Diseases of the throat and nasal passages; a guide to the diagnosis and treatment of affections of the pharynx, sophagus, trachea, larynx, and nares

Front matter

"I give the/e Books : for the founding cf a College in this ColonfA

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TRANSFERRED TO YALE MEDICAL LIBRARY

Preface To The Second Edition

A second edition of Diseases of the Throat would have appeared several years ago, according to announcement, had not its preparation been interrupted by a series of circumstances over which the author had no control. It is to be hoped that it will be none the worse for having been some time out of print. To the reader familiar with the first edition, considerable change will be apparent in the present one. Some material has been suppressed, some modified or augmented, and some added. Certain illustrations have been discarded, and others introduced. The bibliography has not been reprinted, because it would have sacrificed many pages devoted to clinical use, and has become the less necessary on account of the appearance of copious references in the collateral portions of Ziemssen's Cyclopaedia, and the current reports on Laryngology and allied topics supplied for some years by Dr. Knight to the columns of the Boston Medical and Surgical Journal, and by Prof. LefTerts to those of the New York Medical Journal; while more recent serial contributions of a similar character by Dr. Porter to the St. Louis Medical and Surgical Journal, and by Dr. Semon to the London Medical Record, and the admirable Index Medicus of Drs. Billings and Fletcher, are additional assurances that there shall be no lack of indicators to sources of information in this branch of professional study. Anatomical considerations of special clinical significance have been introduced into the text, as before, at points deemed most useful, and have been still more closely confined to matters as yet unincorporated in the most accessible text-books. Those who read German will find copious clinical disquisitions in the various anatomical works of Prof. Luschka; and those who do not, will soon find the deficiency supplied to some extent in the forthcoming treatise of Prof. Allen. Special manipulations, operations, and therapeutic measures are described either when first alluded to, or in connection with the subject matter to which they are most applicable, instead of being consolidated in a separate chapter, as has been done by other writers ; — a plan less systematic, to be sure, but not less likely to

VI PEEFACE TO THE SECOND EDITION.

elicit clinical interest. The nomenclature of the most recently published edition of the Pharmacopoeia of the United States has been employed, as best in accord with the present requirements of the iAinerican reader. The great majority of illustrations of appliances are reproductions from the woodcuts of Mr. G. H. Gemrig, of Philadelphia, so long and so favorably known for the accuracy and quality of his work. The publishers have kindly allowed a reproduction of many original and selected illustrations prepared for their edition of Ziemssen's Cyclopaedia.

The author's Lectures on The Surgery of the Larynx, Nares, and Trachea, delivered before the College of Physicians of Philadelphia (1872), and those on Fetid Coryza (1873), on Sore Throat, and on Diphtheria (1874), before the classes in Jefferson Medical College, and published respectively in the Philadelphia Medical Times, Philadelphia Medical and Surgical Reporter, and New York Medical Record, have been substantially incorporated into the present edition.

1431 Walnut St., Philadelphia, March, 1879.

Preface To The First Edition

The preparation of the following pages has been no holiday task on the part of the author. Only such irregular intervals as could be snatched from the requirements of an unusually arduous practice could be devoted to the' purpose. Hence there has ensued an inequality in composition, of which the writer is sensibly cognizant. Some subjects have had to be discussed in a manner rather different from that originally contemplated, and the context of numerous references, toilsomely collected for their elucidation, has remained unincorporated.

With the exception of a few hospital and dispensary patients, seen from time to time at the request of his professional friends, the author's entire experience has been confined to his own private and consultation practice. This has debarred him from much opportunity for personal pathological research; but it has facilitated the description of morbid processes as they are met with in the ordinary routine of practice, a matter of no slight recommendation to the general professional reader, and one which it is hoped will compensate, at least in part, for deficiencies in other directions.

The limits of a moderate-sized volume preclude the composition of an exhaustive treatise on the subject of Diseases of the Throat. It has been thought advisable, therefore, while presenting a comprehensive view of the entire field, to dwell longer upon subjects which are important by their frequency and by the fresh light shed upon them by recent investigation; and to treat concisely of those points which by their infrequency on the one hand, or their thorough discussion in the standard medical works of the day on the other, seem less to call for amplification.

It is impossible to furnish an explicit and perfect description of a disease so as to afford a complete and satisfactory mental picture of the condition of every example of it which may come under notice. Each case exhