the same; this he called inflammatory croup. In twenty-five years he met with 131 cases which he considered croup, but found membrane to exist in only twenty-two, and of these last nineteen died—figures which show that mem- brane is comparatively rarely found, but when present is excessively fatal. As to the inflammatory cases, we may perhaps suppose that in some only a small quantity of exudation was formed and rapidly expectorated, or more probably swallowed; while others, perhaps the majority, were simple catarrhal laryngitis, in which it is common, as already shown, to find signs of laryngeal obstruction. The narrowness of the infantile larynx, and the tendency to spasm in children, are most important factors in croup. The small glottis of a child is easily obstructed; out of the body it may be completely closed by a powerful suc- tion at the trachea. Hence the danger of laryngeal diseases in children. Even in catarrhal laryngitis, signs of obstruction may be produced by the congested, puffy, perhaps cedematous, condition of the mucous membrane. * Diet, de Me lecine. f Traite Pratique des Maladies des Enfans Nouveaux-Xes, et des Enfans a la Manielle. X Contributions to the History and Diagnosis of Croup. croup. 165 W hat, then, can be anticipated, when in such a case extra secretion—perhaps thick, tenacious, and stringy—is poured out? Such secretion, if it do not block the larynx, may provoke spasm. If the secretion be thicker still, a solidifying exudation or a false membrane, it may completely line the air-tube and so contract its calibre as to give rise to symptoms of obstruction; or ,it may—a more common event—become detached partially and entirely, and play the part of a foreign body; as such, it may mechanically block the air-passage, or bring about the same result by provoking fatal spasm. These cir- cumstances give rise to serious difficulties in diagnosis, but they illustrate our position, that the primary disease is inflammation of the mucous membrane, and that its results are determined by several circumstances. In one case abundant tough exudation is present, and suffices to account for all the symptoms. In another no distinct membrane is expectorated during life, and none is dis- covered after death ; and yet the symptoms have been similar. Nowt, this is usually ascribed to spasmodic clos- ure of the glottis, which is more easily brought about in the child than in the adult. It is unquestionable that laryngeal spasm may be fatal, but it is not often so in the first attack, and then the disease is characterized by dis- tinct intermissions. At the same time we must not forget that there are remissions in true exudative inflammation, as the membrane may be expectorated or removed from the narrow chink of the glottis. There is, however, another condition the opposite of spasm, which is as likely, according to Schlautmann and Niemeyer, to occur, and which would account for many cases. This is paralysis of the muscles which open the 166 SORE THROAT. glottis. Rokitansky has shown that the pale, infiltrated, relaxed state of the muscles points to paralysis rather than spasm, and, in fact, all muscular tissue is liable to be thus injured by inflammation. In croup the inflam- mation is severe, and extends through the membrane to the submucous tissue. The muscles beneath have even been found sodden from infiltration. If, then, the crico- arytaenoidei postici be paralyzed, wre have the same result as a spasmodic closure of the glottis, so far that we have inability to open it, though we may often see at a glance that false membrane is present. The attempt to deter- mine these conditions by means of the laryngoscope can only be made during a remission, and in children it is not likely to prove very successful. It may, therefore, be well to remark that, when the glottis is mechanically narrowed, the entrance and exit of air are both impeded, so that both inspiration and expiration are laborious. But in paralysis the air in expiration forces the glottis open without muscular effort, while in inspiration there is obstruction, since as soon as the air in the trachea is rare- fied the vocal cords come together, and the incoming cur- rent does not separate them; hence in paralysis inspira- tion alone is laborious. Thus we have three sources of dyspnoea,—the mechanical, spasmodic, and paralytic. This is no mere useless refinement. He who can best find out the conditions presented in a given case will be able best to decide on what to do and what to avoid. The complications of croup require skilful ausculta- tion and percussion, and it is the duty of the physician to watch for the first indications. Bronchitis is in some stage almost sure to be present, and perhaps fewer es- cape pneumonia than is generally supposed. One sound TREATMENT OF CROUP. 167 masked as it is to a great extent by another, will be liable to deceive all but well-educated ears. It scarcely enters into our programme to go into these details, but we may remark that much more exact knowledge than most men possess may be gained by attentive listening, both in simple and complicated cases, provided the rationale of physical diagnosis be kept in view, and pathognomonic ideas cast away. It is desirable in every case to form an accurate opin- ion on the patient's state, and the natural difficulties of the physician are often increased by his only being called in at a late stage, and then obtaining but an imperfect history. He must first satisfy himself that the impedi- ment to respiration is situated in the larger air-tubes, and that any accompanying states are complications, although these greatly influence his prognosis and treatment. The next step is to ascertain the presence or absence of false membrane. If exudative inflammation be once proved to exist, this fact ought not to be lost sight of for a mo- ment. True croup comes on more gradually than the spurious form; it continues to get worse in spite of mani- fest remissions. False croup comes on very suddenly, soon reaches its height, and is characterized by perfect intermissions. This cannot take place in the more serious affection. The presence of fever will not be overlooked in a diagnostic view. Treatment of Croup.—In respect to treatment, two points demand constant remembrance. First, the sudden onset and rapid progress point out that no time is to be frittered away. Second, the naturally remittent nature of the disease must not lead the attendant into the error of relaxing his vigilance, and encouraging the ill-founded 168 SORE THROAT. joy of anxious parents, soon to be plunged into bitter disappointment; nor into the equally dangerous fallacy of repeating remedies which appeared to arrest a former paroxysm. Perhaps it is forgetfulness of such points which has made all specific directions for the treatment of this disease bad in themselves, mere treatment by rule only hastening the catastrophe. For this reason too much detail will be avoided here. In former editions the author spoke in rather strong terms of the teachings of certain textbooks respecting bloodletting. During the period which has since elapsed he has seen a gradual but constant approach to the views he expressed nearly twenty years ago, and for which he was at the time subjected to some adverse criticism. There are but few now who practice venesection in children. Even leeches are less frequently used than formerly, although many still recommend them in cases where there is much inflammation and fever runs high in robust chil- dren. Although local depletion may moderate hyperaemia in the neighborhood, it is now generally admitted that it cannot arrest the process of inflammation; still less can it prevent the formation of exudation. It may, however, debilitate the child, and in puny patients it is not jus- tifiable. No doubt the excessive congestion which some- times occurs in this disease may bring about infiltration of the tissues and aggravate the danger; and it is, per- haps, by temporarily restraining this congestion that leeches have seemed to so many practitioners to render important service. This, then, remains the only plea for their use in robust patients. I notice that Steiner is of my opinion in this matter; he has never seen any benefit derived from leeches. If used they should not be put TREATMENT OF CROUP. 169 over the larynx, because there it will not be possible to arrest the bleeding by pressure. The usual spot is over the manubrium sterni. Emetics fill a most important place in the treatment of croup, but not as antiphlogistics or revulsives, still less as specifics. They often enable a child to bring up false membrane which he could not expel by his own efforts. For this mechanical purpose they are indicated when false membrane is acting as an obstacle to the breathing and cannot be coughed up; the impediment to expiration is of great value as a sign of this. It will be seen, there- fore, that full emetic doses must be given, and when the drug selected does not operate another must be used, or other means resorted to in order to excite vomiting. A good deal of false membrane is often brought away by this act, which may be excited every two, three, four, or six hours. The emetic most frequently resorted to is perhaps anti- mony, which also enjoys a reputation as an antiphlogistic. But we have seen that this is not the object of emetics; nor is their recognized diaphoretic action. Moreover, the depressant effect of tartar emetic ought not to be forgot- ten, nor its tendency to produce diarrhoea. In delicate children for this reason ipecacuanha is often preferred, but it is less certain and rapid in action. It is, perhaps, a perception of these differences which has led many to combine the two with good effect. If antimony be decided not suitable, or, as will now and then happen, if it will not excite vomiting, other emetics may be tried. Where there is want of tone, sul- phate of zinc is very valuable, and may be combined with ipecacuanha, or given alone. Sometimes it may be 170 SORE THROAT. advisable, when emetics fail to act, to add to them stimu- lants, which often cause them to operate. Occasionally mustard or ammonia in strong decoction of senega may be tried. Sulphate of copper has been highly extolled, and its small bulk renders it easy of exhibition, but it is a powerful poison. Alum is very much relied on by Dr. Meigs.* An emetic always at hand, and generally ef- fectual, which I recommended twenty years ago, is com- mon salt. It has an undoubted chemical effect on the exudation, so that it will be likely to detach any mem- brane located in its passage to the stomach. It may, too, be absorbed and exercise some effect through the blood. At all events it will never do harm. A little mustard added to it combines a saline and stimulant emetic of great use, in obtaining which there will be no delay. Vomiting may sometimes be provoked by topical appli- cations, just as when we tickle the fauces for that express purpose. Time is so often against us in these cases that those having the material at hand will not need to be reminded of the emetic power of hypodermic injections of apomorphia. From what has preceded, it will be seen that there is nothing in favor of giving nauseating doses of antimony or other emetics between the acts of vomiting. The practice, still sometimes pursued, perhaps from the idea of its antiphlogistic power, is fraught with danger. Such doses not only debilitate, but frequently frustrate the intention of the larger ones, by rendering the stomach more tolerant of them. Mercury was long believed to have the power of ar- * Diseases of Children. TREATMENT OF CROUP. 171 resting croup, and now many who scarcely credit it with this think well to administer it. On the use of this drug the German school is as divided as the English, for while Oppolzer condemns it as only likely to produce diarrhoea, debility, and ptyalism, Niemeyer sanctions it. Those who follow the old plan will do well to suspend it during the exacerbations, and give the emetic which is most indi- cated, or they can use mercurial inunction. Counter-irritation has provoked much difference of opinion. The practitioner will bear in mind that chil- dren are tender, and will not wish to distress them when he can help it. Here, perhaps, is the place to mention the remedy which above all others no one can find a fault with, pro- vided it cure; it was proposed by Dr. Lehman, of Tor- gau, and its efficacy was relied upon by the late lamented Graves, of Dublin. It consists merely in the application of hot water by means of a sponge, squeezed half dry, and held close to the skin covering the larynx and tra- chea. As it cools, it is to be changed for another in readiness. In ten or twenty minutes great redness exists, perspiration occurs, and relief of cough and breathing. Dr. Graves considered he saved several patients by this method, but that it is only applicable to cases seen at the onset; obviously it could have no effect on membrane already formed. There is, however, one antiphlogistic which is highly prized by the German school. Both Niemeyer and Steiner are convinced of its value, and it has long been in use with certain practitioners. This is the local application of cold; cold compresses to the neck afford the readiest mode of bringing this agent to bear, and the medical 172 SORE THROAT. man will do well to apply the first himself, in order to instruct the nurse how to do it properly. Where a bladder and ice are at hand, dry cold can be used. It should be observed that the use of cold to the neck does not interfere with warmth to the general surface, still less with vapor to the mucous membrane. Cold cannot move plugs of exudation, nor is it to be continued when as- phyxia impends; it has no power to prevent poisoning by carbonic acid retained in the blood. Tracheotomy is still a mooted point. It is not to be denied that an artificial opening into the air-passages will prolong life in cases of obstruction to the free entrance of air above such opening, nor that in many cases of croup such obstruction is the immediate cause of death. So far as this point is concerned, it does not even matter that the aperture is not constantly closed by lymph, for it may easily be sufficiently obstructed to cause asphyxia; besides which it may be said that, in consequence of the irritation produced by the foreigm substance, spasm fre- quently completes this closure. By tracheotomy, pro- vision is made for the admission of air when the exuda- tion does not extend too low down; but this too frequently happens. Even then, however, the operation may suc- ceed ; besides, able observers are of opinion that trache- otomy tends to arrest the morbid process. It cannot be said to cure croup, but it provides a passage for air, and thus prevents the patient from being asphyxiated by closure of the glottis. So emetics do not cure croup, but by removing false membrane the act of vomiting often saves life. When this removal cannot be accomplished, and the glottis is becoming closed, what can be more rational than to admit the vital fluid through an artificial TREATMENT OF CROUP. 173 opening below the seat of obstruction ? The operation has been too often looked upon as the last resource, and therefore postponed until death had too evident a hold on his victim. If an opening is to be made at all, let it be early enough; at the same time, many will think that cases thus cured might have been tractable under ordi- nary measures. In private practice, several causes will combine to delay it longer than is advisable. The oper- ation, when it fails to save life, renders death easy and painless. Parents who dread such a procedure will not hesitate to give their child the chance it affords when they learn that nothing else can be done; and that, even if it be without avail, their darling will be saved the horrors of a death-struggle most painful for any one to witness, and, instead of in a scene they dread to con- template, sink peacefully and painlessly into the final slumber. Although suggested by Home in 1765, this operation was first performed by John Andr6, in London, in 1782,— at least this is the earliest case that remains on record. In 1818 M. Bretonneau performed it, but his patient died. In 1X24 he tried it again with the same result. In 1825, notwithstanding his previous failures, he once more resorted to it, and this time success crowned his efforts. Since then numerous patients have been sub- jected to the operation, of whom about a fourth have recovered. For a time Trousseau seems to have saved half his patients. Steiner's mortality has varied, in dif- ferent periods, between 60 and 70 per cent. Others men- tion about the same; but Greve, of Sweden, speaks of only 23 per cent. But are there no less terrible means at our command 174 SORE THROAT. than the inflictions hitherto discussed ? Without for a moment wishing to lessen the promptitude with which the disease is met, we venture to say, Yes. We may en- deavor to dissolve, or at least render less coagulable, the false membrane; or, failing this, we may remove it me- chanically. The application of the vapor of hot water is most sooth- ing to the lining of the larynx. It is obvious that inha- lations in the usual way would be a matter of considera- ble difficulty for children. Moreover, in such a disease as croup, the respiration is so impeded as of itself to consti- tute an objection, both to the sponge and the inhaler. It is easy, however, for the little patient to be kept in a warm, moist, uniform atmosphere. For this purpose, as urged by me twenty years ago, the temperature must be kept much higher than is usual in any sick-room. Moist- ure, too, when employed, must be in proportion. The patient is to be kept, as it were, in a vapor-bath, though in the early stage it may be found that hot air alone is more effectual; or, in some cases, impregnated with steam, in others not. It is not to be supposed that vapor thus used will remove the exudation, which we know is insol- uble in water; but the presence of moisture and warmth during formation may modify its consistence or its tenac- ity, and experience encourages us to follow up what is so soothing. Moreover, we may make the vapor a vehicle for chemical agents intended to act upon the exudation. This is simple enough with volatile substances, but in the case of fluids we may avail ourselves of the atomizer to distribute the remedy, in the form of a fine spray, through the apartment, or through the inclosed space where the little patient lies. With very young children such a TREATMENT OF CROUP. 175 space may be formed by blankets suspended round a large bed, the steam and spray being supplied regularly. In this case it is necessary to look after the ventilation, which is apt to be forgotten. The patient needs a continual, free supply of fresh air, however warm and saturated with vapor and spray it may be. Care should be taken to convey it continually into the room, and thence behind the blankets. It seems reasonable to expect relief; and the sponge to the throat, topical applications to the mem- brane, and, indeed, all the other remedies which have been recommended, may be used at the same time. There is nothing new in the principle of this treatment. For a long time it has been customary to keep the room warm, and even to add some moisture, by means of a kettle kept on the fire, with a long tube attached to its spout to conduct the steam into the apartment. But such a course is insufficient. What I recommend is, that the heat and moisture be increased to a much greater extent than occurs in this way. To produce an effect on the skin, the temperature must be greatly increased; to get the effect of the vapor on the exudation, the air is to be saturated. The slaking of successive portions of lime has lately been resorted to as a ready means of carrying out this treatment, and some of the lime-water thus formed is thought to pass into the air and act on the false membrane. When this plan fails, we may still attempt the mechan- ical one. When false membrane endangers life why should we hesitate to wipe it off, and apply local reme- dies to the inflamed mucous surface beneath? It is quite practicable to do this in the case of the larynx. In pre- 176 SORE THROAT. laryngoscopic days this procedure was recommended* by the late.Dr. Horace Green. Some of his contemporaries would not admit that his applications entered the larynx ; but now that we have been for years accustomed to see and demonstrate to others the steps in difficult operations within the larynx, it is no longer necessary to reply to those who doubt the possibility of doing what all skilled in laryngoscopal therapeutics find an easy feat. Local remedies are intended either to dissolve the false mem- brane, or act on the mucous surface. Of the former, lactic acid and lime-water are most esteemed, and should be used before resorting to the others, of which nitrate of silver is the chief. Chloride of iron, tincture of iodine, alcohol, chlorate of potash, and other drugs have their advocates. In using them the mechanical effect of wiping off the exudation should not be forgotten; and though firmness of touch is needed, the utmost gentleness is es- sential in dealing with the sensitive, inflamed larynx of an infant. False Croup.—A few words must be added on false croup, crowing inspiration, or laryngismus stridulus, as it has been called, since serious errors in diagnosis, tend- ing to improper practice, have been made. A little care will distinguish the two affections. False croup is essen- tially a spasmodic ailment, whatever may be the exciting cause of the spasms; consequently it is not accompanied by sympathetic fever, and wheifthe paroxysm has passed the respiration is free. It is not half so important to distin- guish the varieties of croup as to separate them all from * Observations on the Pathology of Croup; with remarks on its Treatment by Topical Applications, New York, 1849. FALSE CROUP. 177 purely nervous disease. Croupal symptoms in laryngitis, in tracheitis, in laryngo-tracheitis, and the pseudo-mem- branous laryngitis of M. Guersant, may be looked upon as one disease. It is well, indeed, to know, not only the existence, but the extent of exudation ; but it is far more important not to confound an inflammatory with a ner- vous affection. In the latter, the temporary obstruction to the inspiration may be greater than in true croup; the cry, when the air enters, louder; but it does not exactly counterfeit the stridulous inspiration of the narrowed tube. This cry, however, of itself is not sufficient to dis- criminate a case; for in true croup the passage may be only slightly diminished. There are often convulsive symptoms in the false variety—so often, that many have looked upon them as a necessary part of the disease. It is intermittent; the paroxysms are very short, and fre- quently occur at night. For a long period it was known to attentive observers that the seizures called false croup might be produced in various ways. It was conjectured, too, that many of the cases grouped under that name might be due to spasm of the muscles which open the glottis, or to paralysis of those which close it. The laryngoscope enables us to say that either of these conditions may exist in adults as well as children. In rickety and scrofulous children, and in those of a highly nervous disposition, spasm of the glottis is easily excited by various causes. Thus, in some such subjects, laryngeal catarrh seems to be the starting-point of this disease, every little cold they take exposing them to a fresh series of paroxysms. These are the cases most likely to be confounded with true croup, but there is only temporary—or, so to say, momentary—obstruction to the 15 178 SORE THROAT. respiration. One remove further from croup—in appear- ance—we get a number of cases difficult to generalize, excepting so far as that they are instances of ailments in children in which spasm of some part of the respiratory apparatus is the prominent symptom. One case will re- semble the catarrhal affection, another borders on whoop- ing-cough, a third, to some extent, asthma. Yet in all these the disease is spasmodic, and may be produced by any irritant to the laryngeal nerves. Thus we may meet such attacks in the course of consumption, of bronchocele, of enlarged glands, or any tumor in the neighborhood. A form caused by enlarged thymus, and called thymic asthma,—very rare,—has attracted attention. Some would add the various causes of convulsive attacks. (See the chapter on Laryngeal Neuroses further on.) DIPHTHERIA. This disease, named by Bretonneau diphtherite, from dtyOipa (membrane or skin), attacks adults as well as chil- dren, but does not necessarily affect the air-passages. In diphtheria the exudation occupies the fauces, and is con- sequently within the range of vision, but it may extend down the air-passages, constituting croupal diphtheria, or diphtherial croup. It is accompanied by intense depres- sion. The fever is of the lowest type. Death occurs more frequently by asthenia, the patient not often being asphyxiated, as is so common in croup. Some of the most distressing circumstances of that disease are, therefore, ab- sent, except in the mixed forms. A very mild form of exudative angina has already been noticed. It is most frequently seen during epidemics of the more formidable DIPHTHERIA. 179 species. Perhaps its mildness is due to the vital power being able in some constitutions to resist the effect of the morbific element. But this must not throw us off our guard, for diphtheria often begins with slight symptoms. A little dulness, a hebetude, some loss of appetite per- haps, a chill, or an uneasiness in swallowing, may be the only warning. In other cases nausea, or even vomiting, with sore throat, may precede the appearance of exuda- tion. But so insidious is the disease that it is only rarely seen by the medical man before some few flakes have appeared in the fauces. At this period a child will per- haps continue to play, or an adult to work with little diminution of energy. Nevertheless, there is danger, for although very mild cases recover rapidly and leave no ill-effect behind, they may at any moment become severe or put on the most malignant form. When, therefore, a person is known to have been ex- posed to the contagion, or when the disease is epidemic, we may feel suspicious of every slight sore throat, espe- cially in weakly people—or when there is adynamic rather than sthenic fever. Let then the glands of the neck be examined, for they are often enlarged very early without much pain. Sometimes stiffness, or pain in the neck, may be the first complaint made by the patient. Luschka has pointed out that the glands lying about the bifurcation of the carotid are in immediate relation with the lymphatics of the soft palate. It should not, however, be forgotten that the cervical glands are liable to enlarge in ordinary inflamed sore throat, and, therefore, the diagnosis is not certain until exudation appears. After that no doubt re- mains, and cases in which only a small quantity of mem- brane forms may run a rapid and fatal course. Even 180 SORE THROAT. when there is no loss of substance perceptible,—no slough so to say,—and the exudation does not become offensive, it is by no means sure to prove a mild case, and the sequelae may be as formidable as in cases beginning with more urgent symptoms. In these, at an early period there is foul breath from putrescence of the exudation— the glands are very large and hard, but do not suppurate. Death may occur early from syncope or general collapse. When exudation takes place in the larynx the symptoms and course will be modified—the case is, as it were, a combination of the two diseases, croupal diphtheria. When it invades the nasal passages other symptoms arise, and these cases, very distressing and very fatal from septi- caemia, are sometimes grouped together as nasal diph- theria. A thin irritating discharge from the nostrils is a serious symptom in. all cases of diphtheria, for which it is well to be on the lookout as the precursor of further trouble. Many attempts have been made to distinguish the exu- dation of diphtheria by the microscope. The discovery that thrush depended on a parasite naturally stimulated the search in this direction for the cause of diphtheria, and the late Professor Laycock, as early as 1858, having met the oidium albicans in a case which he considered diphtherial, was inclined to regard that fungus as the effi- cient cause of the disease. But in his case the appearance of exudation supervened on a lengthened illness, and may probably be regarded as an aggravated case of thrush oc- curring during an epidemic of diphtheria. At any rate it cannot be called a typical case of the disease; and more recent observations seem to show that diphtheria is an- tagonistic to the presence of the oidium albicans. In DIPHTHERIA. 181 1868 Oertel, Huebner, and Buhl almost simultaneously announced that they had found certain forms of bacteria in the exudation of diphtheria, as well as in the subjacent tissues, and even in the blood of their patients. Since then they have strenuously maintained that diphtheria is essentially a parasitic disease. According to them, with- out parasites there can be no diphtheria. The organisms they describe are exceedingly minute, and mostly belong to the bacteria of Cohn. One in particular, sphaero-bac- terium—the micrococcus of Oertel—is always present. It is accompanied in lesser numbers by the bacterium termo, a rodlike organism. Other forms are also sometimes seen. It is obvious that if these bacteria be the sole cause of diphtheria, we may distinguish this disease by the microscope, as Oertel and others declare they can, and the influence of the theory on practice is also important. With regard to the benign organisms—oidium, spirilla, leptothrix, etc., so constantly present in the mouth, Oertel says he has seen them disappear on the advent of the deadly diphtherial vegetation, and only return after the departure of the micrococcus. The last, therefore, ap- peared inimical to the others. Moreover, the bacteria are said not only to abound in the exudation, but to penetrate the tissues beneath, and find their way into the blood. Of late years a considerable number of observers have embraced the parasitic theory of diphtheria, but it is by no means universally accepted. The question is of prac- tical importance in reference to the infectiveness of the disease, respecting which very diverse views have been maintained. All epidemics present difficulties in inves- tigating this property. That every exudative inflamma- tion is contagious I cannot admit; but that this special 182 SORE THROAT. form may thus be propagated is not, we know, improb- able. Bretonneau strongly maintained that it had this property. Yet he declared its contagiousness far less energetic than that of other diseases. It has often failed to spread by direct implantation of the exudation; but, on the other hand, it has more than once appeared to do so by an accidental inoculation, several medical men having fallen victims to such an occurrence when per- forming tracheotomy. Trousseau and Peter actually inoculated themselves with diphtherial exudation, and no effect followed; still this experiment does not prove that the disease cannot be so communicated. Some other persons, having too much respect for themselves, inoculated dogs aud other animals without results, but Trendelenburg and Nassiloff after- wards proved the possibility of infecting animals by in- oculating the trachea and the cornea. Nassiloff, together with Oertel and Hueter, described the appearance of the bacteria after such inoculation, and maintained that their presence was necessary. If this be admitted we may rationally conjecture that, when the inoculations failed, those organisms were not preseut in the exudation em- ployed, or else they did not find a suitable nidus. In the former case it would be said that the cases yielding the morbid product were croup, not diphtheria. The exudation, though more adherent, is generally less solid than that of croup. Indeed, all exudations appear to be firmer in proportion as the inflammation is of a sthenic kind; the least dense are those of the lowest epi- demics of diphtheria, In these, large quantities of serous fluid, and even of blood, are often poured out. The exudation thereby disintegrated mixes with fluid and DIPHTHERIA. 183 detached sloughs, the Avhole in a state of decomposition forming abundant discharges of a most intolerable odor. The glands of the neck early enlarge, and abscesses often take place in their neighborhood. These traits suggest that diphtheria must be to a great extent a blood disease. No mere local lesion gives rise to such a formidable train of symptoms, and the consequences which often follow point in the same direction. Various complications are likely to arise in the prog- ress of diphtheria. Haemorrhage from the nose, throat, and air-passages is not uncommon. Pulmonary compli- cations must be watched for throughout. Albuminuria, first noticed by Dr. Willoughby Wade,* is present at an early stage in about a third of the cases, and may also come on later. It is, however, a transient phenomenon, and does not seem to increase the danger. The glandular swelling may call for unremitting attention. The most remarkable sequel of diphtheria is the paral- ysis. This comes on often after convalescence has seemed established. It usually begins in the throat, and displays a remarkable tendency to occupy successive groups of muscles, ultimately perhaps involving the whole body. As soon as the voice becomes nasal, or deglutition im- paired, attention must be given to the danger. Soon food will return through the nose, or remain in the throat, or find its way into the air-passages and set up inflammation. The paralysis involves both motor and sensory nerves, and may become complete, when the ingenuity of the attendant will be exercised to provide for nutrition and avoid the incidental dangers. If these * Midland Quarterly Journal of the Medical Sciences, April, 18.r>x. 184 SORE THROAT. be safely surmounted recovery usually takes place, the several muscles being restored in the order in which they become affected. Treatment of Diphtheria.—The nature of the disease being kept in mind, we shall not confine our attention to either local or constitutional treatment, but avail our- selves of both. All depressing remedies are to be avoided, and the treatment had better partake of a supporting character as soon as the least indication appears. On this principle, if emetics be given, sulphate of copper, mus- tard, or ammonia with senega, will be selected in prefer- ence to others. Where a decided stimulant does not seem so imperative salt may be tried. It has all the benefits of saline remedies, and may be used while support and tonics are given in the intervals. Chlorate of potash may be tried by those who have faith in it, and recently some fresh testimony has been adduced in its favor, but other drugs are more to be re- lied on. Dr. Willoughby Wade combines it with iodide of potassium, and, where this last drug was vigorously pushed in five or ten grain doses every two or three hours, he reported unusual success, with no subsequent paralysis. Perchloride of iron has seemed more effica- cious to others, and may be given in combination with quinine; it has also been applied locally. The main indi- cation for constitutional treatment is to keep up the pa- tient's strength. This is to be attempted by nourishment in every form that ingenuity can devise—by quinine, bark, stimulants, and all the other means used in equally dangerous diseases. Detailed instructions for conducting the case will not be expected here, especially as our liter- ature teems with suggestions. DIPHTHERIA. 185 Much good may be effected by local measures. Ni- trate of silver has been successful with not a few, and perhaps too exclusively used. Stronger caustics, includ- ing the mineral acids, have also been used. Bretonneau used undiluted muriatic acid. As an application incap- able of doing the mischief of these, but probably quite as efficient, I formerly recommended a strong solution of salt,—brine. Other remedies seem more effectual in prac- tice, and are shown by experiment to have more power to dissolve the exudation. The alkalies and the organic acids are the best for this purpose. Of the first kind is lime-water, of the second lactic acid. I have more ex- perience of the latter, which I have applied in gargle or with a brush, or in spray by means of the atomizer, ac- cording to circumstances; the lime of the former seems likely to be rapidly converted into carbonate by the respiration, orjo be acted upon by the secretion. Still more simple is the use of steam. In treating of croup I have explained my view of the value of vapor. I insisted on this in all exudations in the first edition of this book published in 1861. It has lately been advised as the outcome of German medicine. Now that this homely remedy has been invested with the glamour of German theories, I am in hopes it may obtain more at- tention than when it was thus urged from the clinical standpoint of the English school of medicine. I confess that I was not led to its use by reflecting on its " pyo- genic properties," nor am I sure now that all its value is to be summed up in the power of warmth to quicken the formation of pus, and so lead to the false membrane bcino- thrown off. I was content to show that it soothed, that it assisted the removal of the exudation—which If! 186 SORE THROAT. seemed to be got rid of and even broken down under its influence,—that it never did the harm which caustics and other irritants sometimes seemed to do, and that it could be used in conjunction with other remedies. I may, there- fore, well feel satisfied that my clinical deductions are borne out by the profoundest theorists, and that even the leader of the parasitic doctrine has embraced my practice as the best of all. I ought perhaps to feel the more satisfied, since this is only one out of several instances in which my teaching has passed over to Germany, and having there received what we must perhaps call the official stamp of this generation, has been afterwards adopted at home. The disadvantage of this custom to our own English school—which certainly bears the palm for clinical, if not for hypothetical work—is that during the time thus lost in procuring a foreign stamp, some patients may be deprived of the benefit of really native ideas. It is when the air-passage is implicated that the pro- priety of tracheotomy must be mooted; but much as the success of this operation seems to depend on the opening being below the seat of exudation, it has undoubtedly saved life where this was not the case. No one would open the air-tube unless the impediment to inspiration seemed likely to be fatal. The operation can have no power to prevent death by asthenia. But there are many cases in which tracheotomy offers an additional chance of life. It is more frequently resorted to on the Conti- nent than in England. The statistics of the Ste. Euo-gnie Hospital, Paris, show that 2312 operations of trache- otomy were performed during twenty-two years, with 509 recoveries. In the hospital for sick children in Paris, DIPHTHERIA. 187 2351 patients were operated on in twenty-five years, with 614 recoveries. In all the hospitals of France, taken collectively, the average recoveries are about thirty per cent. Dr. Kronlein has recently furnished a report* of all the cases of diphtheria admitted to Von Lano-enbeck's Hospital from January 1st, 1870, to July 31st, 1876. There were 567 cases, of which only eight were adults. The mortality gradually sank from 76.7, in 1870, to 60.3 in 1876. Tracheotomy was performed in 504 of the cases, of which 357 died, the mortality falling in the latter part of the time; but whether this depends on improved after- treatment, or abatement in the virulence of the epidemic, is doubtful. In 1876 the mortality was 60.3 per cent. There were eleven recoveries in children of the first and second years, the youngest being only seven months old, so that it would appear that the operation may save life in these unfavorable cases. It should be observed that tracheotomy fulfils only one indication, and that besides the necessary after-treatment, which is of vital importance, other measures are to be employed with the same diligence as before the operation. It is also possible to apply local remedies through the tube. When the operation is refused we can only per- severe in such means as are available, the most desperate cases having occasionally been saved. In nasal diphtheria, local measures should be had re- course to from the first appearance of any discharge from the nostrils—weak disinfectant, and sometimes astringent liquids being frequently employed. * Langenbeck's Archiv, bd. xxi, heft. 2, 1878. 188 SORE THROAT. CHAPTER XL EXANTHEMATOUS SORE THROAT. The whole of the mucous membrane is liable to be affected in the eruptive fevers. The gastric as well as pulmonary portion is often seriously implicated. Chronic diarrhoea, from ulceration in the bowels, and phthisis and chronic bronchitis, are among the sequelae of this class of diseases. In measles and scarlet fever is most manifest the complete upset to the system; the patient droops and declines after either in much the same way. The physi- ognomy is somewhat diagnostic between the two. The most important eruptive fever is scarlatina, but the others deserve mention. For the most part, the eruption seems to extend from the skin. The affection of the mucous membrane usually commences with an erythem- atous congestion, and then proceeds to put on the dis- tinctive form. In small-pox the eruption very often spreads to the mucous membrane of the mouth and throat, and presents precisely the same appearance as in the skin, but besides the pustules, when distinct, there is the inflammation of the intermediate surface. The pituitary membrane may also suffer in the same way, though perhaps both nose and fauces are more often highly inflamed with a very few or no pustules. There is so much discharge in such cases that the nostrils are often quite blocked. The probability SMALL-POX. 189 that this statement is the correct one is increased by what we see in the eye. The conjunctiva is almost always in- flamed, and there is copious secretion and great sensibility to light. Sometimes a pustule forms on the ocular con- junctiva, and leads to ulceration and destruction of the cornea. The larynx and trachea suffer in this way to a considerable extent, The throat symptoms come on about the sixth day. Inspection then shows the inflam- mation of the mouth, nose, and fauces. There will be excessive flow of saliva, coryza, difficulty in swallowing, hoarseness, dyspnoea, and other symptoms corresponding with the part most affected, and these symptoms will in- crease in severity. Tiirck* watched the development of pustules in the larynx in the earlier days of laryngoscopy. It was previously known from post-mortem research that they formed in the larynx and trachea. There is, how- ever, no doubt that the laryngeal and tracheal symptoms depend on the acute deep inflammation. Indeed, oedema of the larynx may occur as the most formidable compli- cations, and the results of the deep inflammation of the air-passages may remain even when recovery occurs. Further, pustules have occurred in the rectum, and it has been conjectured may be present along the whole alimen- tary tract. There is no reason why any individual part should not be attacked, though we can scarcely picture a patient surviving such an extent of the disease. We see, too, that even the genito-urinary mucous membrane very often suffers in this dire disease. I have not met with any proof that in this case it is pustular. Varioloid erup- * Klinik, p. 180. 190 SORE THROAT. tions, as well as true small-pox, may be complicated with sore throat. In measles we observe inflammation of the respiratory mucous membrane from the very commencement and often throughout its extent. The alimentary lining is also very generally in an irritable state, and this often passes into severe disease. The peculiar character of the ailment is not more distinctly marked in mild cases, being only a state of inflamed sore throat; but in severer cases it puts on a more definite appearance : the fauces become dusky and livid, and that in distinct patches, which on careful investigation are observed to present appearances similar to the cutaneous rash. Sometimes exudation may take place, leading to pseudo-croup, or even without this there may be occasional attacks of spasm of the glottis. From this liability of mucous membrane to suffer, we see in every bad epidemic what are called the compli- cations of measles,—tonsillitis, pharyngitis, laryngitis, tracheitis, bronchitis, parotitis; indeed, inflammation in any part terminating in all its forms, from resolution to gangrene. But the feature of the disease is rather the extent of a superficial inflammation of the respiratory tract,—a true catarrh of the air-passage. The pituitary membrane suffers from the first, so often does the conjunc- tiva. Hence with what is called a severe cold in the head—a true rhinitis—the child has watering of the eyes, a bloodshot condition of the lids and globe, and increased sensitiveness to light. Backwards the catarrh takes its way, and spreads over the whole faucial surface, but it has not skipped over the frontal sinuses, and the patient has headache, or pain, or fulness in this region. Hoarse- ness supervenes, and the larynx can be seen to be in- EXANTHEMATA—SCARLET FEVER. 191 flamed in the mirror. The disease spreads along the trachea and bronchi if it have not earlier infected them ; and then there is tightness or stuffiness of the chest, quick respiration, and on auscultation the signs of bronchitis. Very often the state of bronchial catarrh appears so early that it looks as if all the mucous surfaces involved were attacked at once. It may be conjectured that sometimes the alimentary membrane thus suffers, for pain in the epigastrium, nausea, and vomiting are not uncommon. But measles should always be regarded in reference to the air-passages. One other portion of mucous membrane is of momentous importance,—that lining the Eustachian tube and tympanic cavity. Deafness often appears early, but much more serious ear symptoms may be present. Numerous cases of permanent deafness are to be traced to this cause. Scarlatina is by far the most important disease of this class in relation to sore throat. The connection between the angina and exanthema has only been established in modern times, and therefore we find the elder writers speak of the eruption as part of malignant sore throat, putrid sore throat, ulcerous sore throat, etc. The iden- tity of many of these cases with scarlet fever is so obvious we shall not enter into the arguments. Suffice it to say, however, that, in our pride of modern progress, we are too apt to neglect such men as Fothergill and Huxhani, who although unable to trace the connection of the dis- eases as we have, did undoubtedly hand down to us most accurate descriptions of the epidemics they witnessed, and whose works now remain, and will well repay attentive study. Very great variations are observed in the course of the 192 SORE THROAT. complaint, We see in one case the skin disease most manifest; in others, that of the mucous membrane. Oc- casionally the throat is the only sufferer. Again, we find measles and scarlatina exhibit a tendency to run into each other ; and consequently a number of cases are grouped ^together which are in some points very dissimilar. The relations between these two eruptive fevers being very intimate, systematic writers have been put to no small trouble to lay down their differential diagnosis. The hybrid forms have been erected into a distinct variety under the name of Rubeola notha, Rotheln, or German measles. In scarlatina, after rigors and pyrexia, the patient usually complains of sore throat, but not invariably, and the soreness is seldom in proportion to the mischief. There may be hoarseness or some variation of voice; hawking, but more often an unpleasant sensation, or pain in swallowing. The whole of the throat is of a vivid rose red, hot and tender. The tongue partakes somewhat of this state, partially disguised by the fur of the fever, through which the enlarged papillae project, giving it the appearance of " strawberries." Now and then the throat, though much affected, gives no pain; and the patient will declare, on your wishing to inspect it, that there is nothing the matter with it. The tonsils suffer to a very great extent; frequently the disease seems to be a malig- nant tonsillitis and pharyngitis. On the tonsils and over the palate and pharynx thickened mucus may be seen which gradually becomes firmer, and flakes of a mem- branous character, exactly resembling the exudation of diphtheria, also appear. Some hold, indeed, that a pro- cess of deep true exudative inflammation occurs in severe EXANTHEMATA--SCARLET FEVER. 193 cases, while others think this is only in epidemics of diph- theria. These flakes certainly consist of detached epithe- lium, mixed with blood and abnormal secretion of the parts, and they leave ulcerated or even gangrenous patches of mucous membrane. In this there is then a strong re- semblance between the two diseases. Effusion into the submucous tissue takes place and interferes with deglu- tition, and sometimes with respiration, even before some of the other more serious changes occur. The nose and ears are both involved, purulent discharges pouring from both passages. The nose may be in some cases occluded, or most offensive discharges may proceed from it, but in milder cases this part of the membrane often escapes. Whenever coryza appears it is far from a favor- able sign. The ear is much more likely to be affected from the pharynx. The inflammation spreads along the Eustach- ian tube, and as in the throat the symptoms may vary from those of a slight sore throat to the most malignant, so here there may be merely temporary deafness or ear- ache, or the inflammation producing these may increase so as rapidly to destroy the function of hearing, and spreading to the brain prove fatal. Scarlatina is one of the most common causes of otitis, otorrhoea, and perma- nent deafness. It is, perhaps, natural that in the anxiety for life in severe cases the ear should receive little atten- tion ; but in mild cases it is most desirable that practi- tioners should pay attention to the first symptoms of otitis, and even anticipate them; many lives might thus be relieved of the burden of deafness. In malignant cases, necrosis of the bones of the ear, and abscess of the brain, may occur. In these, too, it is that rapid 194 SORE THROAT. sloughing of the tissues of the throat may occur, then the glands become attacked, and the surrounding structures of the neck; suppuration and ulceration or sloughing may then occur. In the first case pus has forced its way into the chest; in the others the great vessels have been opened, and thus a sudden termination put to the case. Even in mild cases the salivary glands enlarge and become tender, and suppuration is threatened in the cellu- lar tissue around them. The cervical glands may be similarly affected. Pain at the angle of the jaw, or stiff- ness should always excite attention, and swelling accom- panying these will be a cause for anxiety. Gangrene is the most serious form the sore throat can assume. Of course, the symptoms vary according to the position in which the fearful changes are hurrying on. It is plain from what has preceded that scarlatina may exhibit all the appearances of sore throat, and all its va- rieties, from a very mild up to a most fatal one; so that the physician has in this complaint an extensive and in- teresting field for observation and comparison. The other differences are just as great, scarcely incommoding one patient, and soon destroying another by the fever alone. It is believed that in some cases the fever kills before there is time for a rash to appear, in others none exists. Probably many cases have a slight rash which is not ob- served ; and I have found it by searching, when friends were very positive no such thing could be seen. What is most important to remember is that the mildest form may rapidly put on the most malignant type. This renders it necessary cdways to be guarded in prognosis. A most innocent-looking hyperaemia of the throat in a EXANTHEMATA—SCARLET FEVER. 195 person who has been exposed to the contagion of scarlet fever should be regarded with suspicion. If the tongue put on the characteristic " strawberry " appearance it is still more ominous. Yet such an attack may pass away rapidly and occur repeatedly in the same person. I have known medical men who always have this when attend- ing cases of scarlet fever, and am myself prone to such attacks under these circumstances. The consequences of the exanthemata are those of blood disease ; secondary haemorrhages occur; even purulent deposits sometimes form ; the blood after death is semi- coagulated. The whole mucous membrane shows the effect of the disorganization. The heart, kidneys, and other viscera are softened. I have shown that otitis is very serious, both as to its immediate and more remote effects. Coryza of the most distressing kind, scarcely arrested by injecting the nostrils with powerful lotions, may cause as much suffering as more fatal complications. Haemorrhage from the mouth or nose, indeed from any part of the membrane, or some other lesion of this tissue, may speedily terminate life. Gangrene of the lips may take place. Congestion of the brain or lungs may appear. The poison circulating in the blood seems to arrest the whole vital powers and disintegrate the living tissues; at least in malignant scarlatina some death-agency seems to penetrate every part of the system. Even in later stages the danger is not over. Convalescence is long before it is really established, and this is as true in the mild as in the malignant form. Anasarca, or some other species of dropsy, often seizes a patient who flattered himself he was well. In fact, acute desquamative nephritis is so frequent a complication 196 SORE THROAT. that some authorities look upon it as a part of scarlatina. The renal disease may appear during desquamation, and even before this should be watched for. There may appear sometimes albuminuria, as inmost fevers; but here it is most ominous, and the urine should be exam- ined carefully in all cases of scarlet fever at frequent intervals, even after apparent convalescence. With re- gard to our subject, the dropsy may affect not only the subcutaneous but the serous membranes, and sometimes the submucous tissue of the larynx. The health is always so shaken that the convalescent is susceptible of every morbific influence. Diseases following this or any of the exanthemata will consequently put on a more adynamic form, and require some modification of their treatment. The sore throat of scarlatina does not often spread down the air-passages, but the larynx, trachea, and bronchi may all be involved, and when oedema of the larynx is produced that becomes the most urgent symptom. The tonsils, when they have not been destroyed, usually remain hy- pertrophied. The diagnosis of the exanthemata is so beset with dif- ficulty that I am tempted to repeat an observation I communicated nearly twenty years ago, respecting their physiognomy. This, I believe, often affords considerable aid in coming to a conclusion ; indeed I have, on more than one occasion, predicted that the peculiar drooping would end in an eruptive fever, and the event has justi- fied the prophecy, as some of my medical friends can testify. It is easier to point out at the bedside than to describe such a sign. The countenance looks heavy, dull, less intellectual than usual, especially in lively children. Seen from a distance, an idea of oedema or EXANTHEMATA. 197 puffiness is conveyed, and a strong impression is pro- duced of hebetude—a peculiar drooping. Strumous patients display this most distinctly. In measles this physiognomy is associated with and partially obscured by coryza or lachrym ition ; in scarlatina it is simple and characteristic. In respect to treatment, the indications are as various as the appearances. No class of complaints exhibits better the necessity of keeping in mind general principles. The local affection, important ns it is, and requiring so often topical applications, ought not to engross the whole attention. The numerous complications need to be vigi- lantly watched for and appropriately met from the first, since in nearly every one the treatment is to be modified by its occurring during the fever, and according to the epidemic prevailing, or the prominent peculiarities. It is proper to urge in this place the importance of a mild, equable temperature, a light diet based on milk, cooling drinks, clean apartments,—disinfected by the due admix- ture of fresh air as well as by chemical agents,—and the more strictly medical means of keeping in check both the fever and the local affection. Aconite is invaluable for both these purposes. Tepid and cold sponging may both be useful to abate the heat of skin, and, when employed, disinfectants should be added to the water. Inunction with suet has been tried with success, but it is not a pop- ular remedy with Englishmen. Ice and cold liquids in the mouth may be tried for the early cynanche, but soon warm inhalations will be needed. Scarification of the tonsils may sometimes be required to reduce local inflam- mation, but it does not seem very effectual, and leeches are more often employed. Gargles and sprays will be 198 SORE THROAT. needed to clear the throat of mucus, or to remove smell. Painting and sponging with medicated liquids must be employed. Cordials, tonics, and stimulants are all in turn required. Chlorate of potash, creasote, carbolic acid, the sulpho-carbolates, the permanganates, mineral acids, quinine, and muriate of iron are the favorite medica- ments. Gentle saline aperients cannot be dispensed with. Long after the danger seems past, the utmost care is to be taken to avoid exposure and restore the health. Further details are purposely avoided, to impress more effectu- ally the lesson that every case is to be carefully weighed in all its bearings, its salient points made out, its promi- nent features distinguished, and its complications duly considered. SYPHILITIC SORE THROAT. 199 CHAPTER XII. SYPHILITIC SORE THROAT. Here we shall only describe certain diffused affections, leaving the more localized lesions to be considered in con- nection with the diseases of the several organs. One of the most common forms of syphilitic sore throat is the inflamed state of the faucial lining met with in the sec- ondary train of symptoms. The association, already in- sisted on, of certain skin eruptions, with varieties in the affections of the mucous membrane, may be again referred to. Thus, with roseola, we meet with the dark red and purple of erythematous inflammation of the fauces, while the papular, squamous, and tubercular skin complications accompany the elevated and well-defined mucous patches. All the parts of the throat may suffer simultaneously or successively. Ulceration is exceedingly common in syphilitic sore throat, often occupying at once the pharynx, tonsils, and velum. Great loss of substance may occur, perforation of the palate is a too frequent event, or adhesions take place, closing the natural passages between the posterior nares and fauces. Tubercular and papular elevations, proliferations, and condylomata, occurring in the course of syphilis, differ very much in their effects, according to the locality they occupy. They are often removed by general treatment, 200 SORE THROAT. Syphilitic sore throat is constantly and intimately as- sociated with diseases of the mouth and nose, having a similar origin. Lesions of the tongue are thus caused, which may be confounded with cancer. The diseases of the nose are occasionally very intractable, some of them closely resembling those of a non-specific nature. These affections may be either superficial or deep. Severe pain sometimes accompanies them, and great deformity fol- lows, and their management exacts the utmost care from the physician. In other cases there is little suffering, but the annoyance is protracted, and the chronic disease leads to further mischief and much misery. Some further ac- count of these diseases may be found in the author's papers on ozaena and syphilitic diseases of the throat, already cited. The treatment of syphilitic sore throat, as well as the accompanying affections of the mouth and nose, must be both local and general. Even in mild cases, it is im- proper to rest satisfied with lessening local manifestations, and leaving a virulent poison to fester in the system ; it will only reappear with redoubled obstinacy. At the same time, it is right to state that topical measures are of the utmost value, both in the mouth and throat. In the early stages, they are indeed less important, and may be simple; but, in the later ones, they are often necessary to the comfort, or even life of the patient. Large perforations of the palate, for instance, such as seen in Plate I, Fig. 1, may be completely closed by judicious, persevering treat- ment ; oedema of the larynx may be relieved by opera- tion ; the consequences of exfoliation of the bone may be greatly mitigated; but general treatment must not be neglected. In tertiary cases, iodide of potassium is the SYPHILITIC SORE THROAT. 201 recognized remedy, but it is also efficacious at an earlier period. In rapidly destructive ulceration, it must be given in large and frequent doses. The quantity is to be measured by the effect on the disease, and the ability of the patient to bear it, A patient may be kept under its influence, just short of iodism, for a considerable period. To produce the full effect, it is desirable for the doses to be given frequently. It is idle to attempt to control the disease with two or three small doses a day. The object is to keep some of the salt continually circulating in the blood; and, as elimination is rapid, the doses must be frequent. Iodide of ammonium is sometimes substituted as more easily tolerated. Some years ago I introduceed iodides of sodium and of calcium. Those who cannot tolerate the more commonly used drug can often take the sodic salt, and that in the same doses, although, weight for weight, it contains more iodine. Iodide of calcium is much less disagreeable, but it is, perhaps, better adapted for strumous patients. The special value of iodoform, as stated by the author in 1871, is well exemplified in syphilitic sore throat, for which, in certain cases, it is the most appropriate local application, while it may at the same time be given in- ternally to bring the system under the influence of iodine. Syphilis in the larynx and elsewhere will be further considered in future chapters, in connection with the dis- eases of the several organs. 17 202 SORE THROAT. CHAPTER XIII. AFFECTIONS OF THE SOFT PALATE AND UVULA. Proceeding with our plan, we now pass on to con- sider the several organs of the throat individually, leav- ing the remaining consequences of inflammation and other morbid processes which affect them to take their places as we proceed. We shall not find it necessary to repeat in reference to each organ a number of observations which have been made as to conditions involving all in turn. We have seen that the soft palate and uvula form a division, though an imperfect one, between the mouth and throat. The anterior surface of this structure is, therefore, open to inspection, which informs us respecting deviations in its form or color, while its irritability is at the same time open to the test of touch. The mucous membrane in this part is thick, its epithelium being of the tessellated kind, and composed of several layers. It contains numerous mucous glands, but solitary follicles are not always to be found. The normal redness of the velum is uniformly spread over the surface, and of less depth than on the uvula and arches. To see the posterior surface we must employ the rhinoscope, when it can easily be brought into view. Here the mucous membrane is thinner; the epithelium in the new-born child is ciliated, but soon acquires the tessellated character, the mucous glands are few in num- ber, above the uvula there are none, and the solitary fol- THE SOFT PALATE. 203 licles are very variable. As to color, it is necessary to remember the different lights by which the two surfaces are observed. The anterior arches are rich in mucous glands, but have no follicles, or only a few towards the base; but on the posterior arches they are frequently to be found, especially on their posterior aspect. The whole soft palate is abundantly supplied with bloodvessels, lymphatics, and nerves. Several pairs of muscles, which in health act in pairs, form a considerable portion of its substance. The form of the parts undergoes continual variation, be- sides which there are great differences of natural con- formation affecting the breadth and height of the isthmus faucium. The physiological irritability of the velum varies to a remarkable extent in different individuals, one appearing to bear almost with indifference what another is quite unable to tolerate. Congestion is exceedingly common in the soft palate, and may be either active or passive, primary or second- ary. Increased redness in contrast with the surrounding structures characterizes the active form which may be produced by any local irritant, and is sometimes seen as an indication of extra blood supply from enlarged left ventricle, etc. The bluish tinge of venous congestion may in like manner be brought about by blood stasis from disease of the lungs or heart, or it may be the result of numerous previous active attacks. Among the irritants in daily use must not be forgotten alcohol, tobacco, and snuftj the former giving rise to conditions deserving the name " tippler's sore throat," the latter to " smoker's" and "snuff-taker's" sore throat. Hemorrhage may be the consequence of congestion or of inflammation, or may arise from wounds by fish-bones 204 SORE THROAT. or hard food, or may be the result of the haemorrhagic diathesis. We see thus ecchymosis, haematoma, or bleed- ing. It is important to trace this to its. source, as blood found on the palate may have escaped from the mucous surface at a distance, or may be the result of disease of neighboring vessels, as aneurism of the internal carotid. Ice to suck, and other measures which will vary with the circumstances, will suggest themselves to the intelligent practitioner. Anaemia, or hypoeemia, is very common on the palate, as an expression of a general condition of the system. In fact, this and other disturbances of the circulation are more readily observed on this sensitive membrance than on the cutaneous surface, or even the lips. At the same time it must not be forgotten that such changes may be very evanescent, suffusion and pallor chasing each other over the mucous membrane with a rapidity to which Me are only accustomed in the blushing and blanching of the face from emotion. Inflammation of the velum in all its varieties is so often only a part of the same disease in a more extensive area —a portion of inflamed sore throat—that we may refer to previous chapters for its nature and treatment. All the forms of inflammation, acute or chronic, superficial or deep, catarrhal, phlegmonous or exudative, primary or secondary, local or general, may here find expression. Each may be confined to the velum, or attack a wider area, though the deeper the disease extends the less is its disposition to spread over the surface. It will be readily understood, that in a part so mobile pain is likely to be a prominent symptom ; and as the part is so much used in deglutition the pain is greatly aggravated in swallowing. AFFECTIONS OF THE SOFT PALATE. 205 In many acute cases food is for this reason refused; and the saliva is allowed to dribble from the mouth, because the patient dreads to swallow it, Another prominent symptom is difficulty and pain in speaking, especially marked in the palatal sounds, so that the speech acquires a characteristic tone. In some cases T>ye hear, instead of this, a nasal twang, through the velum being unable to properly close the posterior nares. Hawking, coughing, or any act involving movement of the velum is suppressed as far as possible, on account of the excessive pain occa- sioned. (Edema of the velum, or arches, is rare as a symptom of a dropsical condition, but not so uncommon as a con- sequence of inflammation in adjoining parts. It may then be extensive, and is of interest, as, arising from such a cause, it may find its way into the larynx. Ulceration may be mentioned separately, inasmuch as certain forms are of special importance, on account of the danger of their perforating the palate. Active meas- ures should be directed to avert this; and usually consti- tutional, as well as local, treatment is essential. It is in syphilis the greatest danger is to be apprehended. When there is rapid destruction of tissue the most powerful caustics are often needed. Concentrated nitric acid, or acid nitrate of mercury, can be applied to the exact spot required, if sufficient care be used. The common method of using a glass rod is rather dangerous, as a drop of the caustic may fall off in the mouth. A bit of cotton-wool or sponge can be easily soaked sufficiently, and used with a suitable holder. It is important, when ulceration is sus- pected, to explore thoroughly with the rhinoscope the en- tire posterior surface of the velum and the arches, behind 206 SORE THROAT. both of which we may often detect this process at an early stage, and thus be able to avert its ravages. Other points have been referred to under the various forms of ulcerated sore throat; and, indeed, all that has been said of the various forms of sore-throat is to be applied more or less completely to the soft palate. Gangrene may begin in the soft palate somewhat as noma does in the cheek, and run a similar course. It has been observed during an epidemic of hospital gangrene, and under some other circumstances. This is to be dis- tinguished from gangrene resulting from intense inflam- mation, or appearing as secondary local manifestation in scarlatina, etc., though all are sometimes included in the term gangrenous sore throat, and all require supporting treatment from the first indication. Atrophy is seen in old age, and after certain diseases. It is mostly met with in connection with the same state in the tonsils, and its origin is not well understood. Perforations cause distress in proportion to their size and position. In the worst cases we may cover the aper- ture with a proper apparatus, so as to prevent the food passing into the nose; but in many instances we may diminish the size of the opening, or cause it to close alto- gether, by a persistent use of remedies. The large per- foration shown in Plate I, Fig. 2, was completely closed by such treatment. Cicatrices often remain, but are of little importance. Tumors.—Morbid growths are not common, but when they occur may impede deglutition and require opera- tion. Papillomata are the most frequent, but other for- mations have been met with. Cysts occasionally are formed by retention of the contents of the mucous glands. AFFECTIONS OF THE SOFT PALATE. 207 Sarcomata and other tumors now and then originate in the soft palate, but more frequently spread to it from sur- rounding organs. This is also true of Cancer, which, though it attacks the velum by exten- sion, seldom begins in it, and still more rarely forms sec- ondary deposits. The end is often hastened by haemor- rhage or starvation. Sometimes asphyxia is produced. Syj/hilis is usually symmetrical, and may put on any of the forms it assumes on any mucous membrane. The tonsil is generally attacked first. In the mildest catar- rhal form it cannot be recognized by the appearance alone, but mucous patches are characteristic. When ul- cers are deep, there is danger of perforation, and great loss of tissue, as in Plate I, Fig. 2. Cicatrices of various forms, contractions, and adhesions follow. Nervous Diseases.—Paralysis is most common after diphtheria, but may occur from other causes, either alone or in conjunction with the same lesion in other parts, e. g., the facial muscles. It may be partial or complete, and affect some or all of the muscles. The paralysis may be central or peripheral, or arise in the course of the nerve. It is seen also in progressive muscular atrophy, and in labio-glosso-pharyngeal paralysis. Spasm is but rarely seen, and little is known of its causes. Anaesthesia frequently accompanies motor pa- ralysis and may also be produced by certain drugs, such as the bromides. Neuralgia and hyperaesthesia are occa- sionally met with. The treatment of all these nervous affections is to be conducted on general principles. Congenital malformations often admit of surgical recti- fication. 208 SORE THROAT. THE UVULA Is but a part of the velum, and, therefore, liable to participate in all its lesions. We need not, therefore, re- peat them, but specify one or two points in which it has characters of its own. Its substance is chiefly made up of mucous glands, with a little muscular and connective tissue. The mucous membrane is rather loose, and some- times it slips in advance of the organ so as to form a prolapsed extension. We sometimes see inflammation of the uvula without anything else being involved,— uvulitis. This is not often observed, since the affection is only trivial. The results of active or passive inflam- mation do, however, trouble the medical man. Of these oedema is an example, a common one, a troublesome one, one easily relieved, but not very often detected for some little time. The swollen and flabby state consequent on oedema requires no description. The symptoms will cor- respond with the increase of size, and the irritability of the parts. It may look like a flabby, distended, reddish tumor, as large as the thumb, but it is generally seen in connection with the same state on the soft palate. The fluid may have to be let out by a puncture or incision, an operation of a simple nature, but requiring an expert hand to do it well. Ecchymoses and haematomata often appear, but.are absorbed or only leave a stain. Elongation is the term usually applied to the chronic relaxed uvula. Astringent gargles may be tried, but it will often be necessary to resort to the knife. Complete excision is attended with no evil consequence, and is strongly advocated by some in opposition to a partial removal. Others, however, still recommend snipping. AFFECTIONS OF THE UVULA. 209 This is easily done with well-constructed uvula scissors; but there is certainly something in the objection that the excised surface does not look backwards, as when a tenac- ulum and bistoury are employed, and the whole uvula skilfully removed. Hypertrophy or enlargement of the uvula, as distinguished from elongation, implies increase in all directions. I have seen it as large as a man's thumb, and hard and unyielding, as if a dense deposit of connective tissue had occurred. In these cases nothing less than excision will succeed in removing the symp- toms it may provoke. It is important to recognize the liability of the uvula to these conditions, in order to prevent errors. Practi- tioners who never inspect the throat, unless complained of, may often be lulling fear in the midst of danger, or exciting alarm without due cause, and in either instance losing reputation. The uvula cough, as it has been called, is peculiar, and may often be recognized by its quick and ineffectual hack; yet not always. It is for the most part worst at night, or when the patient lies on his back. Often he is woke up suddenly with the sensation of being choked, even when he takes a nap on the sofa. Catarrh, relaxation, dyspepsia, want of tone, etc., are sure to ag- gravate the symptoms. The peculiarly troublesome cough sometimes gives rise to pains in the chest; and in long-standing cases, many of the symptoms of consump- tion may be assumed. Dr. Stokes declares he has seen all the symptoms of phthisis, except physical signs, thus produced. Further, neglected conditions of this kind may even rouse up to activity pulmonary disease, which had otherwise long lain latent. This is the less to be won- dered at, inasmach as a strumous diathesis is a most 18 210 SORE THROAT. powerful predisposing cause of diseased uvula; an ob- servation which will be of value in deciding on constitu- tional treatment. When rapid destruction of tissue takes place, as in the course of sloughing, or syphilitic ulceration, the uvula may be consumed by the process, or it may be perfo- rated (Plate I, Fig. 2), or be separated by the destruction of its base, and fall off, amputated by the morbid pro- cess; it may be more or less involved in any of the dis- eases that affect the velum. Now and then a polypus or other tumor finds its seat on the uvula. Warts are com- mon in this locality. Paralysis of the azygos uvulce is sometimes complete, and if unassociated with a similar lesion elsewhere gives no information as to the seat of the disease. When only one side is affected the organ is turned up on the other side; when both sides are involved it hangs down and simulates in an exaggerated degree the conditions we have spoken of as elongation and relaxation, in which there is, no doubt, some paresis as the result of previous inflammatory action. Spasm can hardly be spoken of as a disease, nor can increase or decrease of sensation ; but it should be observed that the physiological irritability of this process varies as much as—perhaps more than— that of the rest of the soft palate in different individuals. In all, however, it can, with care, be brought to tolerate the contact of the laryngoscope if properly and steadily held. AFFECTIONS OF THE TONSILS. 211 CHAPTER XIV. AFFECTIONS OF THE TONSILS. On looking into the throat the tonsils may easily be seen snugly ensconced between the anterior and posterior pillars of the fauces. In size and shape they have been compared to almonds, and have therefore received the additional name of amygdahv, but their appearance varies much in different persons. Sometimes they are nearly round instead of oval, and almost globular rather than flattened. The fact is that perfectly normal tonsils are rare, and should be looked-for in the infant before its first catarrh. A very considerable variation in size and shape may be admitted within the range of health. A little more than half an inch long and one-third of an inch wide is considered a fairly full size, but a much better idea is to be derived from the relations of the parts. Thus the tonsil in health usually projects beyond the an- terior pillar towards the median line, but the posterior pillar passes a little beyond the tonsils in the same direc- tion. The lacunae, from twelve to sixteen or twenty in number, are lined with epithelium continuous with that on the surface. The tonsils may be regarded as agglom- erations of follicles composed of reticular tissue, containing a few capillaries and round cells. A quantity of firm connective tissue forms a strong framework, and supports the vessels, for there are arterioles between the follicles 212 SORE THROAT. and veins around them. To the outside of the tonsil and closely attached to it is a dense aponeurotic structure, which lipiits the growth in that direction. Beyond this lie the great vessels of the neck. The nearest—the in- ternal carotid artery—is usually quite half an inch distant, but occasionally it curves inwards, and lies along the fibrous separation, a fact of the utmost importance in reference to the danger of wounding the vessel when op- erating in this locality. The external carotid is about one-fifth of an inch outside the internal. Inflammation, acute or chronic, superficial or deep, may attack the tonsils, or spread to them from neighboring parts. The latter -course is more common in catarrhal inflamed sore throat, when if the tonsils become more affected than any other part, they may give their name to the attack, tonsillitis, amygdalitis, angina tonsillaris, cy- nanche tonsillaris, etc. This inflammation of the mucous membrane covering the tonsils may creep along the lacunae, there is then more swelling, and a perverted secretion es- capes from the openings, or may be penned up and pro- duce deeper inflammation, or small abscesses like those seen in acne; on the other hand, it may dry up and leave concretions behind. In acute phlegmonous inflammation the symptoms, both local and general, are much more intense. Only one tonsil may be affected, or both may be simultaneously attacked, or the second may begin to swell just as the first is getting better. Very often there is simultaneous inflammation in the soft palate or one of the pillars. The pain and swelling in acute parenchymatous ton- sillitis are both marked from the first, and increase rap- idly until perhaps no solid food can be taken, and fluids INFLAMMATION OF THE TONSILS. 213 are swallowed with difficulty. There is high sympathetic fever, which sets in early, often even before much pain is felt. It begins with distinct rigors, and if already sore throat be complained of, it may lead to a suspicion of scarlatina or other more serious disease. The fever goes on concurrently with the local disease, exhibiting all the characters so often described as sympathetic or inflam- matory fever. The pulse is full and frequent, 120 or more. The temperature rises rapidly to 102°, 103°, 104°, and even 105°. There is severe headache, thirst, furred tongue, and, after a time, but not necessarily, anorexia. Occasionally in weakly persons, or in children, delirium occurs, but in the latter this is more frequently replaced by convulsions. The local lesion runs a rapid course. In a few hours the swollen tonsils, where both are at- tacked, may meet in the median line, where they some- times press each other so firmly as to cause ulceration, or where they imprison the uvula and cause it to inflame, or to adhere to some part of the surrounding structures. Sometimes the swollen tonsils press more forwards, pushing the inflamed velum and arches before them. If only one be affected, the protrusion is of course only on one side; in either case it may be so painful for the patient to open his mouth, that it is difficult to obtain a view of the parts. This acute pain is aggravated by pressure at the angle of the jaw, where there is often considerable swelling of the cellular tissue. The parts in the neighborhood are also sometimes swollen. The pain frequently darts along the Eustachian tube, when earache is complained of, and in- flammation may spread along the same channel and give rise to serious mischief. On the other hand, deafness is sometimes present from an early stage. The pain is so 214 SORE THROAT. intense on attempting to swallow, that.patients allow the saliva to run from the mouth, and when they do swallow the act is usually accompanied with grimaces or curious movements. Even speaking aggravates the pain so much that the patient is glad to keep silence, and when he tries to say anything his speech is observed to have acquired a peculiar nasal twang, or it may be thick, and as it were smothered or reduced to a lisp or noisy whisper, the various tones depending on the degree of interference with the function of the pharynx. When the inflammation is thus intense suppuration occurs early, and if near the surface it soon spontaneously bursts, when all the symp- toms speedily subside. If the abscess be deep there is longer delay, which it may be desirable to abridge by the lancet. No doubt it was to tonsillitis running this well- marked course and ending in abscess that the word cynanche was first applied, and our own word quinsy, which like the French esquinancie is derived from the original, is usually applied, and should be restricted to such cases; but the suppuration is only the result of phlegmonous inflammation, which may subside without the formation of an abscess. We may distinguish abscesses formed in the connective tissue surrounding the tonsils; they are most common in that which is packed between the tonsil and the anterior arches of the side affected; for this form is perhaps most often unilateral, though the opposite side frequently follows suit. The appearances here are such that the disease has been thought due to lesion of the arch or velum, the swelling of which may quite conceal the tonsil. If the abscess occupy the posterior part it will, on the contrary, be more prom- inent. Clinically these cases comport themselves like ABSCESS OF TONSILS—QUINSY. 215 abscess in the tonsil, and may be included in the term quinsy. Notwithstanding the pain and distress caused by the disease, there is scarcely any danger to life, and after the crisis recovery is as rapid as the invasion and march of the malady. Nevertheless, in bad constitutions the evacua- tion of the pus is now and then followed by ulceration and sloughing. Moreover, there is a liability to recurrence of the inflammation on slight exposure, rendering it de- sirable to take measures for the prevention of repeated attacks. Some persons are so prone to tonsillitis that they suffer from it with every cold in the head until they are subjected to radical treatment. Others never have a second or perhaps third attack. The disposition to disease of the tonsils manifests itself at an early age. In childhood catarrhal tonsillitis is common—quinsy or abscess rather rare. With increasing years the latter becomes more frequent, so that it is regarded as a dis- ease of youth and the early half of adult life. In the female, affections of the tonsils, as I was the first to point out, are frequently associated with the active de- velopment of the reproductive organs, and concurrent or alternate ovarian attacks are observed. See the last sec- tion of this chapter. The treatment of acute tonsillitis is the antiphlogistic diet and regimen. As to the former, the unhappy suf- ferer has no alternative but a bland fluid diet; often he is compelled to starve, and that when he has a keen ap- petite. Of course the utmost care must be taken to avoid cold currents of air, or anything likely to aggravate the attack. Bleeding is not needful, in spite of all that has been said in its favor. Leeches are constantly ordered 216 SORE THROAT. with a success which satisfies many ; the author does not recommend them. Scarification is a more effectual mode of treatment. It empties the engorged organs of blood which is doing harm, and only harm; it diminishes the tenseness, and so relieves the pain. When adopted at the right time it seems to arrest the disease in many cases, and renders it milder in others, but it is to be carried out carefully and with a definite object. The minute super- ficial incisions made for this purpose differ entirely from that made for the evacuation of pus. In quinsy the ab- scess should be opened before too much mischief is done, or too much suffering needlessly endured. It is, indeed, maintained by some that it is always better to allow the pus to escape spontaneously; but while deprecating too early, and therefore useless or injurious incisions, I abide by the practice inculcated in my first edition, ever since which I have felt called upon, from time to time, thus to afford my patients relief and save them much unneces- sary suffering. It is freely admitted that many abscesses, perhaps the majority, burst before it becomes imperative to lance them. In opening an abscess in the tonsil, the point of the knife should describe a course inwards as well as backwards, on account of the position of the caro- tid artery. At an early stage it has been thought the attack might be arrested by the local application of cold. The suck- ing of ice is sometimes agreeable, and can then be fairly tried, and to this cold compresses have been added. It sometimes happens, however, that these remedies aggra- vate the pain. They must then be laid aside; and it will also be well to relinquish their use as soon as it be- comes obvious that suppuration must ensue. Warmth TONSILLITIS--TREATMENT. 217 should then be resorted to, and from the first is frequently found most grateful. The neck may be wrapped in flan- nel or cotton-wool, and fomentations may be used at in- tervals. In addition the most soothing remedies are ano- dyne inhalations and mouth washes—gargling usually being too painful a process. Purgatives, diaphoretics, febrifuges, and counter-irri- tation in turn enter the phalanx of most practitioners. The only remark the author would make about them is to beg his readers not to punish their patients by too much treatment. As a diaphoretic it is well to choose one that is also anodyne, for which purpose Dover's pow- der is often employed, and entails the use of purgatives and salines. It is generally better to choose a medicine which, though equally effective, is without this disadvantage. Aconite has proved the best drug in the author's prac- tice. It is safe, pleasant, efficacious, and allays the fever at the same time. It rapidly reduces both temperature and pulse, and has also a powerful local effect. It can be given when other medicines are a great cruelty. Even if sucking a lozenge is too painful, or swallowing impracticable, it can be applied to the mouth with a camel- hair pencil—tincture diluted with water or glycerin. M. Velpeau eulogized the application of powdered alum with the finger, and considered it capable of arresting ton- sillitis. It is not used much now, not having answered the expectations of many. Guaiacum, recommended by Sir T. Watson, the late Mr. Harvey, and others, is believed by many to exercise considerable control over tonsillitis. The thick mixture often prescribed is particularly inapplicable when there is great swelling and tenderness. It can be replaced by 218 SORE THROAT. ammoniated tincture or by lozenges. This drug is fre- quently employed in rheumatism, and it may therefore be supposed to be more suitable in cases of rheumatic sore throat than in tonsillitis. Attempts have been made to arrest quinsy by the ap- plication of nitrate of silver, a strong solution being painted, or the solid stick rubbed, over the parts. It adds to the misery of the patient a most nauseous taste, and the necessity of hawking and spitting until the su- perficial slough it produces has been removed; it often fails to arrest the disease, and has too frequently been applied at a period when such a hope must be futile. Emetics have been asserted to have the power, if given early, of completely arresting the attack. They are not popular, and I think seldom successful in the object, and should therefore be left to optional use by patients who are subject to frequent attacks. As, if the disease pursue its course, the patient will be deprived of food for some time, it seems a strange preparation of his system to empty the stomach of that which it contains. Of course, if digestion be not much affected at the time, he can take food soon after the emetic, which should not be depressing—salt or mustard may be selected. An emetic is sometimes given for another purpose,—-to burst an abscess by the compression to which it is sub- jected in the act of vomiting. It is more painful than the knife, or even than pressure with the fingers, but some persons mucji prefer it in repeated attacks. If there be a large quantity of pus collected it does not in this case run into the stomach, which sometimes happens when the abscess opens spontaneously; and as it is often highly offensive, provokes nausea or vomiting. Of course DISEASES OF THE TONSILS. 219 an emetic will be useless for this purpose until the abscess is quite ripe, and even then it may fail to accomplish the desired end. An opening into the trachea has been spoken of as ad- visable when suffocation seemed imminent, but this will only be requisite when inflammation has extended to the larynx and brought on oedema—an event which is very rare, and completely alters the aspect of the case. Ulceration, sloughing, or even gangrene may super- vene. Instead of an ordinary inflammation, we then have to deal with a deadly disease—tonsillitis maligna. As the destruction of tissue generally involves other parts, putrid, malignant, or gangrenous sore throat are terms under which we have described such cases. These should be compared with the exanthematous and exudative forms. It should be remembered, too, that syphilicic ulceration is peculiarly prone to commence on the tonsils. Chronic tonsillitis often succeeds the acute form. In infancy it frequently takes place without any previous acute attack being noticed ; or it follows a series of colds, in which, no doubt, superficial tonsillitis has occurred. If the lining of the lacunae be affected, this is most likely to occur. Its causes, symptoms, and treatment naturally partake of those of the acute or subacute, but in a mod- ified form. Local treatment will be useful, but the con- stitution is generally much at fault. Dyspeptic ailnients must be rectified, and where struma is prominent, as it so often is, iodide of iron or cod-liver oil will be found most valuable. Lacunal Tonsillitis.—M. Bouchut has lately called at- tention to a condition in which cheesy masses are found in the lacunae. It is not a new observation. I have for & 2:o SORE THROAT. many years been familiar with the several changes he describes, and with others which may occur from similar causes. The catarrhal inflammation is, in fact, very apt, as already shown, to extend along the lacunae; and it may be confined to them, especially in the chronic form. We then have perverted secretion of various composition, either escaping from the openings or, if these be closed, retained in the tubes. The contents may be grayish, opaline, yellowish, or brownish. The accumulation may be fluid, or its consistence that of treacle; or it may be- come solid—these variations depending partly on the time it is retained. It may be composed almost entirely of epithelium, or contain pus-corpuscles, or crystals of cholesterin or earthy matter. The last may be increased to such an extent that the concretions have been termed calculi. We may add that in these situations, as else- where, the imprisoned secretions have contained bacteria. When the contents of the lacunae can escape we see thick- ened secretion, white or yellowish, coming away in moulds, and being renewed just like the comedones so frequent on the face. Sometimes these plugs are mistaken for other diseases; just as semi-solid condensed follicular secretion has been mistaken for patches of false membrane by per- sons on the look-out for diphtheria. Sometimes they are offensive, and impart a sickening odor to the breath. When the openings are quite closed these masses, or a more fluid secretion, may accumulate and distend the lacunae until two or more communicate with each other. The result may be a cyst; or, if the concretion be solid, it will have the shape of the cavity it has occupied. Of course, an abscess may at any time result, giving rise to one form of quinsy; or several single lacunae may sup- DISEASES OF THE TONSILS. 221 puratc, and, if small, simulate acne. More commonly, there appears to be enlargement of the tonsil, but its true tissue is really diminished, and replaced by the accumu- lation. There is, in fact, atrophy of the tonsil which looks so large. I have dwelt thus at length on the in- flammation of the lacunae, because this form of tonsillitis, especially chronic, seems little understood; and some of its results have lately been spoken of as if they were un- recognized conditions. It may be well to add that some of these conditions may occur from any cause of obstruc- tion at the orifices of the lacunae ; and, therefore, without inflammation, although this is commonly present at some stage. The treatment of such cases should be adapted to the conditions found, and may therefore embrace much that is appropriate in acne, comedones, cysts, or abscesses elsewhere. At the same time an effort should be made to induce healthy action of the mucous surface. Further, it should be remembered that the chronic inflammation which exists is likely to give rise to repeated attacks of acute or subacute tonsillitis, both catarrhal and paren- chymatous. Hypertrophy, enlargement, induration, are terms ap- plied to a state which often results from inflammation, either acute or chronic. It frequently follows a series of attacks of subacute superficial inflammation ; but it some- times takes place without this process appearing to precede. The ailment then goes on so slowly that when at length it is discovered it has made considerable progress. This is most common with children. A peculiar snore during sleep, a thickness of the voice, some difficulty in swallow- ing, at length attract attention. Deafness in some degree is common. This has been considered the effect of ob- 222 SORE THROAT. struction of the Eustachian tubes; but congestion of their lining, induced by the disease in the neighborhood or spreading along the mucous surface, must be a more ac- tive cause. All the symptoms are often aggravated by a cold, and a chronic cough of a teasing kind persists. The consequences of considerable enlargement of the tonsils are not always so slight as these. The constant impedi- ment at length betrays itself by impressing a peculiar physiognomy on the little patient, whose face looks small in proportion to the body, and whose nostrils often look pinched or sunken. The palate and dental arches are developed unequally. Deglutition and even respiration are impeded; although the breathing may be for the most part calm, yet it is usually accelerated, and spasmodic dyspnoea often occurs. Laryngotomy has even been per- formed to save suffocation in one of these fits. We think then that, obscure as the complaint sometimes is, and trivial as many may deem it, it is by no means unde- serving attention. Hypertrophy of the tonsils should lead the practitioner to suspect a strumous tendency, and while the child is growing up is the time to employ judicious means for the establishment of the strength. We are also to remember that acute tonsillitis is more liable to occur when any en- largement exists, and that then the consequences are so much more serious. Other diseases occurring: at such a time are increased in fatality; scarlatina especially. It is therefore a vital error, or unpardonable carelessness, to induce parents to look upon such a state as of no conse- quence. It is quite true that a strumous child with en- larged tonsils may acquire a more vigorous habit, and lose his ailment, especially when he can get sea air and ENLARGED TONSILS. 223 bathing, with good diet; but this is no excuse for telling mothers that their children will outgrow a disease, the existence of which is a proof that they have a constitu- tion liable to sink under the process of growth, rather than to spring up into unusual health. We have not yet stated all the evil enlarged tonsils may do. Not only does this complaint sometimes simulate consumption; probably it may arouse that dire disease into activity. Such a fear should not seem exaggerated, when it is remembered that hypertrophy of the tonsils is one cause of pigeon-breast. On this point Mr. Shaw collected important evidence.* The fact that the two conditions were frequently asso- ciated had long been known. The impediment to respi- ration preventing the lungs from filling with each breath, the external pressure of the atmosphere causes the walls to yield where the resistance is least, and thus produces the pigeon-breast. Such is the explanation approved by Shaw, Dupuytren, Pitha, and others, who also hold that the deformity frequently diminishes after removal of the diseased organs. With these circumstances in view, few can object to the operation for excising largely hypertrophied tonsils. Yet we are not to rush into the other extreme, and de- clare all enlarged tonsils fit for removal by the knife. Again do we repeat, the constitution is at fault, and con- stitutional treatment is the sine qua non of beneficial prac- tice. The patient must be got into good health, and then if the effect of a clearly morbid growth is obviously in- jurious, excision is to be resorted to. Much has been written in favor of and against this operation. It has * Medical Gazette, October, 1841. 224 SORE THROAT. been tried extensively as a cure for deafness—with results varying with the nature of the cases operated on. The late Mr. Harvey* opposed it for several reasons, one of them being that the tonsils are not merely secreting organs, but exercise important sympathies in the economy. My own observations on this point seem to bear him out. Another reason he assigned, that the mucous membrane is extensively affected, also fully coincides with the views expressed in this volume. I apprehend, however, that few will deny the necessity of the operation in such cases as those in which I have recommended it above, just as other more important members are removed when their disease acts injuriously on the patient. If the health be greatly improved, slight enlargement may thereby be cured. Local treatment, especially repeated scarification or interstitial injections, may remove very formidable hypertrophy. In numerous cases it is advisable, in others necessary, to take awray the growth which is doing serious mischief, and although radical measures are sometimes the only ones permitted, they are tedious and more pain- ful than excision. A small portion sliced off is an effect- ual remedy, as the remainder of the tonsil shrinks within the pillars, and the cure is complete. When this is done, it is to be remembered that one symptom of the constitu- tional derangement is henceforth unobservable, and a closer watch is therefore to be kept on others. For the operation a pair of curved forceps with tenacu- lum points, and a strong, short-bladed, probe-pointed bis- toury, with a slighter curve than usual, are all the instru- ments required. The operator ought to be ambidexter. * The Ear in Health and Disease, London, 1856. ENLARGED TONSILS. 225 The condemned tonsil is drawn forwards and inwards, and so much as may be wished is easily sliced off. The cut- ting edge of the knife is to be turned away from the caro- tid artery. It is by no means necessary, and seldom advisable, to take away the whole tonsil. About as much should be left as the healthy size of the organ. Some operators prefer to use the guillotine, or tonsillotome, and in young children or timid patients this is convenient. If both tonsils need excising they may be both done at the same sitting. This plan has the advantage that there is only one period of soreness before complete recovery. No food should be taken for two or three hours, and it is often well to take only soft substances for a day or two. I have, however, seen a child eat heartily within two hours, evidently feeling no inconvenience. Occasionally haemorrhage may be troublesome, but it is usually re- strained by tannin; if not, pressure with the finger should be applied to the wounded surface. If the bleeding mouth of any enlarged vessel were seen torsion could be tried. Attempts at enucleation have been made, but in sim- ple hypertrophy we have seen how needless is such a proceeding. Ligatures and ecraseurs are objectionable ; powerful escharotics painful and uncertain; nitrate of silver, though often employed, is not likely to accomplish its object. The galvano-cautery may do this, but even that is not to be compared to the skilful use of the knife. Atrophy of the tonsils has been mentioned as taking place after abscess or operations and also as occasionally being actually present when there is an appearance of hypertrophy. ft 226 SORE THROAT. Cysts, concretions, and other conditions have been dis- cussed in connection with inflammation of the lacunae. Syphilis constantly attacks the tonsils. Erythema may be mistaken. Mucous patches are more characteristic. Ulcers on these bodies are always suspicious, especially when both are attacked at once without prior tonsillitis. Constitutional remedies must be employed, as well as local. Cancer very rarely begins in the tonsils, though it spreads to them from neighboring parts. SYMPATHY BETWEEN THE TONSILS AND OVARIES. The effect of disease of the tonsils on the general health has already been noticed, but a word or two more may be said on the sympathy of these bodies. Many years ago I first laid before the profession* the history of a case in which there appeared a strong sympathy manifest between the tonsils and the ovaries; stating that case to be one of several under observation. Dr. Gray soon after publishedf a case in point, and I have since had a con- siderable number illustrating the fact. In my original paper I put forward no theory, although I did hint that the facts were too numerous to be considered as mere coincidences, and others which I have since adduced will, doubtless, go far to establish in many minds that some intimate sympathy more readily recognized than ex- plained must be at work. Many will say that in these cases I have merely traced an interesting physiological fact of uervous sympathy. Yet if they meet with the * Med. Times and Gazette, September, 1859. f Ibid., Mirch, 1860. * THE TONSILS AND OVARIES. 227 association as frequently as I have done, they will be pleased to anticipate the complication, rather than to be confounded by its occurrence in a more than commonly marked form. The fact that metastasis takes place from the parotid gland to the breast, the testicle, and even to the brain, may be considered as somewhat allied. While correcting these pages I have accidentally met with a case which may be mentioned in connection with this sub- ject, reported by Dr. Charles P. Knapp.* At five succes- sive menstrual periods, his patient, set, 20, suffered from attacks of pain, tenderness and fulness in the right ova- rian region, complicated with an affection of the parotid gland, which enlarged, though without pain, in one at- tack and subsided in the next. After the fifth attack (May, 1878) no recurrence took place. * Philadelphia Medical Times, August 30th, 1879. 228 SORE THROAT. CHAPTER XV. AFFECTIONS OF THE PHARYNX. The musculo-membranous bag which is called the pharynx is placed behind the larynx, nose, and mouth, and in front of the spinal column. On each side run the great vessels of the neck. It is said to reach from the basilar process of the occipital bone to the fifth cervi- cal vertebra, ending in the oesophagus just behind the cri- coid cartilage. It is thus about four inches and a half long. Its walls are made of mucous membrane, outside this a fascia, very tough above, but less dense as it de- scends, and outside the fascia the constrictor muscles, whose office it is to force downwards the food which the act of swallowing places in their power. The mucous membrane varies in color and thickness. At its junction with the Eustachian tubes and nares it is very fine. Here its glands are very numerous. A mass of these bodies runs along the back of the fauces, from the orifice of one Eustachian tube to the other, and here, therefore, we should look for disease. Yet there are many other follic- ular and racemose glands. In the upper pharynx, which can only be seen by the rhinoscope, the membrane looks redder and moister than below. *Lt is, too, thicker and less movable above. On the roof the mass of adenoid tissue, which we have mentioned as sometimes called the pharyngeal tonsil, may be discerned in the mirror, and PHARYNGITIS. 229 the longitudinal ridges in which it is arranged made out. In the fossae of Rosenmuller, and in the neighborhood of the Eustachian orifices, the same tissue also prevails. Above, the epithelium is furnished with cilia, but lower down they disappear, and it assumes the squamous form. Inflammation.—Acute pharyngitis is not very common, if the term be restricted, as it ought to be, to inflamma- tion affecting the walls of the pharynx only; but this again is constantly involved in the various forms of sore throat which have been described. The localized affec- tion may be acute or chronic, catarrhal or phlegmonous, and may result in any of the consequences mentioned when treating of a more diffused inflammation. The in- terference with functions will be proportionate to the se- verity and localization of the disease. Thus dysphagia —difficult or painful deglutition—is an accompaniment of acute pharyngitis. If the Eustachian tubes be in- volved there will be either deafness or, on the other hand, noises in the ears, tinnitus, or earache. If the nares are implicated we have stuffiness, or coryza, with nasal voice. Instead of this the inflammation may be confined to the lower part of the organ, and is then apt to extend to the larynx. Catarrhal cases are mostly brought on by " catching cold," and these are seldom confined for any length of time to the pharynx. The characteristic changes produced in the early stage are red- ness and swelling, and the extent of these can be deter- mined by the rhinoscope, which also enables ns to dis- cover localized pharyngitis in the parts inaccessible to ordinary inspection. Increased and perverted secretions, with other changes, succeed, and give rise to various ap- pearances. 230 SORE THROAT. Phlegmonous pharyngitis is often traumatic. It may be set up by swallowing hot or irritant or caustic liquids, when traces of the agent may be left on its path ; or fish- bones and other solids may be arrested in their passage, and give rise to slight or serious injury. Fatal results have occurred from pins, bits of bones, or pointed bodies perforating the walls and penetrating other parts. Some difficulty may be experienced in deciding whether the foreign body remain in the pharynx, or only the injury it has done give rise to a sensation as if it were still present. The laryngoscope will discover very small bodies in various situations and guide us in the use of instruments to remove them, after which the inflamma- tion is to be treated on general principles. Chronic inflammation may succeed the acute or sub- acute form, or may commence insidiously ; or may super- vene on congestion arising from interference with the circulation, local or general. It is extremely important to differentiate these latter cases, which are sometimes subjected to topical treatment of a most useless or injuri- ous kind. As in acute, so in chronic pharyngitis, the inflammation may implicate the whole surface, or be con- fined to special districts. One of the localities most prone to suffer is that portion of the posterior wall which is visible on ordinary inspection, but the discovery of disease in this part should not satisfy the physician, as the morbid process frequently occupies a large area, the extent of which can only be defined by rhinoscopic ex- ploration. This part of the pharyngeal wall is the most exposed to the contact of irritants. At the same time it is here that the mucous membrane is least sensitive. Hence in this locality, inflammation manifests itself with PHARYNGITIS. 231 less intensity, but more persistency. Often it will linger here long after it has disappeared from the rest of the throat. So obstinate does it sometimes seem, and so little effect do remedies sometimes exercise, that the most powerful applications have been recommended. It is well, however, to remember that chronicity is a natural feature of the case, and, therefore, very vigorous meas- ures, even such as may be dangerous, cannot cope with the condition, which is, nevertheless, amenable to steady perseverance in prudent but rational treatment. The congestion in chronic pharyngitis varies with the origin and course of the disease, as well as with the gen- eral condition of the patient. It may be active or pas- sive, the membrane may be of uniform hue, florid or livid ; or the coloration may occur in patches; or vessels —arterioles or venules—may be seen coursing over the surface. Sometimes the coarser veins become varicose. There may not be any considerable degree of thickening uniformly over the surface, but the glands and follicles are very apt to become hypertrophied. The epithelium increases in patches, and sometimes puts on an appear- ance which might be mistaken for exudation. The in- creased secretion, too, becomes dry and hard, and may cause similar appearances; or it may form an adherent thick lining, tough and leathery, whitish, brownish, yel- lowish, or greenish, and sometimes most offensive. Much of these offensive secretions descends from above, but some are formed here, and on removal leave a breach of surface. Instead of this, haemorrhage may result from the congestion when it is rather more active. CEdema too is now and then seen. As the disease is often provoked or kept up by local 232 SORE THROAT. irritation, the avoidance of these is of great importance. The tippler's sore throat is a good illustration of this, but much more obscure causes may sometimes be traced. The most useful local treatment is by the pharyngeal douches, succeeded by sprays, but it is also necessary to pencil the parts with astringent or other liquids. In regard to congestion brought on by constitutional states, or interference with the circulation, the physician should give his patient the needful advice, and only in excep- tional circumstances, or to afford temporary relief to ur- gent symptoms, make local applications. Even in these cases sprays or lozenges may suffice. Granular pharyngitis is only one form of the follicular or granular sore throat already described, but it is the most obstinate. Though when taken early it may often be restrained, if neglected it will proceed,—slowly but surely,—and generally torments its victims for a long period. Ulceration of the follicles succeeds the earlier stages. All kinds of local treatment have been recom- mended, from the mildest stimulant or astringent gargle up to the galvano-cautery. The most generally used, and too often abused, is nitrate of silver. It is easy to apply—either in solution to the whole membrane, or fused on a probe to touch the individual ulcers. It is often resorted to unwisely. Tincture of iodine, or a so- lution of this drug in glycerin, may in many cases advan- tageously replace it. Ulceration, tubercular, scrofulous, and syphilitic, have been considered in a previous chapter. Pharyngitis sicca is the condition of the posterior wall which we have called "dry sore throat." Instead of increase we have diminution of secretion, and instead of DISEASES OF THE PHARYNX. 233 thickening a thinning of the mucous membrane, which looks like a varnished surface. It is smooth, dry, tense, and shining, often so thin that the muscular tissue be- neath shines through and lends it a deeper color, other- wise it may be less red, or even brownish or yellowish. It is an atrophy of the membrane; depressions caused by follicles, which no longer exist, may be observed, and the glandular tissue throughout the pharynx is much diminished. It seems closely allied to, if not identical with, a condition met with in old age, and sometimes it supervenes on long-continued inflammation or follicular disease. • The symptoms may be slight or severe. In this, and other respects, dry resembles granular sore throat, Mild applications, even bland ones, are most successful. Demulcent lozenges and confectionery are almost always tried by the patient, but there are more effectual and non- > irritant remedies suitable for sprays, douches, and occa- sional pencillings. Hypertrophy.—Instead of the atrophic process de- scribed in the last paragraph, we meet with the opposite condition. Hypertrophy of the mucous membrane may be general throughout the pharynx and nasal passages. It is then difficult to detect. It may be more local, when it is easily discovered. The epithelium may in- crease in thickness, showing discoloration, with perhaps elevated papillae, the secretion being more copious. The glandular tissue increases still more remarkably, giving rise to roundish prominences, polypoid growths, folds or ridges, and other projections. The connective tissue is at the same time increased. The vessels may be dilated; 20 234 SORE THROAT. the acinous glands enlarged and occasionally converted into cysts. The treatment of hypertrophy, like that of atrophy, should be directed first of all to the underlying condition, which is almost always chronic catarrhal inflammation. To promote retrogression we resort to general treatment of the constitution. Scrofulous and underfed youths seem most liable to hypertrophy, but it sometimes attacks others. Local stimulant applications of nitrate of silver, iodine, and other substances hasten the cure. In aggra- vated cases superficial scarification may be tried, or the growth may be destroyed by the galvano-cautery, or oper- ative procedures undertaken. The last are by no means without danger, and are only justifiable in extreme cases. Considerable masses have disappeared under persistent constitutional and local treatment. Atrophy has set in after long use of douches with occasional applications of nitrate of silver. Polypi.—The various growths found in the pharynx may be mentioned. Nasal polypi may descend from the nose and be seen here. The so-called naso-pharyngeal polypi grow from the periosteum covering the base of the skull. Then we find other forms of tumor both benign and malignant. Cancer of the throat usually begins in the pharynx, and almost always involves it. Pharyngocele may be confused with tumor. It is a pouch formed by a dilatation of the outer coat, in which food may accumulate and be pressed out. Rumination has been noticed in such a case. The disease originates in rupture of the lining, or ulceration through it. It may sometimes be made out by external pressure causing the tumor to disappear, and a sound may be introduced DISEASES OF THE PHARYNX. 235 into it. Perhaps pressure applied and some stimulant, such as iodine, might cause it to close if the patient were fed by a tube. More severe measures have been proposed. Emphysema is sometimes produced by air finding its way through an aperture into the cellular tissue. It has occurred during catheterism of the Eustachian tube. Dysphagia and change of voice direct attention to a con- dition rapidly spreading, but easily arrested by snipping the uvula or incising the soft palate and other accessible parts. (Edema has in the same way been produced in injecting the middle ear. Syphilis simulates various conditions. Its ulceration has already been named, but it is necessary to add that in the pharynx it may put on any of the appearances which it assumes on the rest of the mucous membrane. We must, therefore, always be prepared for its occurrence, and when found direct the treatment accordingly. Retropharyngeal Abscess.—Behind the pharynx is a quantity of loose connective tissue, connecting its walls with the prevertebral fascia. This is sometimes the seat of abscess, giving rise to some anomalous pharyngeal symptoms. It may occur at all ages, and many patients have died with it undetected—some, even, when it has been suspected. The symptoms are at first those of pharyngitis, afterwards of suppuration. Where this se- quence is observed, and the shivering is marked, most careful search should be made. The swelling may some- times be seen bulging forwards from the posterior wall; but if it is situated lower down, as is often the case, the finger must be passed as far as possible, and may detect 236 SORE THROAT. it. This is often the only means, as in numerous cases the disease occurs in young children. Stiffness in the neck, and spasm, with difficult deglutition, should, in infants, lead to an examination for abscess. If found, and accessible, there only remains for it to be opened, which, with great care, may usually be safely done. It occasionally bursts, and discharges its contents before it is discovered. If suspected, but incapable of being found, an emetic might possibly burst it. This abscess may originate in an erysipelatous inflammation, but more often it is a symptom of disease of the vertebrae. In either case the pus has mostly an offensive odor. I have met with a case in an adult which has caused great trouble, but remained undetected for a long period. I opened it, and after discharging a large quantity of offensive pus the patient completely recovered. The late Mr. John Adams had a case caused. by a piece of fish-bone be- coming impacted between the vertebrae. Of course, when caused by caries of the vertebrae, as it too generally is, the treatment resolves itself into the management of that disease. Nervous Affections.—Hyperaesthesia is more common than, perhaps, is suspected, and neuralgia may present itself. On the other hand, anaesthesia is not often met with, except as a sequel of diphtheria, in combination with paralysis, which lesion may, however, occur in other cir- cumstances. Dysphagia is the first symptom of paralysis. The patient, finding some difficulty, will adopt singular attitudes to assist in deglutition; then he finds either he cannot swallow at all, or the aliment returns through the nose. Solids seem to find their way more easily than liquids, so long, at least, as the paralysis is not complete. DISEASES OF THE PHARYNX. 237 Particles are apt to get into the larynx. Labio-glosso- pharyngeal paralysis should be discriminated. Spasms should also be recognized as sometimes affecting the pharynx. The treatment of all these nervous affections should be in accordance with the principles of electro-therapeu- tics ; but neurotic medicines are sometimes of great use. 238 SORE THROAT. CHAPTER XVI. AFFECTIONS OF THE NASO-PHARYNX. The upper part of the pharynx, which is only visible in the rhinoscope, is called the naso-pharynx or naso- pharyngeal cavity, and constitutes clinically a tolerably distinct division. To save repetition, it may be stated that the morbid processes we have been studying in the pharynx may all occur here, so that the following remarks should be compared with those in the last chapter. Hypercemia.—Congestion in the upper pharynx not unfrequently gives rise to haemorrhage, the extent of which depends on the condition of the parts. When considerable, some of the blood usually comes from the nasal passages, which are particularly prone to bleed. In small quantities, blood is frequently mixed with the se- cretions from the upper pharynx. Congestion due to general diseases also occurs in this locality, and gives rise to haemorrhages and to increased secretion. Inflammation may be acute or chronic, catarrhal or phlegmonous, and its symptoms are usually well marked. The remarkable increase and perversion in the secretions can only be understood by bearing in mind the laxity of the membrane and the copious blood-supply of the parts, circumstances which also explain the abundant haemor- rhages frequently met with. In the same way the red- THE NASO-PHARYNX. 239 ness and the swelling are both well marked, though the latter may be sufficient to disguise the former. The swelling which occurs in this region in acute catar- rhal inflammation may easily be mistaken for more per- manent hypertrophy. In a severe cold in the head the mass of adenoid tissue on the roof of the pharynx, which has been called the " pharyngeal tonsil," may be an inch and a half thick, and the longitudinal ridges may appear, to any but a skilled observer, large enough to suggest more serious disease. In chronic catarrh, or in the state induced by a series of colds, the danger of mistake is nat- urally greater, especially if the parts have been cleansed from secretion by the douche, or otherwise. Of course, the appearances are often completely concealed by exces- sive secretions, which may be of various consistence, are often most offensive, and must be removed before any opinion can be formed on the state of the parts. Some- times the redness is localized in patches, or is more vivid in one part than another. The anterior lip, and as much of this part of the wall of the Eustachian tube as can be seen, is both red and swollen in most cases; but the inferior part retains its normal condition, or is so little affected that the contrast is manifest. The swelling reduces the orifice, and makes it slit-shaped, but it never quite closes it. Ulceration.—Erosions may appear on any part of the surface. Follicles swell up and suppurate, so that on rhinoscopic examination the membrane may look as if strewn with gray granules. Such follicles may unite and form abscesses, to which ulcers succeed, followed by scars. Both in consumption and in syphilis we may also have ulceration as well as other changes. Cysts and cystlike formations frequently occur; they 240 SORE THROAT. seem often to depend on closure of glands, lacunae, or follicles. Polypi and other tumors, fibromatous, sarcomatous, enchondromatous, or cancerous, may also occupy the naso- pharynx. Hypertrophy is associated with, and seems the result of, chronic catarrh, and polypi are often present at the same time. The glandular tissue is specially increased and leads to important changes. The " pharyngeal ton- sil " may become so much hypertrophied as to hang down over one or both of the choanae, so as to interfere with nasal respiration. This disease is described by Mayer as very common in Denmark. In this country it is less frequent and does not attain so great a development. It may be seen in the rhinoscope usually presenting a series of ridges, which may also be felt with the finger. Mayer described the aggravated cases as feeling like a bag of earthworms. It is important not to mistake for this dis- ease the swelling described in the last page as occurring from simple catarrh, or the ridgelike appearance of the natural conformation. Rhinoscopic examination is always profitable, and may be made subservient to local treatment, In acute cases topical applications are not often desirable, and in chronic ones they are to be resorted to with circumspection. In- halations and fumigations find access to this cavity, and in acute cases soothing remedies in this form are most grateful. At a later stage gargles, the atomizer, or the nasal douche, may be needed. The solutions employed should not be too strong. The use of snuffs, injections into the nose, and other methods of reaching this cavity will at times afford assistance. Pharyngeal douches and THE NASO-PHARYNX. 241 other remedies will often be needed in these obstinate cases. Rhinoscopal therapeutics are of great value, but should be undertaken only by skilled hands. The parts are highly sensitive, and much useless pain may be inflicted. The greatest care and gentleness is required, and then much good may be accomplished and much evil avoided. If this warning seems needful in regard to pencillings, cauterizations, and other applications, it is not necessary to add that it is equally important in operative procedures in this region. 242 SORE THROAT. CHAPTER XVII. CONNECTION OF SORE THROAT WITH AFFECTIONS OF THE NOSE AND EARS--THROAT DEAFNESS. We have seen in the last two chapters that diseases of the pharynx and naso-pharynx are closely related to those of the nose and ears. In catarrh, in hypertrophy, in polypi, and in other affections, the nose may be ob- structed and the breathing thus interfered with ; or dis- charges of a copious or offensive character may be set up, as in ozaena; the delicate sense of smell may be injured or destroyed; the nasal passages at any point may be in- flamed or ulcerated ; and other diseases may supervene— on the one hand exceedingly painful, on the other so in- tractable and annoying as to make the patient a burden to himself and friends. In all such cases the passages should be carefully explored by both posterior and an- terior rhinoscopy, and when once the cause of the diseases is discovered the resources of rhinoscopal therapeutics may enable us to cope with it. So it is in affections of the ear. Besides the numerous cases commonly called throat deafness, there are many instances of loss of hearing which are caused by the con- ditions previously passed in review, and can be relieved by the application of similar principles. Thus, over and over again, we have had to speak of deafness as caused by disease in the organs we have been considering. Other THROAT DEAFNESS. 243 conditions depending on the connection between the ear and the throat—some frequent, some rare—have also had our attention. Moreover, besides impairment of hearing, we may meet with increased sensitiveness to sounds and other impressions—more or less painful. Earache, tin- nitus, singing or noises in the ears, giddiness, and other distressing symptoms cannot be successfully encountered by confining attention to the external and middle ear, while these parts may be permanently injured by the local action set up in more general diseases, as we have seen, for example, in the exanthemata. The study of aural diseases, while working with my late friend Mr. Hinton, impressed upon me the necessity of investigating the connection between the throat and ear. When the Eustachian tube is patent, the density of the air in the cavity of the middle ear is affected by every change.of atmospheric pressure in the naso-pharynx, whence may arise changes in the function of hearing. This pressure is affected by gaping, coughing, sneezing, and other variations of respiratory movements. When the tube becomes closed, whether by secretions, or by the swelling of its walls, or by pressure without, the inclosed air is too rarefied; whence falling and increased tension of the membrane of the drum and the chain of bones. With nothing further than this, it is easy to see the hear- ing may be impaired, or even abolished, or other func- tional disturbances may ensue—such as pain, or un- pleasant sensations, or noises. If these conditions last, congestion or inflammation, with swelling, effusion of liquid, or other changes in the tympanic cavity may follow with still more grave results. It should be remembered, too, that when from any cause the nasal passages are 244 SORE THROAT. occluded, rarefaction of the tympanic air is caused every time the patient swallows, and this may give rise to deaf- ness, which may be due to disease in the naso-pharynx, in the nose, or in the ear itself. Pain in the ear, espe- cially on swallowing, is more likely to be caused by the throat disease extending into the Eustachian tube. Oedema and escape of blood into the tissue may also close the orifice of the tube, while the hypertrophic changes, and new formations described in previous chap- ters, may any of them produce the same result. Hyper- trophied tonsils do not, as some have supposed, press together the sides of the Eustachian tube,—for the ante- rior lip of that tube is too firmly adherent to the pterygoid process,—neither does a swollen or hypertrophied velum close the tube in this way ; but both these affections may set up disease of the mucous membrane extending along the tube, and that deafness is common at some period of their progress must be familiar to every observer. So with regard to polypi, they may stop the tubes by their size just as they obstruct the nose, or they may set up disease of the orifices, or they may so hang as not to in- terfere with the openings, and leave the hearing unaf- fected. In atrophic processes the reverse obtains. Thus in " dry sore throat," if the disease be of long standing, it may extend in the same direction. It is not generally known, but is none the less true, that such a condition may give rise to various symptoms connected with the ears. This state may be diagnosed by the rhinoscope, and, what is of more importance, the instrument may pre- vent erroneous practice and save the patient from serious THROAT DEAFNESS. 245 injury. It is in such cases that nasal douches are likely to injure the ears. The effect of neuroses may be seen in the fact that we meet with both spasm and paralysis of the tubal muscles. These, however, are conditions which are only likely to be appreciated by those who have carefully studied dis- eases of the ear. Dr. Woakes has lately suggested an explanation of the mode in which some other nervous influences are concerned in the production of aural symp- toms. Foreign bodies are often put into the nose; sometimes they gain access to the naso-pharynx; occasionally they have got into the Eustachian orifice. In all these cases, common-sense as well as special skill are required to re- move them with a certainty that no damage shall result. 246 SORE THROAT. CHAPTER XVIII. AFFECTIONS OF THE OESOPHAGUS. Turning now from the upper to the lower extremity of the pharynx, we find it connected with the gullet, an organ which many will think is scarcely included in the word throat; but inasmuch as its diseases have certain definitive relations to those described in previous pages, and the author has had unusual opportunities of observing them, he has thought that some remarks based on his experience may be acceptable, more especially as these affections are universally pronounced to be among the most difficult to detect and deal with. The mucous lining of the oesophagus may be attacked by any of the morbid processes we have described as affecting the pharyngeal membrane; but in the gullet the likeness of mucous membrane to skin, on which we have insisted, is more strikingly exemplified than else- where, and its diseases are modified in accordance with its structure. Inflammation, acute and chronic, catarrhal, follicular, phlegmonous, exudative, erosions, ulceration, haemorrhage, hypertrophy, morbid growths, and other changes may take place here, all of them interfering more or less with nutrition. The oesophagus may also be affected by diseases seated in the trachea, bronchi aorta, or other neighboring organs, while each of these AFFECTIONS OF THE OESOPHAGUS. 247 may in turn suffer from morbid processes originating in the gullet. Inflammation.—In acute catarrhal oesophagitis pain is not a prominent symptom, but may be felt along the course of the tube, especially in swallowing. In chronic cases it is less likely to be described. There is no doubt hyperaemia, but it is not visible, and the condition de- scribed in many textbooks is purely hypothetical. The thick epithelial covering protects the part, and to this structure is due the different appearances. What we really get is a kind of desquamative inflammation, and in the few cases in which inspections can be had, soften- ing and thickening are marked features. The membrane looks opaque, of a dull white color, and rather dry, for excessive secretion is not present. A layer of thick mu- cus may indeed be found, but then it will be seen that the glands are involved. Phlegmonous oesophagitis is best studied in traumatic cases, especially in those set up in swallowing hot, acrid, caustic, or corrosive liquids. In small-pox pustules form along the tube. Ulceration.—Erosion may result from catarrhal in- flammation, and be followed by small, shallow, but well- defined ulcers ; these never seem to extend to the deeper layers, but traumatic ulcers such as occur from the im- paction of foreign bodies will cause perforation. Follic- ular ulcers may be differentiated, for though the follicles here are few, they may inflame and then ulcerate; such ulcers can only be distinguished by their position. Exudation seldom invades the oesophagus. In diph- theria the disease scarcely ever extends below the pharynx, but now and then it has done so. Hypertrophy of the mucous membrane is the character- 248 SORE THROAT. istic of chronic inflammation, and it has been so localized as to cause a kind of stricture. Increase of tissue also leads to Morbid groioths, of which epithelioma is the most fre- quent and the most important. These growths cause im- pediments to the passage of food, which begins to " stick fast in the way," and this symptom increases until there is complete stoppage. This and other forms of stenosis are often confused under the term Stricture, which is therefore said to be simple or malig- nant. Spasmodic stricture is also recognized, and must be carefully separated; we include it in the neuroses. Stricture in the wider sense of the term may also be caused by pressuee from without, as in aneurism of the aorta and other tumors. Dilatation^ or pouching, is another distinct condition caused by any obstruction below the pouch. It may arise from all the coats of the oesophagus being distended, or from some of the muscular fibres allowing the mucous membrane to pass between them. In either case there is impediment to the passage of the food, of which, how- ever, a portion is retained for a time in the pouch, and afterwards regurgitated. Foreign bodies find access to the oesophagus. Among these may be mentioned parasites; the oidium albicans of thrush invades the tube ; so does the trichina ; ascari- des, and other worms find their way from the intestines. A great number of substances have also been swallowed and become impacted; for their removal various instru- ments have been designed, all of which should be used with the greatest care. In some cases cesophagotomy has had to be resorted to. AFFECTIONS OF THE OESOPHAGUS. 249 Neuroses.—Paralysis is one of the sequelae of diphthe- ria ; it is seen in the later stages of general paralysis of the insane, progressive muscular atrophy, labio-glosso- pharyngeal paralysis, and other neuroses; it also seems sometimes to occur independently; it is simulated in hys- teria. When incomplete, we often observe that liquids are less easily swallowed than solids. Spasm occurs more frequently; to it is perhaps due the sensation of constriction in swallowing which troubles many nervous people, and the globus hystericus. It may proceed so far as to prevent deglutition, forming a spas- modic stricture, which is .characterized by its sudden ac- cess and complete intermission—very different from the steady advance of organic stricture. The symptoms, course, and results of affections of the cesophagus are, it will be seen, very various, and their diagnosis, prognosis, and management attended with the greatest difficulties. Yet by bringing to bear upon their study the knowledge of morbid processes elsewhere, and taking into consideration the peculiarities of the organ affected, we may, it is submitted, shed light on these obscure diseases, and do much to alleviate the sufferings they cause. Pain, as we have seen, is not necessarily urgent; in some cases it is scarcely felt, in others it is constant, and generally dull; when acute, often due to secondary causes. Dysphagia is the most constant symptom ; any interference with the ease of swallowing may be so called; it may be only an undue consciousness of the act of deg- lutition, felt in most of the diseases; it may be an un- easy sensation, or a feeling of heat or burning, or pain thus set up, as in oesophagitis; it may be a difficulty in 21 250 SORE THROAT. completing the act, as is common in paralysis; it may be a sense of the morsel sticking fast at some defined spot, as frequently occurs in stenosis. These and other char- acteristics of this symptom are full of interest, but do not suffice for diagnosis; we therefore resort to physical signs. Percussion and auscultation are both of service. The latter has been systematized by Hamburger, whose conclusions, however, seem to be too arbitrary; we are, nevertheless, indebted to him for a considerable advance in this respect, as shown by an abstract of Oppolzer's lectures, translated by Dr. Clinton Wagner, for the au- thor's Reports on diseases of the throat.* The sound or bougie is also of importance for diagno- sis ; by it we estimate the diameter of the tube, deter- mine if contraction exist, and, if so, to what degree; the sensitiveness of the mucous surface throughout is also thus manifested; pulsation may be propagated along the instrument, which on withdrawal may bring with it mu- cus, pus, or blood. Clearly, then, it affords great assis- tance, and provided it be only with the utmost gentle- ness, may be properly employed. Treedment.—Only some general indications, such as naturally result from what has preceded, need be laid down. The use of demulcents is general in irritation along this tube. Opiates may often be advantageously added, especially in acute oesophagitis. In chronic in- flammation and in ulceration astringents are often ad- vised, but their utility is not unquestionable. If parasites be present the special liquids which destroy them can, perhaps, be slowly swallowed. In dilatation, when the * Medical Press and Circular, vol. xiv, 1872. AFFECTIONS OF THE OESOPHAGUS. 251 food is retained, the use of antiseptics is a comfort to the patient, provided they are not too nauseous; boracic and salicylic acids are therefore suggested. In stenosis we have to determine whether external pressure or intrinsic disease gives rise to the stricture. In the latter case we may try mechanical means. It is true that lamentable accidents have occurred, even to able operators, but with extra care it is to be hoped they may be less frequent. The bougie need not, therefore, be abandoned, and used with the ut- most gentleness in appropriate cases may prolong life as well as diminish the patient's distress; further, in some cases the success may be still greater. The author's ex- perience includes many cases in which he has been glad to resort to the bougie, but not one in which he has had cause to regret it. In malignant disease, in aneurism of the aorta, and other conditions, mechanical treatment should not be employed. When such conditions are sus- pected, the utmost care is necessary in passing a bougie, even for diagnostic purposes. In these distressing cases our attention must be directed to maintaining as far as possible the nutrition of the patient, and alleviating his sufferings in the later period of the disease. In some cases operative procedures seem to be justifiable. In the neuroses the use of strychnia, bromides, and other neurotics will be indicated, and the resources of electro-therapeutics should not be forgotten. In spas- modic stricture the gentle pressure of the bougie, if pro- longed, often suffices to demonstrate the nature of the case, and seems even to assist its cure, but it should be followed up by proper constitutional remedies. 252 SORE THROAT. CHAPTER XIX. AFFECTIONS OF THE LARYNX AND VOICE. In treating of the art of laryngoscopy, I have given a full description of the laryngeal image, and a brief gen- eral account of the variations in the view produced by disease. In the present chapter these changes will re- ceive their practical application. First of all, changes of color are most easily appreciable, and, at the same time, as increased redness is characteristic of all congestive dis- eases, most frequent. There may, however, be diminu- tion of color or pigmentation. Each requires a few words. Anosmia, or hypocemia of the larynx, is met with as an item of a general anaemic condition, however produced. After profuse haemorrhage, or in convalescence from vari- ous diseases, it can be well studied. It may also be due to local defective nutrition, and I have shown its signifi- cance among the earliest symptoms of consumption. Pigmentation may take place in various states, and may be general or localized to a small part of the membrane. The yellow discoloration of jaundice and the bluish tinge of cyanosis may be named among the former, but care should be taken in drawing conclusions when using arti- ficial light. Ecchymoses and varicosities are to be seen sometimes, and the stains of blood or secretions coming from this or any part of the membrane; also stains pro- AFFECTIONS OF LARYNX AND VOICE. 253 duced by the substances swallowed may affect this part, as mentioned when speaking of gargles. The possibility of inhalations and sprays producing discoloration is now and then forgotten, and ludicrous mistakes have occurred from this cause. Another source of accidental discolora- tion is breathing an atmosphere loaded with impurities. Soot, dust, and the products of factories may be named- Miners' melanosis may be mentioned here. Hemorrhage may be traumatic, or may arise from ulceration or other solution of continuity, and occasion- ally appears when no ruptured point can be detected. I have seen it produce very anomalous symptoms; and if, as is usually the case, the amount be very slight, there may be a small clot formed, the nature of which at first is rather puzzling. A little ice to suck, and sprays of alum or iron may be desirable; but the principal indications must depend on the origin of the haemorrhage, which may be an almost trivial symptom, or one of grave im- port. A small bleeding point has been seen on an in- flamed vocal cord, as well as on other parts of the larynx. More copious haemorrhage from the trachea and from the lungs may take place, and larger clots may sometimes form in the larynx. Hypercemia is common to the several congestive dis- eases. It may, however, be only a passing condition, a blush provoked by slight causes, or it may be more per- sistent, continuing for a long time without proceeding to laryngitis. When it seems to approach the border, it is often distinguished as Congestion, which term is also frequently used to ex- press a milder degree of inflammation. In the acute form it is usually the result of slight irritation, such as 254 SORE THROAT. overexertion of the voice, or the temporary presence of foreign bodies. In the laryngoscope we often see a blush appear at the close of a prolonged note, especially a high one, and this may assist in the explanation of certain in- juries which may occur from overstraining the voice. In youths whose voices are breaking there is often per- sistent hyperaemia, which may be a key to the active changes going on in the organ, but which may become excessive. After a particle of food has gone the wrong way, and been expelled with some difficulty, especially grains of salt or condiments, congestion may last several hours. Passive congestion may be induced by violent paroxysms of cough following such an accident, or set up by disease, e.g., whooping-cough. Chronic conges- tion of a passive kind is seen when the venous circula- tion is retarded, as in some forms of asthma and heart disease. INFLAMMATION. Formerly the description of laryngitis naturally em- braced the superficial and deep forms, as well as the oedema, which is often superadded. The distinctions be- tween them have been so completely established by the laryngoscope that I now deem it proper to divide the subject of inflammation into several varieties. These I shall describe from a laryngoscopy point of view, confin- ing myself almost entirely to my own clinical experience. Acute catarrhal or erythematous laryngitis is the re- sult of aggravated congestion, and may arise from any irritation to the mucous membrane, but in this climate is mostly due to " catching cold," and the causes of this LARYNGITIS. 255 are too well known for it to be needful to run over them. It is well, however, to mention certain special injurious influences, such as going direct into the cold outer air after breathing for some time the hot and vitiated atmos- phere of the theatre, opera-house, concert-hall, or ball- room. The artists are specially liable to suffer from this, as they have been subjecting the organ of voice to a cer- tain strain; so, though in a somewhat different manner, preachers, lecturers, and public speakers may be injured by exercising the voice in hot rooms, or in cold or damp buildings, or out of doors. In either case, overexertion, or the use of the voice when the larynx is already suf- fering, is still more prejudicial. In the slightest cases there may be no pain, no cough, scarcely any uneasiness. A little mucus collects, and is expelled with a hem; and there is hoarseness, or, at the least, some change of voice, with fatigue on exerting it. Singers at once perceive the loss of purity in tone, though others may not notice it, and, but for the accompanying cold, would scarcely admit they were hoarse. With the laryngoscope we see the mucous membrane to be unusu- ally red, the false cords anol posterior commissure being frequently most affected. A faint, rosy color of the pos- terior part of the true cords is often seen. In more se- vere cases the uneasiness which prompts to clearing up increases to a feeling of itching, dryness, or even pain, and provokes a cough, which in its turn fails to relieve. Very little, if any, expectoration can be raised. The voice, too, is more affected—hoarseness of all grades may be present, or aphonia may ensue. Tenderness on pres- sure may be present, and febrile disturbance; but this last will depend more on the extent of membrane in- 256 SORE THROAT. volved than on the position. The laryngoscope now reveals more congestion and swelling, with perhaps loss of lustre or cloudiness of the epithelial surface. As the false cords swell they approach each other and partially conceal the true cords, which thus look narrower. Their breadth may be reduced almost to a line in this way, and it is constantly reduced a third or half. At the same time their surface may become red, and small vessels may be seen upon them, or there may be ecchymoses. The membrane covering the arytaenoid cartilages is spe- cially prone to suffer, and we often see a pair of red glob- ular swellings in this locality. These appearances may be studied in Plate I, Fig. 1, taken from an acute case of laryngitis. In the most acute cases of all the swell- ing is so great and rapid that obstruction to inspiration becomes the one urgent fact, and unless it is relieved the patient is soon asphyxiated. In these cases there is gen- erally oedema into the submucous tissue. In the cedem- atous parts the swelling is paler, but the rest of the mu- cous membrane is deeply injected. Laryngitis may form a part of the inflamed, exuda- tive, exanthematous, erysipelatous sore throat, etc., in all of which the occurrence of oedema is a source of olanger. Apart from this, dyspnoea is not urgent in adults, but in children the mildest attack is likely to set up stridulous breathing and attacks of laryngeal spasm. The phenom- ena of false croup, already discussed, may, most of them, thus be due to slight catarrh. In these young patients, too, the cough is paroxysmal, and often accompanied by a loud, stridulous inspiration, so that it resembles whoop- ing-cough. On the other hand, it may be of a deep bass, buzzing character, perhaps due to vibration of the ary- LARYNGITIS. 257 taeno-epiglottidean folds. In adults, cough at first is hoarse; as the swelling goes on it loses its tone, and as soon as secretion is poured out becomes moist, The voice may be husky, hoarse, or completely lost, or the ability to utter certain tones may be absent, while others are within the patient's power. If the patient only speak in a whisper, it may be because of the pain caused by talking aloud, but real aphonia may be present. The hoarseness—or aphonia—is the result of interference with the functions of the vocal cords, and interesting ques- tions arise as to how, in each case, this is brought about. No doubt the fine membrane of the cords may be so swollen as to considerably affect their vibration. So it has been thought that the swelling may interfere with the action of the muscles, which again may undergo an alter- ation in their fibres, while others think that the change of voice is usually dependent on deranged innervation. I think all these causes may beat work in different cases. Mechanical prevention of the movement of the vocal cords unquestionably takes place at times, the influence of the nerves is demonstrable, and the peculiar inequality of tone seems likely to be due to incomplete and unequal muscular action. The expectoration is at first scanty, sometimes it is streaked with blood, and now and then there is sufficient haemorrhage to cause symptoms of fluid in the air-tube. Occasionally a firm clot has formed in the larynx in such a position as to be a dangerous imped- iment to respiration. Pain in swallowing is present when the epiglottis or the parts pressed upon by closing this valve are involved in the inflammation. (Edema of the larynx may supervene in a slight case of superficial inflammation, and may speedily terminate 99 258 SORE THROAT. life. If not relieved it will be fatal in a few hours, and cases are recorded in which no warning preceded death, which, therefore, may be termed suolden. As the infil- tration takes place into the submucous connective tissue, oedema might be called a symptom of phlegmonous lar- yngitis, but it is a condition so important as to deserve to rank separately as a disease; never forgetting that it may be superadded to any laryngeal affection, or indeed to most forms of sore throat. It is almost always a sec- ondary affection. It is brought ofi by acute laryngitis in any of its forms, especially those caused by injury. Any form of traumatic sore throat induces it; scalds are almost always accompanied by considerable oedema. In the throat affections of the exanthems and infective dis- eases, in all cases in which inflammation may spread from other parts to the larynx, we must also look for its occasional appearance. In deeper disease in the larynx itself, as perichondritis, abscess, etc., it is likely to occur. Besides these forms, there is a non-inflammatory oedema which may appear in the course of Bright's disease, or as the result of obstructed circulation, a veritable local dropsy; but this too is dangerous to life, in the same way as the more acute form. OSdema derives its serious aspect from the locality in which it occurs. An infiltration which elsewhere might be trivial may here completely close the narrow air-tube, and thus suffocate the patient. The symptoms are those of suffocation, or rather of obstructed respiration. In- spiration is most laborious, and accompanied by loud stridor. The patient makes most violent efforts to draw in his breath—he often feels as if something were present to prevent this. Expiration is easier, but in time this OEDEMA OF THE LARYNX. 259 becomes difficult. If no relief be obtained, the agony of impending suffocation may close in a final struggle, or the patient may have a respite, to be followed by a sim- ilar paroxysm. Thus, even with permanent obstruction there is the same marked tendency to exacerbations and remissions observed in other laryngeal affections. The inspiration is difficult, because from the position of the parts the two swollen folds are drawn together by the stream of air, but in expiration they are pushed apart. When, therefore, the expiration is also impeded, it is because the swelling is increased, or the folds have become so distended as to be immovable. This, there- fore, marks a higher degree of danger, If no relief be obtained, and the patient does not die in a paroxysm, the aeration of the blood is sufficiently interfered with to change the picture. The gasping and stridor may give way to delirium or coma, and the duskiness and livid- ity common to all forms of impeded respiration ap- pear. The cough, which was painful, and perhaps at first loud, becomes slight or suppressed, as the patient cannot properly inflate his lungs ; or it is interrupted by striolor or gasping ; or it is muffled or noiseless according to the interference with the vocal apparatus ; and the same may be said of the changes in the voice. The ary- taeno-epiglottidean folds are almost always infiltrated, and not selolom the oedema is limited to them, occasion- ally to one of them, or one is much less affected than its fellow. The enlarged folds may be reol, or rather pale, according to the tension, but the point is the swelling which transforms them into a couple of rolls or blisters, which, approaching each other, narrow the opening of the larynx. The word blisters really describes the ap- 260 SORE THROAT. pearance of some of these swellings, which instead of red or pink, are sometimes of a straw-color, anol at the first glance might be said to be collections of fluid beneath the tense membrane—blisters. In other cases there is less tenseness, and so a red or rosy appearance. The epi- glottis may be in a similar condition, and this valve may sometimes be seen on merely depressing the tongue. In other cases the false cords are the seat of the oedema; they then advance over the true cords, hiding them in proportion, and may meet in the centre and close the glottis, or when only one is affected it may advance and cross over to the other side. In rare cases there may be infiltration into the submucous tissue of the true cords, closing the chink of the glottis, but the membrane here is closely attached, and sets a bound to the oedema. OSdema below the cords is equally rare, but was admitted by Cruveilhier and Sestier. Since then Gibb reported cases, anol described some pathological specimens. Ses- tier saw oedema extend into the trachea, but only in seven instances out of 132 cases of laryngeal oedema.* The laryngoscope furnishes us information not only of the presence of oedema, but of its precise position and extent, enabling us to watch its progress, and to intervene at the right time. The examination must be skilfully and rapidly made, and care must be taken not to increase the difficulty of breathing by the position in which the patient is placed, or by prolonging the period of explo- ration. In children, and sometimes in adults, it may be desirable to introduce the finger, which may enable us to determine the position and extent of swelling, or the * Traite de l'Angine Laryngee CEdemateuse, 1852. OEDEMA OF THE LARYNX. 261 presence of a foreign body; but digital is necessarily in- ferior to ocular exploration, and, moreover, is very apt to provoke a paroxysm of spasm. Trousseau mentions a case which for some minutes he thought had proved fatal from this cause. Phlegmonous laryngitis is met with in other forms. A distinct abscess may be formed, either as a result of in- jury, or in the course of perichondritis, which itself is a form of parenchymatous inflammation. Diffuse suppu- ration, though very rare, has been met with by Cruveil- hier and Rokitansky. Diffuse cellular inflammation, accompanying purulent infiltrative erysipelas, is described by Ryland and Porter, and is to be distinguished from the eysipelatous sore throat which occurs in facial ery- sipelas. Treatment of Acute Laryngitis.—In mild catarrhal cases, the treatment aolviseol in inflamed sore throat will suffice. If fever be present, aconite will restrain it, and soothing inhalations, succeeded by astringent sprays, will suffice for the local lesion. In many cases the disease may be cut short by pencilling with an astringent, or by the use of the atomizer. The former plan is, however, only to be resorted to in selected cases. In severe cases more active measures are called for. The first wish is to pre- vent oedema, and that involves arresting the inflamma- tion. Some believe that venesection can do this, and on account of the urgency of the symptoms bleeding has maintained its place in very acute laryngitis longer than in many other diseases. No doubt the circulation is temporarily relieved by the abstraction of blood, and the respiration seems easier. Krishaber and others still ad- vise bloodletting, and afterwards cupping in the neck, 262 SORE THROAT. even when oedema is present. If bleeding be resorted to let it be early enough. As an antiphlogistic or de- pressant, its one advantage is the rapidity with which its effects are produced. With respect to leeches, less differ- ence of opinion exists, and as much may be said for counter-irritants, purgatives, mercury, and antimony. It is natural, in view of the urgent necessity of doing some- thing, and the idea of combating inflammation, that the practitioner should feel impelled towards active antiphlo- gistic treatment; but the results are little encouraging, as pointed out in the first edition of this work, when I ventured to solicit further attention to other methods. I then proposed keeping the patient in a hot, moist atmos- phere, and urged^ too, that anodyne inhalations should be more frequently used, and that chloroform was a justi- fiable remedy, which, though not to be given in a close- fitting inhaler, on account of the gasping for breath, could be dropped on a handkerchief or probang, and held near the mouth. I also recommended ice to be held in the mouth, a remedy which may be supplemented by cold compresses to the neck. Rest to the inflamed organ is most important. The effort to speak is too often encouraged by the friends, and when improvement begins, the physician's intentions are frequently frustrated by allowing talking, or by his directions in this respect being disregarded. Many believe that the application of a strong solution of nitrate of silver will prevent oedema, if applied in time; and others think it may arrest its progress. It must be carefully applied by the aid of the laryngo- scope. Trousseau recommended sprays of tannin or alum, and several cases have been reported in which the LARYNOilTIS. 263 persevering use of these remedies saved the necessity of resorting to operation. But if the oedema be considera- ble, the natural indication is to make an opening for the escape of the liquid. This can be effected by scarifica- tion, guided by the mirror, which should be done when- ever the obstruction to respiration becomes dangerous and is progressing. Incisions, not mere punctures, should be made, when the swelling will collapse unless the liquid be thick, and in such case it should be pressed out, This operation can be performed without the laryngo- scope, but then it is completely a blindfold act. It was first done by Lisfranc before the era of laryngoscopy, and should not be omitted because a laryngeal lancet is not at hand. I have shown how the swollen epiglottis is somot:imes visible on pressing the tongue well down. In such a case it could be scarified with a common bis- toury, the edge being wrapped round with plaster or rag up to within half an inch of the point. A gum lancet might be used if at hand, or in the absence of a pocket-case any knife or other cutting instrument which could be made to answer. So when oedema is not visible, it may sometimes be felt with the finger, and this may serve as a guide to the same improvised instrument. Any practitioner may suddenly find himself face to face with a case in which there is not a moment to lose, and in which this rude but ready method of operation may save life. I am, therefore, more anxious to impress its value on my brethren as a proceeding available in emer- gencies. A still simpler method, when practicable, would be to burst the blister by sudden pressure with the finger, as suggested by Stromeyer, or even to sharpen the finger nail to a point, and try with that, as proposed by Le- 264 SORE THROAT. groux, to let out the fluid. These suggestions have been smiled at—of course they are only available when the oedema is within reach of the finger, and then it may ex- tend much below, so that an effectual vent cannot be provided in this manner; but it is worth while to make the attempt. It is possible the act of vomiting might rupture a tense swelling, so that in some cases an emetic might be useful, or tickling the fauces woukl be more rapid. Although I have dwelt thus on these rough and ready methods, I would have it understood that whenever the instruments can be had in time, the laryngeal lancet guided by the laryngoscope is infinitely superior. The laryngoscope changes this somewhat dangerous proceed- ing of groping blindly in the dark into a precise, safe, and sure operation. It is only, therefore, in emergencies that we should dare to dispense with its assistance. If scarification gives no adequate relief, and if in spite of all our efforts suffocation be impending, we have still a last resort m an artificial opening into the respiratory tube below the seat of obstruction. This operation is not to be delayed until all hope is gone, but performed as soon as other means fail to relieve the progressive dyspnoea. Furthermore, when apparently arriving too late it should not be omitted, some patients having been resuscitated from apparent death by the operation and artificial respiration. Still laryngotomy or tracheotomy may be performed. It is no longer denied that the oedema does not extend below the glottis, therefore either operation will fulfil the indication. Professor Stannus Hughes, in a lecture at the Royal College of Surgeons ('HRO)NIC LARYNGITIS. 265 in Ireland,* has ably summed up the arguments in favor of laryngotomy. The ease with which it can be per- formed, and its efficiency for the purpose, seem to indi- cate it as preferable to the more dangerous proceeding when the opening is only expected to be temporary. These, therefore, seem to be the cases in which it will be selected. In subglottic fibrinous infiltration tracheotomy should be performed. (TIRONIC INFLAMMATION. Chronic cedarrhcd laryngitis may succeed an acute or subacute attack, or may be brought on by any of the causes of an inflamed sore throat, of which it often forms a part. It lingers after the rest of the mucous membrane is restored, or is kept up by the use or abuse of the voice, or by breathing a dusty atmosphere, or any irritation of the larynx. Singers, preachers, lecturers, teachers, hawkers, and others who are obliged to exercise their voices, are very subject to the disease, which also plays an important part in the processes brought about in the larynx by syphilis, consumption, and typhoid fever. The symptoms of chronic laryngitis necessarily may also be produced in the course of caries of the cartilages, or as the results of injuries, or by pressure on the larynx or trachea, as in goitre, or by tumors involving or irritating the laryngeal nerves, as in aneurism. The symptoms may be so slight as scarcely to attract the patient's atten- tion, or so severe as to run into subacute inflammation. It is the voice which furnishes the most striking change. * Med. Press and Cir., May 8th, 1872. 266 SORE THROAT. There may be any degree of hoarseness, or in the mildest cases, only fatigue in speaking, or diminished purity of tone in singing may be noticed. Some hawking, or cough and uneasy sensations, or even pain in the larynx, may be generally present, or only after exerting the voice. The diagnosis is made by the laryngoscope, in which we can watch the course of the disease anol the effects of rem- edies. Congestion is seen differing in every degree,—a partial or general hyperaemia of pinkish hue, or the deep- est red, or livid. There is also swelling, anol later on thickening. The interarytaenoid fold, the false cords, and the edges of the true cords, especially at the posterior part, are most frequently congested. The swelling of the mem- brane in these situations interferes mechanically with the vibration of the cords, and thus the voice may be affected in various degrees. The cords themselves are sometimes deeply congested with or without the same state in the other parts. The epiglottis is also apt to be swollen and red. After awhile thickening takes place; then there is further interference with function. The ventricular bands advance over the cords and restrict their movements. The cords themselves assume a granular or a muddy or dirty-red appearance, and their vibrations are less dis- tinct, and perhaps irregular. Other motor derangements may be added, but these will occupy us further on. Ero- sion is not common, anol ulceration so rare as a result of simple laryngitis that many deny its occurrence. It is common in phthisis and syphilis, but the chronic laryn- gitis of these diseases is so important that I separate it from the common form. Papillary excrescences, and even polypi, seem to develop from neglected catarrh. Granular or follicular laryngitis is recognized by most CHRONIC LARYNGITIS. 267 but not all observers as a process similar to the follicular sore throat. Hypertrojjliy of the mucous membrane, similar to that spoken of in the upper pharynx, may also be seen. I am inclined to regard the thickening already spoken of as of the same nature, as well as the cases described by Tiirck as chorditis tuberosa and tracheoma of the vocal cords. A more important hypertrophy is that which now anol then occurs on the under surface of the cords, anol gives rise to narrowing of the air-tube, on account of which tracheotomy has had to be performed, though in one case recorded by Tiirck the hypertrophy diminished. Rokitansky, who seems first to have noticed this stenosis, regarded it as the result of inflammation, and as having a constant tendency to contract. Venous congestion may lead to a dilated condition of the veins. This is most common on the epiglottis, which is thus varicose. Dr. M. Mackenzie met with it in the larynx, and called it Phlebectasis laryngea* the distended veins running along the orifice of the ventricle, ventricu- lar bands, and vocal cords. He regards it as constitu- tional, but Ziemssen and Duchek believe it to be the re- sult of local inflammation. Treatment.—The mildest forms of chronic laryngitis may be removed in the early stage by the use of astrin- gent solutions administered as atomized spravs. But the cure will be more certain and rapid if pencilling with a stronger astringent be also employed. In more severe and more chronic o-ascs these topical applications must be regularly employed, and it may be needful to increase * Lancet, July 6th, 1862. 268 SORE THROAT. their strength. The salts of zinc, alum, iron, copper, and others are used of varying strength, according to the con- dition presented. When there is great irritability of the parts, or a subacute inflammation, inhalations—anodyne or stimulant—may be premised; creasote and various essential oils are suitable. In other conditions, solution of chlorate of potass, and still oftener bromide of potas- sium, 20 to 30 grains to the ounce, used in the atomizer, will relieve the irritation, and promote healthy secretion. At other times iodine fumigations are better. In still more obstinate cases, with thickening, nitrate of silver of a strength from 30 to 100 grains to the ounce, may be applied; or, instead of this, tincture of iodine, or a stronger solution in glycerin. In the worst cases, solid nitrate of silver may be applied to the hypertrophied membrane by means of the laryngeal cauterizing probe. Sometimes the resources of electro-therapeutics enable us to cope with this obstinate disease. Counter-irritation is sometimes tried, but I have more confidence in constitu- tional treatment, the judicious use of which will often add greatly to the efficiency of local measures. Some cases have been so long neglected or so inefficiently treated that the patients despair, and as soon as a little tempo- rary relief is obtained no longer submit to the restrictions it is desirable to impose. They will drink mineral waters or go for change of air, but do not like to give up habits which aggravate their complaint, or persevere in treat- ment. The influence of a genial bracing climate is gen- erally favorable, and therefore a winter in some southern health-resort may be useful; but neither climate, baths, nor mineral waters should be resorted to until a thorough course of local treatment has been carefully carried out, PERICHONDRITIS. 269 Having spent several entire seasons in various winter health-resorts and summer spas, I have been able to ac- quire practical experience of the therapeutical value of climates and mineral springs, which I by no means un- dervalue, but am the more anxious that these influences should not be brought into disrepute by reliance upon them in unsuitable cases. The fauces sympathize with the larynx, and often need treatment at the same time. Thus, while it is necessary to regulate or restrict the use of the voice, it is equally important to avoid all irritation of the throat, whether by alcohol, condiments, hot fluids, snuff, or other articles. Considering the differences imposed by diathesis, we should not neglect to attend to any constitutional indica- tions. Where hypertrophy has become excessive, it may be found that it progresses in spite of all the treatment de- scribed. Then my glass director may be used to convey more potent destruo'tive agents to the part, but these re- quire the utmost care and circumspection. When the stenosis advances to the extent of hindering aeration of the blood, tracheotomy must be performed. PERICHONDRITIS. We have seen that this is generally secondary, but as it may be traumatic, anol as Schrcetter, Tiirck, anol others have founol it without a primary disease, while some think it may be olue to rheumatism, we olescribe it sepa- rately. It is seldom recognized in its early stage, unless as a part of phthisis. With inflammation of the peri- chondrium comes an abscess which may point into the 270 SORE THROAT. cavity of the larynx, or externally. The pus may be quite circumscribed, or may burrow ; it is seldom possi- ble to distinguish it from a more superficial abscess. The cartilage, deprived of its nutrition, exfoliates; parts may be loosened and escape, or be removed by operation, or suddenly blocking the larynx suffocate the patient, or the dead cartilage may keep up a constant discharge of pus. Very rarely, after exfoliation, a spontaneous cure has ensued. The deformity of the larynx which results usually contracts the tube, and according to the extent of this stenosis will the clinical picture vary. The duration of the case varies as much as the other features. The utmost skill and patience are alike required in the progress of the disease. External abscesses should be opened early. It may be desirable to attempt to remove portions of the necrosed cartilage, and an early opening into the air-tube may be called for. Even in the most favorable cases the stenosis occasioned by the destruction of part of the framework of the larynx necessitates trache- otomy. Generally the unhappy sufferer is condemned to breathe through the artificial opening for the rest of his days, though in this and some other forms of contraction excellent results have recently been obtained by mechan- ical treatment. Curious events occasionally happen, among which may be named the formation of a fistula between the larynx and the pharynx, on the one hand, or the external skin on the other; and the even more rare occurrence of emphysema of the tissues from the air find- ing its way into them through the opening formed by the abscess. The appearances in the laryngoscope present great variety and can scarcely be studied satisfactorily, except in connection with individual cases. GROWTHS IN THE LARYNX. 271 GROWTHS IN THE LARYNX. Polypi, and other laryngeal growths, were very obscure diseases prior to the introduction of the laryngoscope. Now not only are they readily discovered, but their seve- ral varieties can be distinguished and they can be sub- jected to manipulation. In suitable cases they may be removed per vias naturales, and when this is impractio-a- ble other operations may be resorted to. It has already been mentioned that out-growths are apt to take place in the course of chronic laryngitis, and this may perhaps be regarded as the chief cause of the benign growths. Papillomata are the most common of all neoplasms, and are found not only where the mucous surface is abun- dantly provided with papillae, but where it is destitute of them. Their form is very various : small proliferations of any shape, warty-looking bodies, and large tumors, like grapes, mulberries, etc., are seen in various situa- tions ; often they are multiple, and occupy a large space; sometimes they assume a fringelike form. The case de- picted in Fig. 4, Plate II, was brought to the author during the present year. Fibromata are frequent and often pedunculated. Mucous polypi and cysts are not so common, and grow slowly, while they can be treated by making an incision and cauterizing the lining. Myx- omata and lipomata are very rare. Recurrence is common in papillomata, but not in fibromata, and, contrary to what might be expected, cysts do not often relapse. The symptoms produced by new growths of a benign character depend on their size, shape, and position; the 272 SORE THROAT. course of them is regulated by the rapidity of the growth. There may be scarcely any indication of a small growth, Avhile a larger one may block up the larynx to an extent endangering life. The diagnosis is made by the laryn- goscope. The treatment depends on the circumstances. Small neoplasms may remain stationary for years, anol not cause any inconvenience, unless in persons who pro- fessionally use the voice. Some of these even find them quite tolerable; but hoarseness, loss of, or change in the voice may supervene. The vocal impediment may be only intermittent or occasional, according as the tumor interferes with the action of the cords. When the neo- plasm is small and inactive, it may be safely let alone. When it increases it can be removed. Small growths may be got rid of by escharotics, of which nitrate of sil- ver is safest. The more potent caustics are only to be used with the utmost caution. Chromic acid is specially apt to extend its destructive power beyond the growth into the sound tissues. For mechanical removal, various knives, scissors, guillotines, snares, and forceps have been devised, and the operator must select for each case the method of extraction he deems most advisable. Gal- vano-cautery has been successfully employed, and of late years I have resorted to electrolysis. Thyrotomy' can still be performed when the tumor cannot be extracted per vias naturales. Some other operations are also pos- sible. Czerny, after removing large papillomata by this method, washed the entire larynx with solution of per- chloride of iron, 30 per cent., as a preventive of recur- rence. Seven months after there were no symptoms of return. Prolapse of ventricle has now and then occurred, and GROWTHS IN THE LARYNX. 273 is mentioned here as it has been mistaken for neoplasm. Professor Lefferts, of New York, has recorded a case which is unique,—prolapsus of both ventricles. He had the gratification not only to diagnose the case, but, by a bold operation, to cure the patient. Cancer may be primary in the larynx, or may extend to it from the pharynx, oesophagus, or tongue. Epithe- lioma is the most frequent form. It is not often observed in its earliest stage. Hoarseness may be the only symp- tom for a considerable period. Then shooting pains in the throat are noticed, and after awhile dyspnoea and other signs of an impediment to the free passage of air, with further vocal changes. The laryngeal contraction increases until it is necessary to perform tracheotomy. Difficulty and pain in swallowing, enlarged glands, haemorrhage, and other symptoms will be anticipated, or perichondritis may set in early, and cause variations of the manifestations. The laryngoscopic appearances vary with the nature, extent, and seat of the cancer. At an early period the diagnosis may be surrounded with the greatest difficulties, especially when, with diffuse infiltra- tion of the submucous tissue, there is perichondritis. In cancer appearing on the vocal cords it is easier to deter- mine the nature of the growth, and when other organs are involved the problem is simple. The course of can- cer in the larynx is slow, and the early performance of tracheotomy seems to prolong life. After the growth has been removed it returns in a few weeks or months ; but Schroetter says he has had four cases in which this recurrence did not take place. Sarcoma, from its excessive tendency to return, may 23 274 SORE THROAT. be looked upon as malignant. In the larynx it is not frequent, and usually spindle-celled. EXTIRPATION OF THE LARYNX. The removal of the entire human larynx was first ef- fected by Billroth in 1873, for cancer. Czerny had pre- viously performed the operation on dogs. An artificial vocal apparatus was made by Gussenbauer, and the pa- tient enabled to speak, though only in a monotone. In several other cases the larynx has been extirpated ; the first case in this country having been for sarcoma by Dr. Foulis, of Glasgow, whose patient I had the opportunity of examining in January, 1878 ; for eleven months he was able to work in a telegraph office. He died of consump- tion March 1st, 1879, seventeen and a half months after the operation. In 1874 Heine removed the lateral por- tions of the thyroid and cricoid cartilages for syphilitic stenosis. The result of this less complete operation was favorable, but the patient dieol a year later from a fresh outbreak of syphilis, combined with lung disease. This would be just as likely to occur after total extirpation, and, therefore, subperichondrial resection has a claim on our consideration. In fact, partial as distinguished from total removal, re-section instead of c.r-section, may, as I have pointed out,* often suffice. Resection of one vocal cord for epithelioma has been reported by Dr. H. S. Chapman,f and last year a man was exhibited at the Clinical Society of London from whom had been removed * Lancet, January 26th and February 2d, 1878. f American Journal of the Medical Sciences, January, 1878. EXTIRPATION OF THE LARYNX. 275 both the true and the false cords of both sides, but who o-ould still speak in a gruff monotone, believed to be pro- duced by vibrations of the arytaeno-epiglottidean folds. This formidable operation had been undertaken for pa- pilloma, and cannot, therefore, be compared with cases of malignant growths. It was not shown why less severe measures were not previously resorted to. The future of rc-section and ea'-section must be largely influeno^ed by the feelings of the patients for whose relief operation may be proposed. Some with fair prospects of survival woulol refuse to submit to extirpation. Others may be glad to have life prolonged under the olisadvan- tages imposed by an artificial vocal apparatus. Others would gladly undergo even a desperate operation which held out to them the hope of relief from their sufferings. The less formidable proceeding of partial removal will be more frequently accepteol. Great responsibility rests upon us in advising the course to be pursued, and it is to be hoped that the future of extirpation may not be imper- illed by a rash resort to it when less radical measures would suffice. SPECIFIC DISEASES. Syphilis is more frequent in the larynx than is gener- ally believed. It often comes on long after the disease was supposed to have been eradicated, and is not only very destructive to the tissues, but dangerous to life. Yet it does not set in with violence, but has often proceeded far before advice is sought. I have discovered consider- able destruction when the patient supposed there was little the matter, and even when he had been unconscious of laryngeal trouble. Congestion or slight inflamed sore 276 SORE THROAT. throat may be the first manifestation of the invasion. Later come the intermediate manifestations well described by Dr. Whistler.* Mucous patches, condylomata, gum- mata, ulcers,—destroying the tissues and leaving exten- sive cicatrices, the contraction of which produces stenosis, —perichondritis, necrosis of the cartilages; these are some of the results of syphilis in the larynx. There is little that is characteristic about some of the manifesta- tions of this disease. Hence in some cases the greatest care is required to avoid errors. Other forms bear upon them distinct marks of their origin. The color to an ex- perienced eye may be suggestive, though it is not pathog- nomonic. Thus, in syphilitic erythema we often find a dusky, dark-red, or even purple hue, sometimes a mot- tled appearance which is very different from the rosy or scarlet hue of ordinary catarrhal laryngitis; this differ- ence of hue I have previously pointed out, but it is not recognized by all observers; at the same time it is to be remembered that, at all stages of syphilitic disease, the larynx may be attacked by ordinary catarrh. Hoarse- ness is often an early symptom, and it has been thought to be characteristic, but impaired voice may occur from many other causes, and the degree of hoarseness or loss of voice depends so much on the position and extent of the morbid process, that the tone of the vox syphilitica can scarcely be distinguished. CEdema may be set up and carry off the patient, and fatal haemorrhage from deep ulceration was reported by Tiirck. AVhen proper treat- ment is not carried out the ravages of the olisease are fearful,—perhaps involving the whole larynx and trachea, * Lectures on Syphilis of the Larynx, 1879. LARYNGEAL SYPHILIS. 277 —even the parts which are not ulcerated being either injured in the course of the perichondritis, or utterly de- formed during cicatrization ; of course the voice is de- stroyed and life is endangered or lost; nevertheless, treat- ment enables us to hold this disease in check, or to arrest it in its progress, or to prevent some of its worst results, or to remedy some of the injury it has done. In Fig. 6, Plate II, is depicted a case in which ulceration occupies most of the posterior surface of the epiglottis and one false cord, while one arytaenoid is also ulcerated. This patient haol greatly neglected himself, and the plate shows the condition of his larynx when I was first consulteol. Many other cases have come under my notice which had in the same way been neglected, and some which had un- fortunately been long treated as simple sore throats. The treatment must be twofold : that directed to the constitutional state, and that proper to the existing lesion of the larynx. It used to be said that laryngitis Was the signal to pour in mercury, but notwithstanding the revival of the tendency to this practice I still prefer in the ma- jority of cases iodine and its salts. The inhalation of a spray of bichloride of mercury has been advised, but it is impossible to measure the quantity of the medicine thus introduced into the system ; and it seems to me in no way preferable to other remedies which are not capable of doing mischief. In ulceration, pencilling with iodine, the bio'hloride of mercury, and nitrate of silver are re- sorted to. If the ulcer be deep I prefer the solid nitrate, and if rapidly extending even more potent caustics may be neeo\ssarv. At the same time iodides must be given in full and frequent doses, the patient being brought as rapidly as possible under the influence of the drug. Con- 278 SORE THROAT. dylomata may be touched with solid nitrate of silver. GCdema, abscess, caries of cartilage, anol other conditions must be met according to the indications. Stenosis, in- terfering with breathing as well as the voice, may demand tracheotomy; after which attempts at dilatation may be made, or in some cases it may be well to divide a part of a contracted membraniform cicatricial band, and then dilate. These cases are very trying to patient and phy- sician, but the results are sometimes such as to amply repay both. Glanders is another disease consequent on the inocula- tion of an animal poison, and which affects the larynx in a certain proportion of cases, but scarcely ever without the pharynx being also implicated, and even the trachea and bronchi. OZclema may supervene. When recovery has taken place, cicatricial contractions have been observed, giving rise to the symptoms due to the deformity. Laryngo-typhus has been proposed as a name for the laryngeal complication which too often attends, or is set up by typhoid, and may be compared to the intestinal lesion. At first there is laryngitis, which cannot be dis- tinguished by any special appearance. It may be superfi- cial or deep. Ulceration or abscess follows, and all the sad train of symptoms which mark perichondritis. This complication is very fatal. For the resulting stenosis tracheotomy must be performed. When recovery takes place the tube usually has to be worn for life. Ulcera- tion may be treated with more hope. It may have al- ready proceeded far before hoarseness has arrested atten- tion, and just as the patient's convalescence from the fever seems established he may be seized with urgent dyspnoea, OTHER LESIONS. 279 which leads to laryngoseopic examination, when a most grave lesion is detected and will probably prove fatal. Lupus of the larynx, of which Dr. Lefferts* gives an excellent description, may be next mentioned. It was first observed by Tiirck, who met with four cases chiefly affecting the epiglottis. If looked for, it must be more common than one might suppose from the literature ; for only ten cases have been reported, and some of these seem doubtful. Ziemssen reports a case in which there was no lupus either of the pharynx or skin. The treat- ment must be cod-liver oil, and locally destruction of the new growth by solid nitrate of silver or such other means as may seem indicated. Leprosy.— In elephantiasis graecorum alterations, iden- tical with those on the skin, have been seen in the larynx, and here they are olisposed to ulcerate early. In May, 1879, Dr. Elsberg exhibited! at the New York Patho- logical Society the larynx of a leper, which he had ex- amined with the laryngoscope the previous autumn, and compared the description he then gave of it with the ap- pearances found after death. OTHER LESIONS. Consumption, as involving the larynx, is so important that I shall consider its phases in the next chapter. Ner- vous derangements, hoarseness, aphonia, and other affec- tions of the voice are also too important to be disposed of at the close of a chapter. Besides these, ossification of the cartilages, anchylosis, and other morbid conditions have * American Journal of the Medical Sciences, April, 1878. f New York Medical Record, August 2d, 1879. 280 SORE THROAT. been noticed. Moreover, the changes caused by the press- ure of tumors or other disease external to the larynx itself may be mentioned. Injuries and wounds of the larynx result from various accidents, from attempts at homicide or suicide, and are more frequent still in war. Contusions, as in throttling, m'ay cause aphonia, and be soon recovered from. Dis- placements, fractures of the cartilages, and other injuries will probably require early tracheotomy. In incised wounds much depends on the position of the injury. In gunshot wounds there is always the question of the presence of the projectile. Foreign bodies finol their way into the larynx under circumstances already mentioned. The symptoms differ with the shape and position of the body, which may per- haps reach the trachea and pass into one of the bronchi —usually the right. It may be necessary to interfere surgically at a moment's notice, or it may be proper to leave the patient at rest for a time, and trust to the body being coughed up, which has happened in many cases. No general rule can be laid down save this, that any body which is accessible by laryngoseopic aid should be removed at once, or it may move to an inaccessible posi- tion and necessitate a serious operation or endanger or destroy life. A list of the bodies which have been drawn into the larynx would occupy no small space. These cases require the application of special skill combined with sound common-sense. LARYNGEAL PHTHISIS. 281 CHAPTER XX. LARYNOJEAL PHTHISIS--THROAT CONSUMPTION. Laryngeal phthisis will be treated here chiefly from a clinical point of view. With the great pathologists at variance as to its nature, and, indeed, with all the doc- trines relating to consumption in a state o>f chaos, it would be impossible in a brief space to examine the various opinions which have been enunciated. I shall therefore chiefly confine myself to the clinical aspects of the disease, on which an experience of many years, as physician to a consumption hospital as well as to the Hospital for Dis- eases of the Throat may entitle me to speak. It is as an addition to pulmonary consumption that we mostly meet with laryngeal phthisis; but eases occur in which the disease may be seen in the larynx before it can be detected in the lungs. Every one is aware how often consumptives suffer in the throat, or have some hoarseness or change in the voice. About two-thirds, perhaps, of all cases present some throat symptoms. About half are troubled to a greater degree. A smaller number suffer much—thus Louis founol ulcerations in one-fourth of the bodies he examined. The symptoms of this formidable disease are those of weakness, succeeded by chronic inflammation and ulcer- ation of the larynx, associated with the general indica- tions of consumption. Chronic laryngitis, or an ordinary 24 282 SORE THROAT. sore throat in a person predisposed to consumption, is a very suspicious ailment, I have, to be sure, seen many such cases rapidly recover, and even granular conditions may amend in such constitutions, but there is always danger, and neglected sore throat is likely to excite the fatal disease. In the earliest, or premonitory stage, the larynx is gen- erally anaemic, and the same condition prevails over the whole throat. Anaemia of the mucous membrane may be only a part of a general anaemic condition, but excluding ordinary causes it is suspicious. At this earliest stage, sometimes the mucous membrane will put on at some spot an appearance of roughness, which will increase until a vegetation seems to sprout up which may resemble a papilloma. It is important not to remove this by opera- tion,—a mistake sometimes made,—as, if the case prove consumptive, the spot will ulcerate and the patient at once be thrown into an advanced stage of the disease. A little later congestion takes the place of anaemia; but the hyperaemia in well-marked cases differs from that produced by other causes. It may occur only in parts or be diffused. Even in the latter case it looks like conges- tion implanted on anaemia, and when it occurs in patches the pallor of the intermediate membrane is easily recog- nized. The vocal cords may become congested, and even when not red the membrane here, as well as elsewhere, loses its transparency, and assumes a peculiar opacity, very significant to the practiced eye. On this, congested ves- sels are seen coursing in various directions. In other cases the congested mucous membrane presents a dull velvety appearance. Besides the peculiar congestion we have swelling. This LARYNGEAL PHTHISIS. 283 is most marked in the neighborhood of the arytenoids. Infiltration takes place in the membrane coverino- the cornicula, and the outline of the parts in the arytamo-epi- glottidean fold Ls lost, so that we have the appearances sometimes thought pathognomonic, but which may be simulated by any cause of tumefaction. Compare the swelling in simple inflammation, Fig. 1, in Plate II, with Fig. 5, which shows the swelling in a phthisical case. A similar infiltration often occurs in the epiglottis, and this valve is often deformed : sometimes one side seems most affected ; at others it is folded together, and in shape re- sembles a horseshoe. The swelling may affect both cor- nicula or one, or one more than the other. It is common for disease in the larynx to begin on the same side as in the chest. At a still later stage erosions and ulcerations take place. The ulcers are not deep but rather flat; their e.Iges may be pale, but are often red ; and an areola of conges- tion may extend around them. They have certain re- semblances to strumous ulceration on the skin. From them small vegetations often sprout up, and may be misr taken for ordinary growths. Occasionally I have seen them of considerable size, and not at all unlike some papillomata. Ulceration usually begins between the ary- taenoids, or near the vocal pro 'ess, but later other parts are affected in the same way. In Plate II, Fig. 5, there is an ulcer on the left false cord. The epiglottis is a fre- quent seat of ulcers. On its posterior surface they are large and flat; at the border they often give a worm-eaten look to the eolge. Such are the more common laryngoseopic appearances in the course of this very fatal disease, but they are capa- 284 SORE THROAT. ble of almost infinite variations. Perichondritis may take place before or after ulceration, and greatly change the aspect of the image. Haemorrhage may supervene, and almost always variation in the secretion will alter the view. The other symptoms, too, may vary. Cough and ex- pectoration may both be slight or very troublesome. Dyspnoea may appear early or not until late. But it will be observed that these are not symptoms exclusively relating to the larynx. In any case we may have with laryngeal disease all the varieties of general symptoms met with in pulmonary phthisis. The voice is more de- pendent on the local condition. Hoarseness is common and appears early. It does not always depend on the congestion of the cords. There may be paresis and early hoarseness, or even aphonia. The voice is usually char- acterized by weakness, and is liable to frequent changes in pitch ; sometimes it is suddenly interrupteol, suggest- ing the existence of a movable growth, momentarily taking a position which interferes with the movement of the cords. This perhaps arises from secretion acting in such a manner, for the voice is often restored after a sputum is coughed up. It cannot be said there is a char- acteristic consumptive voice. Pain in the larynx is not uncommon, and tenderness is usually manifested on pres- sure, but pain in swallowing is far more important, It may appear early and is progressive, often being the source of the patient's greatest misery. AVith this dys- phagia there may be, too, return of the substance through the nose or into the mouth. This begins with liquids, but may also extend to solids; it is the bar to nutrition caused by this dysphagia, which often hurries on the case CONSUMPTION. 285 to an early fatal termination. It is partly due to the in- terference with the action of the epiglottis, permitting ali- ments to enter the larynx in the act of swallowing, partly to compression of the larynx by the constrictors, and partly to more local izeol changes, inflammatory or ulcera- tive. The constitutional treatment of laryngeal phthisis need not detain us, as it does not differ from that of pulmonary consumption. The local indications differ much in in- dividual cases, and also vary during the progress of the o-ase. But this may be positively asserted,—much relief may almost always be afforded, and permanent benefit may be conferred by careful topical treatment. Not- withstanding the naturally fatal character of the disease, cure may sometimes occur. Several recoveries have now taken place under my care, and in opposition to the ma- jority, I must therefore maintain that laryngeal phthisis is not incurable. Some of these cases I communicated several years ago to the British Medical Association. One of them was in a young woman whose lungs were both oliseaseol as well as her larynx. This had proceeded to ulceration, and the case is one of the most satisfactory instances ever recorded of arrested consumption. A picture of the laryngeal image was published in my " Lessons in Laryngoscopy and Rhinoscopy," after the patient had for some time resumed her career as an opera- singer. In the earlier stages when there is, as it were, only a constitutional chronic laryngitis, remedies appropriate for that condition may be tried, and they will sometimes serve to restrain the morbid action, but only the mildest are to be selected or mischief may ensue. Sprays are for 286 SORE THROAT. this reason most suitable. It may be desirable sometimes to supplement them by pencillings, but this method is only to be resorted to when the indications are clear, and only repeated when really required. Nee nimis vcd.de, nee nimis sozpe, would be a good motto for those having charge of these cases, for the relief afforded by a well-timed measure often leads the sufferer to desire its repetition in less suitable circumstances. It may be neces- sary to precede all other measures by anodyne inhala- tions, which will often have to be largely used in later stages. Stimulant inhalations and fumigations are also useful. Carbolic acid, creasote, and iooline are the most commonly used, but should be carefully prescribeol and the effect watched. As soon as astringent and tonic sprays can be taken, they seem most effective, and prior to them we may use bromides and other salines in this form. Lozenges, gargles, and other modes of medicating the en- tire fauces will all, in turn, be useful. When pain and dysphagia become distressing, insufflation of morphia from time to time gives relief, and anodyne inhalations may be called for at more frequent intervals. It may be necessary to apply nitrate of silver to the epiglottis when ulceration of the edge is accompanied by intense pain in swallowing, but the strength should be carefully adjusted to the case, and the operation is not to be per- formed unless absolutely necessary—still less desirable is it to repeat it. Alum anol tannin are often recommended in such cases. Acute oedema may occur, and of course must be treated according to the degree of stenosis it pro- duces ; but the chronic infiltration we have described is very different, and does not call for scarification. The wound made would not heal, and this infiltration and CONSUMPTION. 287 thickening could not be cured by the incision like simple oedema. In fact, nimia diligentia medici is to be avoided throughout the treatment, and instead of interfering too much with the larynx, it will be better for the attendant to olirect his ingenuity to the problem of maintaining nu- trition, which is often sadly interfered with. Local ap- plications to the throat may also restore for a time the power of swallowing, and are therefore a source of the greatest comfort; in many cases this is the chief, almost the only indication. The food must be carefully pre- pared and presenteol in a soft or semisolid state, eggs and milk being largely made use of. In some cases it is neces- sary to feed the patient through a tube. Tracheotomy may possibly be required on account of oedema, or the consequences of perichondritis. It has been proposeol to perform this operation in order to afford rest to the larynx, but the disease is not an encouraging one for such an effort. Some recent statements seem to show that the question may have to be entertained more frequently than it has been. 288 SORE THROAT. CHAPTER XXI. LARYNGEAL NEUROSES--AFFECTIONS OF THE VOICE. We have seen that the true vocal cords are in con- stant movement, alternately approaching and receding from each other, thus closing or opening the glottis. During perfectly quiet respiration they may be watched nearly or quite motionless in the position of rest. On a deep inspiration being taken they separate widely, re- turning in expiration towarols the median line, where they meet on vocalization. The voice is, in fact, formed by the vibrations of these vocal cords when stretched tensely from front to back across the larynx. Thus we see that interference with their movements will affect both the breathing and the voice. If they cannot approach the median line the voice will be lost. If they cannot be drawn apart the breathing will be distressed in exact proportion to the extent to which the glottis is contracted. If, when brought near each other they cannot be made tense or set in vibration, the voice will be changed or lost according to the extent to which their actions are impaired. Now the movements of the vocal cords may be im- peded by extrinsic circumstances. Thus swelling of the parts around may prevent their approximation or proper vibration, in which case loss of voice or hoarseness will LARYNGEAL NEUROSES. 289 ensue; anchylosis of the arytenoid cartilage may produce similar interference with vocalization ; a polypus has been spoken of as sometimes coming between the cords. These and other circumstances, including the changes we have witnessed in the diseases already discussed, may any of them prevent the free movements of the vocal cords. But, in addition to all this, the movements may be im- paired or abolished by intrinsic changes,—paresis or pa- ralysis. When all control over a limb is lost it is said to be paralyzed. But palsy is not always complete, and we seek to know what muscles or groups of muscles are un- able to act. Just as we speak of the flexors and exten- sors of a limb, so the muscles which move the vocal cords towards the meolian line may be called ao?ductors, while those which withdraw them towards the sides of the larynx may be termed a&ductors. Now, as the chink of the glottis is widened by the latter and closed by the former, the two groups are also named respectively di- lators or openers, and contractors or closers of the glottis. Here, as elsewhere, in health two antagonistic forces balance each other, and if one be interrupted, the other will have full play. If, then, the action of the a&ductors or openers of the glottis be impaired, their opponents— the adductors—will be proportionately unrestrained, and by maintaining the vocal cords near the meolian line re- duce to the same extent the aperture of the glottis. The consequence is inspiratory dyspnoea with stridor, which usually comes on gradually, is greatly aggravated by ex- ertion, and suffocative paroxysms are apt to occur. Yet there may be no congestion or inflammation and the voice mav not be affected. There is no hindrance to 290 SORE THROAT. vocalization, but the disease affects the respiration in the gravest manner. The passage for air is in fact closed in the exact degree in which the cords are not drawn apart. The only help for such a case is to perform tracheot- omy. It is the respiratory not the vocal function that is interfered with, and life is therefore at stake. Fortunately such cases are rare. When an opposite condition exists—paralysis of the closers of the glottis—respiration is free, life is not en- dangered ; but inasmuch as the adductors cannot bring the cords to the median line, the voice is lost. This is a very common affection, is frequently associated with hysteria and various nervous disorders, and spoken of as functional, hysterical, or nervous aphonia. Of course the same paralysis may be produced by organic causes. It may be caused by congestion and inflammation, and linger after these have passed by. Central nerve lesions may also give rise to it, but this is rare. It is amenable to treatment, Instead of both vocal cords, only one may be paralyzed. To distinguish such cases the term unilateral paralysis is used, the word bilateral being applied when both cords are affected. I often use the words single and double for the same purpose. The symptoms of paralysis of a single cord are naturally less intense, and the laryngoseopic ap- pearances are characteristic. Thus, when the abductors of one cord fail to act, it is not drawn aside, and only half the glottis is opened. Though the dyspnoea and stridor are not so urgent as in the bilateral, or as I propose to call it, double form, on the least exertion they become very distressing, and various constitutional symptoms will arise in the course of the disease. This paralysis is gen- AFFECTIONS OF THE VOICE. 291 erally dependent on distant lesions, and little can be done for its relief; but if suffocation seems threatened, trache- otomy may be performed. When the opposite paralysis of a single cord exists, respiration is free, but phonation is affected because the paralyzed cord cannot be brought to meet its fellow. The voice is not, however, necessarily lost in this single paral- ysis, for increased action on the healthy side to some ex- tent compensates for the loss of power on the other. Thus we see in the laryngoscope that on phonation the healthy cord is carried beyond the median line towards the opposite side. In this way the cornicula laryngis sometimes actually cross each other, and the glottis looks oblique. The degree to which the voice is affected de- pends on the amount of interference with the normal movements. The disease is usually more important in respect to the voice than otherwise; but if there be pa- ralysis of any other part, or any sign of central nerve disease, the case assumes a more serious aspect. Instead of the muscles which open and close the glot- tis, paralysis may affect those concerned in vocalization. It is true, that for the exercise of this function the ad- ductors must bring the cords together, but that is only a preliminary step. They must then be made tense and set in vibration. The vocal muscles or tensors of the cords must therefore be calleol into action. Just as in tuning a harp or violin, we first screw up the strings tight enough to enable them to give out tones; so the tensors may be regarded as stretching the vocal cords be- fore they can be made to vibrate. The larynx is, in fact, the most marvellous of musical instruments, and from its two strings—the vocal cords—are elicited the innumera- 292 SORE THROAT. ble variations of the voice. Notwithstanding the simple manner in which we may group the muscular mechanism for attaining this astonishing result, it is necessarily ex- ceedingly complex, and its study as difficult as it is at- tractive. As in other parts, it is desirable to study the effect of paralysis of indiviolual muscles as well as groups, and a good deal remains to be done in this direction, though something has already been accomplished. The degree of hoarseness or the extent of loss of voice through paresis or paralysis of the vocal apparatus depends very much on the muscles involved, and may vary from abso- lute aphonia to mere impurity of tone. So the patient may have the scale considerably diminished, or may per- ceive a want of clearness or ease in the production of a single note. In the coarser forms of paralysis of the tensors we see in the laryngoscope that the cords, instead of being stretched tensely across the larynx, are loose, either in part or throughout their length, so that the shape of the glottis is altered by that chink being wideneol where the cords are not tense. We may thus have an elliptical glottis bounded by two curved cords, or if the paralysis be single the opening is straight on one side and curved on the other. In the same way either the inter-cartilag- inous or inter-ligamentous portion of the cords may either of them fail to meet. Other deviations may also be noticed. The difficulty of deciding the exact deficiency in a given case, is increased by the fact that the individual muscles may not act alone, but that their co-operation is often required to produce the delicate movements of vo- calization. Moreover, in some cases the fibres of a muscle may not all act at once, or in the same olirection. To AFFECTIONS OF THE VOICE. 293 specify the ao-tions of which the several laryngeal muscles are capable, is not necessary for our present purpose. We need only remind the reader that their functions may be impaired by organic changes in their own tissues, or by any morbid process in the neighborhood, e. g., in any of the forms of sore throat we have had to consider. This is why hoarseness, or else inability to emit certain notes, is one of the commonest symptoms of sore throat, which may also give rise to complete aphonia. Either the swell- ing which accompanies the hyperaemia of the mucous membrane suffices to impede the delicate movements of the muscular fibres, or else it so acts on the nerves as to produce a similar result. In fact, we may lay it down as a rule that catarrh produces paresis, and cull examples of this condition in catarrh of the bronchi, stomach, and intestines, and still more often the bladder. A parallel case of loss of function in a sensory nerve also occurs when a cold affects the nose. Loss of smell is experienceol as soon as the swelling of the membrane produces a sen- sation of stuffiness. This brings us to consider that the muscular palsy of which we have been treating, is to be traced back to interference with innervation. This may not only occur at the periphery, as in the cases mentioned, but in any part of the trunk of the nerve, or at its origin. In fact, paralysis of the vocal cords is to be studied in the same way as other forms of palsy. While, therefore, only the laryngoscopist can appreciate the varieties of nerve lesions in the larynx, he must bring to their study all the information that has been accumulated respecting the diseases of the nervous system. While fully alive to the possibility of tumors in the course of the recurrent existing, it has happened in cases of laryngeal paralysis 294 SORE THROAT. that able observers have been unable to detect any such lesions, although long afterwards aneurism of the aorta, or cancer of the oesophagus, became manifest. So tumors in the mediastinum, or at the base of the skull, and cen- tral nervous disease, must not be forgotten as possible causes of a paralysis, which might otherwise be attributed to curable conditions. The treatment of laryngeal paralysis depends so ob- viously on the case that general rules are of little value. In purely functional aphonia most striking results are often achieved, but they are apt not to be permanent when only local measures are employed. Anything which will produce a sudden approximation of the cords,—a spasm, —even an unexpected mental influence, will restore the voice instantly in hysterical and nervous aphonia. I have often had results from most simple means, which the patients and friends looked upon as almost magical. But in such cases the nervous system requires fortifying, and it is most desirable not to confine our attention to the laryngeal manifestation. The resources of electro-thera- peutics are of the greatest value in aphonia. In the de- fects which result from overstraining of the voice in speak- ing or singing, we may obtain satisfactory results from a regulated series of vocal gymnastics. It is almost need- less to repeat what I have taught for twenty years, that hundreds of cases of failure of the vocal power in the clergy, public speakers, and singers—all who employ the voice professionally—are caused by an improper use of the voice, and may be cured by regulated training ; any abnormal condition which may have been brought on or coexist being of course first removed by appropriate remedies. AFFECTIONS OF THE VOICE. 295 Spasm of the Vocal Cords.—Instead of decreased action in the muscles which move the vocal cords, there may be the opposite condition. When the adductors are thrown into spasmodic action, the glottis is suddenly closed and the breathing interrupted. Then we have the phenomena of so-called spasm of the glottis, already considered in connection with croup and false croup. Glottic spasm is the feature of various forms of paroxysmal interference with respiration, met with in children, and which have been termed false croup, spasmodic croup, cerebral croup, laryngismus stridulus, child-crowing, crowing-inspiration, suffocative catarrh, Millar's asthma, Kopp's asthma, be- sides numerous other names. The essential condition in these cases is commonly termed " spasm of the glottis," a phrase manifestly inaccurate, but sufficiently expressive. Spasm of the vocal cords is more correct, as it is excessive action of these which occurs ; but, of course, only by their muscles being thrown into undue contraction. This may be due to peripheral causes, or to any irritation in any part of the nerve, or to central disease, just as in the case of paralysis. Moreover, we may divide the irritants into direct and reflex. If now we consider the various ways in which spasm of the cords may occur, and then the ex- treme liability of children to all convulsive diseases, and of the infantile larynx to take on spasm, we shall be able to understand the difficulties which have been met with in the cases described under such various names, and to appreciate the clinical descriptions which have been handed down to us. Here, too, it is well to repeat what has been previously stated, that paralysis of the dilators of the glottis may certainly produce a similar train of 296 SORE THROAT. symptoms, and was considered by Dr. Ley* to be the es- sential cause. The phenomena are so characteristic of spasm that in the majority of cases we must recognize that condition, but paralysis also occurs, though more rarely. The degree of spasm accounts for the symptoms ; when complete the breathing is arrested, when incomplete the inspiratory stridor is the leading phenomenon. If momen- tary only, there is merely the catch in the breath, often observed in the early stage. If prolonged it may destroy life. Generally, the spasm relaxes as soon as insensibility approaches. Though most common as an affection of chilolhood, spasm may attack adults, but in these paralysis is more frequent. Among the numerous possible causes of spasm, it has lately been again suggested by Franz Heller that acid fluid from the stomach may pass through the cardiac orifice, and when the position is favorable reach the larynx. Perhaps this may be admitted as one cause—an occasional one; for we know that the contents of the stomach are easily eructated, besides which when the patient lies on the side with the head low, fluids easily slip from that viscus along the oesophagus. Dr. Solis Cohenf suggested that the epiglottis might become im- pacted, and so cause spasmodic cough and suffocative paroxysms. He has lately recorded^ two cases in which sudden incarceration of this valve was founol to exist, and on being released the paroxysm subsided. It is obvious that such impaction would arrest respiration as readily as spasm of the vocal cords. In this case, how- * A Treatise on Laryngismus Stridulus, London, 18.36. f Diseases of the Throat, New York, 1872. X Medical and Surgical Eeporter, Philadelphia, March 16th, 1878. STAMMERING OF VOCAL CORDS. 297 ever, laryngeal spasm is not a misnomer, since the epi- glottis is supposed to be first drawn down by inordinate action of the arytaeno-epiglottidean muscles, and then to become impacted. SjHismodic cough also affects both children and adults, and is closely allied to the diseases already mentioned and other nervous disorders. I have known constant barking spasmodic cough, which seemed to produce no local effect, continue for Aveeks uninfluenced by treatment, Hysteri- cal and nervous laryngeal coughs are recognized by many and are very intractable. It is necessary in all these cases to employ general treatment, carefully aolapted to each patient. Spasmodic action of the cords is also met with in whooping-cough, and I have observeol that anomalous cases of laryngeal spasm seem often to be but the remnants of that disease. Stammering of the Vocal Cords.—Under the title of "a hitherto undescribed laryngeal affection," I submitted to the last annual meeting (August 1st, 1879) of the British Medical Association a brief description of a disease which seems to be due to a defect in the power of co-or- dinating the intrinsic muscles of the larynx, and which I proposed to call vocal stammering, or stammering of the vocal cords. In this disease the vocal apparatus fails at intervals to properly carry out the behests of the will, giving rise to sudden interruptions to the voice, while the articulating power may be unaffected. As in the gener- ally recognized impediments of speech, the harmonious action of the groups of muscles engaged in articulation is disturbed ; so in the vocal derangement I have discovered there is an analogous laryngeal motor disturbance. The disordered co-ordination Avhich so commonly interferes 2o 298 SORE THROAT. with the utterance of syllables may disturb the production of voice only. Thus Ave see the movements required for producing syllables perfectly performed, Avhile the vocal sound is at intervals suddenly arrested. There is an in- termittent momentary voiceless condition. This may cause the patient to stop speaking, or he may continue a sentence from Avhich some A\Tords are lost to the listener. A cler- gyman suffering from this disease in an aggravated degree was exceedingly distressed by his consciousness of the fact that though he kept on reading the service, some of the worols dropped soundless from him, and his friends Avatched his lips mo\Ting in the usual Avay Avhen Avorcls and phrases Avere lost in silence. The sudden interruption of the function of the vocal cords in such cases is most difficult to demonstrate; it is very unlikely to occur during the utterance of such sounds as are usually emitteol in laryngoseopic examinations. I had to Avateh for a long period and to devise special methods before obtaining ocular demonstrations of this stammering of the vocal cords. Isolated sounds in the most confirmed stammerers may be correctly articulated ; so also in these vocal impediments the patient can emit separate tones, and may even run up and doAvn the gamut Avith ease. But now and then Avith certain combined sounds rapidly produced in succession, a sudden hesita- tion or temporary arrest of the laryngeal movements will occur. The vocal cords hesitate or tremble for an instant at a point not sufficiently approximated for vocalization, Avhere they move as with a series of ineffectual efforts to obey the will, or display the paroxysmal spasmodic or ir- regular actions seen in the mouths of confirmed stammer- ers, or the less distinct interferences Avith utterance called AFFECTIONS OF SENSORY NERVES. 299 " hesitation of speech." In fact, most of the derange- ments commonly grouped under the expressive term im- pediments of speech may henceforth be said to have their counterparts in similar vocal impediments occurring Avithin the larynx. These and other nervous affections may prove a heavy burden to persons Avith Avhose occupation they do not in- terfere, while they may altogether suspend the work of clergymen, barristers, singers, and others aat1io make a professional use of the voice. Affections of Sensory Nerves.—Anaesthesia, hyperaesthe- sia, neuralgia, and parasthesia have been established as sometimes affecting the larynx. I ha\Te long recog- nized these conditions, and recently they have. received more attention. Diminution and abolition of sensation in the throat is known as a sign of approaching death, as Avell as of diphtherial paralysis. I haATe found distinct laryngeal anaesthesia in the latter as Avell as in labio-glosso- pharyngeal paralysis, and although this has only lately been generally admitted, Chairou, \Ton Ziemssen,Schnitz- ler, and others have reported cases. The same condition accompanies some other nervous affections. Neuralgia of the larynx is not very frequent, and moderate degrees of hyperaesthesia are difficult to appreciate in consequence of the great range of normal sensibility in different per- sons. Nevertheless, I haATe had cases which Avere unmis- takable. The spasmodic cough alluded to above would seem to be associated Avith hyperaesthesia, if not depen- dent upon it, in connection, perhaps, Avith increased reflex sensibility. The treatment of laryngeal neuroses is to be conducted Avith care. In electro-therapeutics Ave ha\-e resources, 300 SORE THROAT. Avhich are not sufficiently appreciated, Avhile other local and constitutional treatment should not be neglected. Sometimes we are baffled by an obstinacy Avhich nothing changes, at others Ave are rewarded with ready success. Anaesthetics and anodynes are sometimes of use locally, but seldom serve any purpose given internally. This is why patients with pure laryngeal cough, spasm, or other nervous affections of the throat, may be half poisoneol by narcotics Avithout procuring relief. Yet when the system has been vainly saturated Avith these drugs, the recogni- tion of the true nature of the case enables us to apply remedies, the effect of Avhich may appear little short of marvellous. But these successes are not achieved by mere happy guesses. They are but the application of general principles to special purposes, and illustrate in the domain of the nervous system the connection already pointed out in so many other respects betAveen affections of the throat and other diseases. TRACHEA AND BRONCHI. 301 CHAPTER XXII. AFFECTIONS OF THE TRACHEA AND BRONCHI. The trachea, or Avindpipe, is the portion of the air- tube betAveen the larynx and the bifurcation into the bronchi, opposite the third dorsal vertebra, from four to four anol a half inches long, and from three-fourths of an ino'h to an inch in diameter. It is composed of from fifteen to twenty rings of o'artilage, connected by mem- brane, together Avith muscular, areolar, and elastic tissues. The organ is supplied with vessels and nerves, and lined with mucous membrane, having ciliated epithelium and glands. The rings of the trachea are not perfect. Behind there is a portion wanting, and the space is filled up by the membrane. The tracheal image, as reflected in the mirror, is portrayed on Plate II, Fig. 3, in Avhich the openings of the bronchi are also seen. The skilled laryn- goscopist Avill not need directions as to the best Avay of examining the image, and the beginner will probably not be able to see beloAv the larynx. The natural angle at the junction of the larynx and trachea must be reduced as much as possible by inclining the head backwards, and the light must be sufficient to illuminate the whole tube. Care must be taken not to mistake for disease the normal pulsation sometimes observed in the lateral Avails just above the bifurcation. This pulsation, first pointed out 302 SORE THROAT. by Gerhardt, and fully described by Schrotter, is prob- ably produced by the vessels Avhich lie in contact Avith the tube. Congestion and inflammation of the Avindpipe are com- mon enough as accompaniments of similar conditions in the larynx above or the bronchi beloAV. The position of the trachea betAveen those organs and the continuity of its mucous membrane Avith theirs, expose it to the same causes of disease. Tracheitis does, hoAvever, occur as a separate lesion, though this is rare, unless occasioned by direct irritation. Pain is usually present, and palpation cannot be tolerated so well as in health. The voice will be un- affected so long as the larynx is not also im^olved, but cough is a constant symptom. The intimate o'onnection of tracheal irritation Avith various forms of cough has been proAred by numerous experiments. In tracheitis the cough is often painful, loud, harsh, noisy, and possesses almost a metallic ring, sometimes termed brassy. The expectoration is scanty, often tenacious, and is occasion- ally said to appear in rings. A more distinct exudation may take place. In croup Ave have seen this process af- fecting the whole trachea to a great extent; and, indeed, the old name of croup—cynanche trachealis—sIioavs that this part of the air-tube Avas supposed to be the seat of croup and the home of false membrane. In the trachea, inflammation does seem to tend toAvards the pouring out of denser fluids, and Avhen infiltration occurs it is more apt to be fibrinous than serous. Abscess, ulceration, and the other consequences of inflammation may occur. The trachea also participates in the morbid changes produced by phthisis, syphilis, and other oliseases, etc. It may equally be the seat of morbid growths. TRACHEA AND BRONCHI. 303 Stenosis, or narroAving of the trachea, may be caused by disease in its own Avails, including cicatricial contrac- tions and neoplasms; or by external compression from tumors, etc. The air-tube being here at its Avidest, as contraction usually occurs gradually, the symptoms often seem to creep on imperceptibly. As soon as stenosis in- terferes with free respiration, there will be quickened or labored breathing—most perceived on exertion. The difficulty is entirely in inspiration. The breathing is noisy, tubular. The voice seems muffled, no doubt on account of the diminished current of air on Avhich the vocal cords can act, Cough is not ahvays present, but is often produced by the cause of the stenosis. After a time paroxysms of severe dyspnoea are apt to occur. When they set in, the stenosis is usually considerable and the patient may perish in one of them. The slower the pro- cess of constriction, the less the dyspnoea produced. In- deed, it is surprising hoAV great a degree of narrowing may be tolerated, provided it takes place very gradually. In tracheal dyspnoea, even Avhen severe, the larynx does not move up and doAvn Avith the activity it displays in laryngeal stenosis. As the case advances there is danger of pneumonia being induced. Instead of this, cerebral symptoms sometimes supervene. Cicatricial bands and membranes may be the cause of the stenosis. These are usually the result of syphilitic ulceration, to which also contractions are often due. Tu- mors in the trachea are rare, but those in the neighbor- hooxl often compress the tube. At a very early stage congestion may be seen, shoAving that in these cases, and in all diseases of the trachea, the mirror will lend us most valuable service. 304 SORE THROAT. Spasm of the trachea has received scarcely any atten- tion, and yet the possibility of its occurrence Avas recog- nized by Porter,* who cited a case reported in the Edin- burgh Medical Journal, in which dissection shoAved a "contraction of the trachea to more than two-thirds of its diameter, and one inch and a half in length, situated mid- Avay betAveen the larynx and the bifurcation of the tra- chea. The contraction relaxed gradually after the tube was slit, so that the day following the part did not appear contracted or in a state of disease of any kind." Something similar seems to have been Avitnessed during life by the late Dr. Scott Alison, avIio describedf a re- duction in the calibre of the trachea affecting the Avhole circumference of the tube at a spot about an inch aboAre the bifurcation. He attributed the condition to a re- duction of the soft posterior part, and this in its turn to " an undue amount of muscular contraction." Exacer- bations recurred in the dyspnoea and it affected both in- spiration and expiration. The narrowing seems to have persisted for some time in Dr. Alison's cases, and gave rise to emphysema in some, while in others it simulated consumption. Nevertheless, as no other lesions were found, except congestion, I have thought it well to in- clude them under spasm rather than stenosis. I would adol that I recognize other forms of spasm of the trachea more closely allied on the one hand to laryngismus strid- ulus, and on the other to asthma. I have pointed out the significance of paroxysms of tracheal dyspnoea in * Surgical Pathology of the Larynx and Trachea, London, 1837. f Morbid Conditions of the Throat and Consumption, London, 1867. TRACHEA AND BRONCHI. 305 gradual occlusion of the tube, and inasmuch as the diffi- culty is not continuous it seems natural to attribute to spasm a share in its production. I may add that catarrh and other causes may set up spasm of the trachea, though this is less frequent and withal less dangerous than spasm of the larynx. We need not here discuss the connection between bronchial spasm and asthma, but may observe that tracheal spasm, too, deserves consideration in connec- tion Avith the same malady. Of course, in any case, laryn- geal spasm produced by the exciting cause may super- vene on the tracheal affection. Treatment.—Tracheal diseases should be managed like those of the larynx on the one hand, or those of the bronchi on the other, according to the nature, position, and extent of the lesion, and the predominance of either set of symptoms, laryngeal or bronchial. The trachea can be influenced jointly Avith the larynx and bronchi by the various remedies we have described, especially by in- halations, fumigations, and atomized sprays. A more localized application may be made by the pipette, or a laryngeal syringe or douche Avith a suitable tube can be advantageously employed in this situation. The instru- ment must be carried down carefully during an inspira- tion between the A^ocal cords. In the same Avay powders can be applied by means of a suitable insufflator. Solid escharotics can also be conveyed to the part by means of proper directors. Lastly, some other operative proced- ures have been accomplished. Tracheal diseases are often exceedingly obstinate, and their treatment is beset Avith numerous difficulties, but Ave must not be discouraged. I have recently obtained un- expected success in long-standing disease of the trachea 26 306 SORE THROAT. when ordinary laryngeal treatment had been previously pursued, but vainly, because the larynx was not the part affected. With regard to stenosis, the indications depend so en- tirely on the nature of each individual case that it would be unprofitable to offer any general directions for their management. Foreign bodies which have gained access to the larynx, may pass further along the air-tube, the position in which they are arrested depending on their size, shape, etc. If not arrested before the bifurcation, they seem more fre- quently to pass into the right bronchus than the left, be- cause the septum is slightly to the left of the median line, and the calibre of the right bronchus is therefore rather the larger. As these bodies, however, are movable, they have been knoAvn to pass from one to the other. The symptoms Avill necessarily vary with the degree of ob- struction to respiration, and therefore with the position and size of the intruding substance. When this has passed the glottis, it is, generally speaking, beyond the reach of laryngoscopal operation and an opening into the air-tube has to be made. Very often the foreign body is spontaneously expelled by a cough the moment the opening is made, but sometimes further interference may be called for. This, however, should not be undertaken unless urgently needed, for a subsequent cough often ex- pels the body through the opening, Avhich, in such case, should be large enough. Moreover, it may be Avell to ob- serve that foreign bodies have sometimes remained for considerable periods in the air-passages, and then been expelled per vias naturales, so that there is not always TRACHEA AND BRONCHI. 307 the urgency for immediate operation that has been gen- erally taught. But every case must be considered by itself, and in reference to the indications present, for the circumstances are so various that scarcely any two cases Avill occur to the practitioner Avhich are in eATery respect alike. 308 SORE THROAT. CHAPTER XXIII. EXTERNAL SORE THROAT. The term angina externa, or external sore throat, was originally applied to mumps, but it may Avith equal pro- priety be applied to cases of enlarged glands, tumors of the neck, and other swellings in this neighborhood, Avhich, by pressure or otherwise, affect the throat. Parotitis, cynanche parotidea, or mumps, is often epi- demic—occasionally it runs through a school, and so seems contagious. It begins as a catarrh, or angina; after a few hours the gland SAvells largely, stiffening the jaw, and disfiguring the face. SwalloAving is often for some time impossible, and there may be considerable feverishness. The disease lasts about forty-eight hours, and then subsides gradually, terminating in resolution, as systematic Avriters say. It furnishes one of the best marked instances of metastasis. The treatment is con- fined to not doing too much. Warmth locally, by dry flannels or fomentations, a diaphoretic or a feAv doses of aconite, and a saline aperient, if indicated, are the chief measures. The metastasis is to be treated on general principles without reference to its origin, except that warmth and stimulants may be applied to the gland, with a vieAv of inducing a return of the ailment. external sore throat. 309 Suppuration may occur in the cellular tissue around the gland, more especially in scrofulous children. In these cases poultices may be applied, and, if needful, an opening made. Phlegmonous inflammation of the connective tissue in front of the neck is a very serious disease. It may ter- minate in resolution, abscess, sloughing, or gangrene. It mostly follows the exanthemata or typhus. I have seen it in diphtheria. Sometimes it appears as a primary af- fection. The disease has been called Angina Ludovici, after Ludwig, Avho fully described it; but other cases of diffuse inflammation in this neighborhood are allied to those he described. It usually begins in the suprahyoid region, and extends in all directions, pushing the floor of the mouth upwards and sometimes reaching the sternum. The swelling is very great, painful, and hard. The lower jaAv cannot be moved ; compression of the larynx, trachea, and vessels of the neck produce various symptoms. If resolution occur, it is long before the SAvelling goes down. Suppuration is more common,—a number of abscesses forming,—or the pus burrows in various directions, or fistula? are established. Gangrenous sloughs separate, and the disease is not only very fatal, but one that de- mands the utmost vigilance and most judicious manage- ment. Sometimes the disease seems to arise in the tissue around the salivary glands; at others it appears to be set up by, or at any rate, a similar affection is associated Avith, periostitis of the lower jaAv. Erysipelas and the puerperal state seem also to give rise to it. The connective tissue and muscles may be transformed into a broAvn semifluid mass mixed Avith sloughs. The parotid anol submaxillary glands have been destroyed by 310 SORE THROAT. gangrene, and secondary deposits have been found in various organs. It has been thought that antiphlogistics could prevent suppuration, but the disease is only seen in debilitated subjects. Pus has to be evacuated, and it is advised to search for it by deep incisions Avhenever the symptoms are urgent and no pointing is perceptible. When found, the insertion of deep hooks and the sepa- ration of the fascia is also advised. It is scarcely neces- sary to advise caution in using the knife in this region, Avhen the position of parts is changed or obscured by the infiltration and swelling. Cynanche thyroidea, or bronchocele, or goitre, is a chronic enlargement of the thyroid body—a olisease en- demic in some localities, and generally attributed to the character of the Avater drunk by the inhabitants. Its appearance is Avell knoAvn, anol it is therefore unneces- sary to describe all its varieties. Of late years they have been treated Avith more effect than formerly. The interstitial injection of iodine, proposed by Luton and Liicke, has giA^en me some good results. I adopteol it at an early period, a gentleman Avho had seen Liicke's early cases having communicated it to me. Since then I have applied electrolysis to the cure of bronchocele. I have also found the injection of ergotin successful. Excision of the thyroid gland has been successfully carried out, but could only be thought of as an extreme measure. In exophthalmic goitre, or Graves's disease,—or, as the Germans call it, BasedoAv's disease,—Ave have besides the enlarged thyroid, the condition of the eye and the heart to consider. They are most interesting cases, though their management is attended with difficulty. Hence they are too often neglected. EXTERNAL SORE THROAT. 311 Acute thyroiditis is very rare, and sometimes proves rapidly fatal. Suppuration may take place, but I have had rapid resolution ending in speedy recovery. A local abscess may occur in enlarged thyroid, and prove a step toAvards recovery, but is not a desirable complication. I have seen it in exophthalmic goitre also. Fibrous and osseous formations occur in the thyroid. Tubercle and cancer are exceedingly rare. Cysts and other tumors occur in this neighborhood. Among them may be mentioned enlarged glands, indu- ration of the sterno-mastoid muscle, which is not very rare in children, enlargement of the bursas of the hyoid bone and thyroid cartilage, fatty and fibrous tumors, and very rarely cancer. Aneurisms, too, have appeared in such situations as to give rise to errors. Cysts may be tapped and injected Avith iodine or perchloride of iron. The management of other tumors must depend on their situation, connections, and nature. Enlarged thymus may produce throat symptoms, and this body may undergo degeneration, or be the seat of cancer. Acute inflammation is also said to occasionally affect it. Enlarged bronchial glands, thoracic tumors, and other possible occurrences may be mentioned as ad- ditional proofs of the necessity for bringing extensive information to bear on every case of disease in this re- gion. INDEX. Abscess of neck, 309 of parotid, 309 of tonsil, 213 retropharyngeal, 235 Acne, 55 Aconite, effects of, 87 value of, 87 in tonsillitis, 217 Aconitin, 89 Air-passages, foreign bodies in, 48, 248, 280, 306 Albuminuria in diphtheria, 183 Alum, 91 in croup, 170 in tonsillitis, 217 Amygdalae, 211 Anaemia, 46, 252 Anaesthesia, 47, 236, 299 Anatomy of throat, 18 Angina, 30, 38 externa, 308 Ludovici, 309 Angine. glanduleuse, 142 granuleuse, 36, 142 Antimony in croup, 169 Aphonia, 59, 256, 257. 284, 290, 292 Aphthae, 31, 149 Aphthous sore throat, 149 Arytaenoid cartilages, 70, 74 Asthma (see also False Croup), 305 Astringents, 91 Atomizer, author's, 97 Atomized fluids, 96, 99 Atrophy, 47 Azygos uvulae, paralysis of, 210 spasm of, 240 Bifid uvula. See Plate I. Bloodletting, 84, 168, 261 Bronchi, openings of, 76 affections of, 301 Bronchocele, 310 Brush, laryngeal, 109 Calcium iodide, 90 Capitulum Santorini, 70 Cartilages, arytaenoid, 70, 74 cricoid, 76 of Santorini, 74 of Wrisberg. 70, 74 Casts, bronchial, 43 Catarrh, 31, 123 treatment, 124 Caustic-holder, 115 " Caustics, 93 Cauterization of larynx, 115 Chlorate of potash, 90, 184 Chloroform, 95 Chorditis tuberosa, 267 Chromic acid, 116 Chronic'inflammation, 130 ulceration, 140 Cilia, 25 Classification, 120 Clergymen's sore throat, 36, 142, 232 Cold compresses in croup, 171 Cold in the head, 30, 125 Color, variations in, 77 Congestion, 28 dry stage of, 29 moist stage of, 29 Consumption of throat, 133, 281 Cords, false vocal, 69, 75 movements of, 73, 288 spasm of, 295 true vocal, 69 stammering of, 297 Corniculum laryngis, 74 314 INDEX. 158 Ear, connection with throat, 242 Fczema, 53 Electrotherapeutics, 117, 237, 251 299 Emetics, use of, 85 in croup, 169 in diphtheria, 184 Emphysema of pharynx, 235 Epiglottis, 21, 70, 72 Epithelium, 24 Erosion, 36, 136 Errhines, 100 Eruptive fevers, 51 affection of mucous mem- brane in, 188 Erysipelas, favorite seats of, 127 of throat, 127 spreading of, 128 Erysipelatous sore throat, 37, 127 appearance of, 129 danger of. 129 diagnosis of, 129 treatment of, 129 EsquinaHcir, 214 Eiher, inhalation of, 93 Eustachian tube, closure of, 243 Exanthemata, 50, 188 complications of, 190 Exanthematous sore throat, 50, 18H Excision of tonsils, 223 Exophthalmic goitre, 310 External sore throat, 308 Exudation, diphtheria, 143, 159 in croup, 40, 161 in diphtheria, 182 nature of, 42 Exudative sore throat, 39, 157 Coryza, 30 Cough, 30 spasmodic, 237 uvula, 209 Cricoid cartilages, 76 Croup, 39, 157 and diphtheria, identity of, ascending, 162 complications of, 166 false, J 76, 295 false membrane in, 163 origin of term, 160 respiration in, 163 spasm in, 165 steam in, 174 symptoms of, 161 tracheotomy in, 172 treatment of, 168 Croupal inflammation, 159 Crowing inspiration, 176, 295 Cynanche, 30, 37 traehealis, 160 Deafness, throat, 242 Degenerations, 47 Dermatitis, superficial, 53 Diabetic sore throat, 135 Diagnosis, means of, 55 Difficulty in swallowing, 249 Diphtheria, 39, 178 and croup, identity of, 157 albuminuria in, 183 bacteria in, J81 complications of, 183 enlargement of glands in, 179 exudation in, 182 haemorrhage in, 183 nasal, 180, 187 Oertel's views on, 181 origin of term, 178 paralyses in, 183 parasitic theory of, 181 symptoms of, 179 sphaero-bacteria in, 181 treatment, 184 Diphtherial exudation, inoculation with, 182 Diphtherial inflammation, 159 Douches, nasal, 105 pharyngeal, 106 Dry sore throat, 35, 232, 244 Dysphagia, 249 Earache, 243 Ear affections in scarlet fever, 193 False croup, 176, 295 False membrane in croup, 163 False vocal cords, 75 Faradization of larynx, 117 Fever, vesicular, 54 Fevers, eruptive, 51, 188 Follicles. 26 Follicular sore throat, 36, 142, 232 Folliculitis, acute, 144 chronic, 143 Fomentations, 93 Foreign bodies in throat, 48, 248 280, 306 Fumigation, 100 Fungous sore throat, 144, 153 Galvano-cautery, 117, 225, 234, 272 INDEX. 315 Gangrenous sore throat, 39 Gargles, 101 Gargling, 102 laryngeal, 103 Glands, 26, 45 Glanders, 49, 278 Globus hystericus, 249 Glossitis, acute, 43 Glosso-epiglottidean ligaments, 70 Goitre, 310 exophthalmic, 310 Gouty sore throat, 134 Granular sore throat, 36, 142, 232 Graves's disease, 310 Growths, laryngeal, 118, 271 Guaiacum, 91, 217 Gummata, 49 Haemorrhages, 55 Herpes, 53 Herpetic sore throat, 53. 139 Hoarseness, 58, 255, 257, 265, 273, 276, 281, 289, 292 Hospital sore throat, 127 Hot water in croup, 171 Hyperaemia, 46 Hyperaesthesia, 47 Hypertrophy, 47 Hypoaemia, 46, 252, 282 Hypoglottides, 107 Image, laryngeal, 72 rhinoscopic, 79 Inflamed sore throat, 122 Inflammation, 28 croupous, 159 diphtherial, 159 phlegmonous, 125 Inhalations, 93 Injections, interstitial, 117 laryngeal, 111 Injuries of throat, 48, 126, 280 Insufflations, 107 Inter-arytaenoid fold, 76 Iodides, 89, 201 Iodine, 89 Iodoform, 90, 201 Irrigations, 107 Iron, 92 Lactic acid, 99, 176 Lancet, laryngeal, 116 Laryngeal brush, 109 image, 68, 72, 76 lancet, 116 Laryngeal mirror, 62 mucous membrane, hypertro- phy of, 267 neuroses, 289 paralyses, 289 phthisis, 133, 281 spasm, 295 Laryngismus stridulus, 176, 293 Laryngitis,30, 254 acute catarrhal. 254 chronic catarrhal, 265 erythematous, 254 follicular, 266 granular, 266 phlegmonous, 261 pseudo-membranous 164 Laryngoscope, 64 Laryngoscopy, 64 explanation of, 66 history of, 67 Laryngostioboscopy, 78 Laryngo-typhus, 278 Laryngotomy, 118 L irynx, aflvctions of sensory nerves of, 300 anrc uia of, 252, 282 cancer of, 273 congestion of. 253 consumption of, 133, 281 extirpation of, 274 faradization of, 117 foreign bodies in, 280 growths in, 271 haemorrhage of. 253 hyperaemia of, 253 inflammation of, 254 injuries of, 280 leprosy of, 279 lupus of, 279 neuroses of, 288 oedema of, 257 papillomat i in, 271 paralyses of, 288 perichondritis of, 269 pigmentation of, 252 polypi of, 271 sarcoma of, 273 sinuses of, 75 specific disease of, 275 stenosis of, 270 syphilis of, 275 ventricles of, 75 wounds of, 280 Leeches, 84, 168, 262 Leprosy of larynx, 279 316 INDEX. Ligaments, glosso-epiglottidean, 7 72. hyo-epiglottidean, 72 thyro-epiglottidean, 72 Linimentum ^Eruginus, 92 Liquids, application of to larynx, ] Lozenges, 107 aconite, 108 effects on stomach, 107 general effects of, 107 guaiacum, 108 how to take, 107 Lupus, 55, 139 of larynx, 279 Measles, 50, 190 German, 192 sore throat in, 190 Membrana propria, 24 Metastasis, 45, 308 Micrococcus, 181 Mirror, laryngeal, 62 Mucous membrane, 23 congestion of, 28 inflammation of, 33 Mucous follicles, ulceration of, 35 Muguet, 153 Mumps, 308 Muscularis mucosae, 24 Narrowing of oesophagus, 248 of trachea, 303 Nasal affections, 30, 242 diphtheria, 180, 187 speculum, author's, 81 Naso-pharynx, n flections of, 338 cysts of. 239 hyperaemia of, 338 hypertrophy of, 338 polypi of, 240 ulceration of, 239 Neck, abscesses of, 309 cyst of, 311 tumors of, 311 Neoplasms, 47 Nervous sore throat, 47, 288, 297 Nettlerasb, 55 Neuralgia, 47 Neuroses, 48 of larynx, 289 of soft palate. 207 Nitrate of potash, 90 of silver, 92, 116 Nitre, 90 Nose, connection with throat, 24 2 i, Nutrition, perversion of, 47 QMema of larynx, 257 Oesophagitis, 247 OEsophagoscopy, 82 OEsophagus, affections of, 246 dilatation of, 248 exudation into, 247 foreign bodies in, 248 hypertrophy of, 247 inflammation of, 247 morbid growths of, 248 narrowing of, 251 neuroses of, 249 spasm of, 249 stenosis of, 248 I stricture of, 248 treatment of diseases of, 250 ulceration of, 247 Oidium albicans, 44, 153 Ovaries and tonsils, sympathy be- tween, 45, 215, 227 Ozsena, 36, 90, 105, 242 Palate, soft, affections of, 202 anaemia of, 204 anaesthesia of, 207 atrophy of, 206 cancer of, 207 cicatrices in, 206 congestion of, 203 gangrene of, 206 haemorrhage from, 203 hyperaesthesia of, 207 hypoaemia of, 204 inflammation of, 204 malformations, 207 nervous diseases of, 207 neuralgia of, 207 paralyses of, 207 perforations of, 206 syphilis of, 207 tumors in, 206 ulceration of, 205 Parse^thesia, 47, 299 Paralyses in diphtheria, 183 laryngeal, 289 Paralysis, 47, 289 of nzygos uvulae, 210 of cords, 289 of pharynx, 237 of soft palate, 207 Parasites, 44, 153, 181 Parasynanche, 37 Parenchymatous sore throat, 37 INDEX. 317 Paresis, 47 Parotid, suppuration in, 309 Parotitis, metastasis in, 308 Pemphigus, 54 Perichondritis, 269 Pharyngeal tonsil, 79, 239, 240 Pharyngitis, 37 acute. 229 chronic, 230 follicular, 232 granular, 232 sicca, 232 Pigmentation, 77, 252 Pharyngocele, 234 Pharynx, 21, 228 abscess of. 235 affections of, 228 emphysema of, 235 hypertrophy of, 233 inflammation of, 229 nervous affections of, 236 oedema of, 235 paralysis of, 236 polypi of, 234 syphilis of, 235 ulceration of, 232 Phlegmonous sore throat, 37, 125, 127 Phthisis, laryngeal, 133, 281 sprays in, 286 stages of, 282 symptoms of, 281 tracheotomy in, 287 treatment in, 286 Potassium, chlorate, 90 iodide, 90 nitrate, 90 Powders for insufflation, 113 Prolapse of ventricle, 272 Pseudomembranous l.iryngitis, 164 Psoriasis, 54 Purpura, 55 Quinsy, 212 Reflector, 63 Relaxed sore throat, 34, 130 Rheumatic sore thro.it, 133 Rhinitis, 30 Rhinoscopal therapeutics, 241 Rhinoscope, 64 Rhinoscopy, 78 anterior, 81 Rima glottidis, 69 Riitheln. 192 Rubeola, 192 Salivary glands, affection of in scar- let fever, 194 Santorini, cartilages of, 74 Scarification, 84, 116 Scarlatina sine eruptione, 51 sore throat in, 191 Scrofulous sore throat, 132, 138 Secretion, 27 Septum nasi, 79 Silver nitrate, 92, 116 Sinuses of larynx, 75 Skin diseases and sore throat, 54 Small-pox, 50, 188 Smoker's sore throat, 203 Snuff-taker's sore throat, 203 Sodium chloride, 91 Soft palate. Ste Palate. Soor, 153 Spasms, 47, 165 295 Specific sore throat, 48, 135, 199 Speculum, nasal, 81 Spray producer, author's, 97 Sprays, 96 Stammering, vocal, 2t7 Steam, use of, 93, 174 Stenosis of oesophagus, 251 trachea, 270 of larynx, 303 Stricture of oesophagus, 248 of trachea, 303 Strumous sore throat, 132 Submucous tissue, 25 Swallowing, difficulty in, 249 Swelling, changes caused by, 85 Sycosis, 55 Synanche, 37 Syphilitic sore throat, 49, 135. 199 Tannin, 92 Therapeutics, general throat, 83 laryngoscopal, 108 rhinoscopnl, 242 Throat, anatomy of, 19 deafness, 242 injuries of, 48. 126, 280 meaning of word, 17 mucous membrane of, 23 speculum, 62 Thrush, 32, 153 Thymic asthma, 178 Thymus, enlargement of, 311 Thyroid, enlargement of, 310 I Thyroiditis, acute, 31L 318 INDEX. Tinnitus aurium, 243 Tippler's sore throat, 203, 232 Tongue depressors, 61 Tonsils, pharyngeal, 79, 239, 240 Tonsillitis, acute. 212 Tonsillotomy, 225 Tonsils, abscess of, 214 anatomy of, 21, 21L atrophy of, 225 cancer of, 226 concretions of, 226 cysts of, 226 enucleation of, 225 hypertrophy of, 221 removal of. 223 sympathy of with ovaries, 45, 215, 226 syphilis of, 226 Trachea, affections of, 301 anatomy of, 301 congestion of, 302 inflammation of, 302 rings of, 76 spasm of, 304 stenosis of, 303 Tracheitis, 30, 302 Tracheotomy, 118 in croup, 172 in diphtheria, 186 indications for, 119 mortality in, 173 tubes, application of local reme- dies through, 187 Traumatic sore throat, 48, 126. 280 Tubercular soi-e throat, 133, 137 Tumors, 48 Turbinated bones, 80 Typhous ulceration, 39, 278 Ulcerated sore throat, 126, 139 Ulceration, 35, 136 Urticaria. See Nettlerash. Uvula cough, 209 Uvula. 20, 202 elongation of, 208 enlargement of. 209 hypertrophy of, 209 relaxed, 208 warts on, 210 Uvulitis, 209 Vallecula, 70 Velum. 19, 202 anaemia of, 204 haemorrhage from, 203 hypoaemia of, 204 inflammation of, 204 irritability of, 203 oedema of, 205 Ventricles of larynx. 75 prolapse of. 272 Vocal cords, 69 movements of, 73, 288 paralysis. 289 spasm of, 295 stammering of, 297 Voice, affections of, 288 breaking, 254 See Aphonia, Hoarseness, and Vocal Cords. Vox clericorum. See- Clergymen's sore throat, 36, 142. 232 syphilitica, 276 Warts on uvula, 210 Windpipe. See Trachea. Wrisberg. cartilages of, 70, 74 HANDBOOKS FOR PHYSICIANS. COMPACT, RELIABLE BOOKS, AT LOW PRICES. 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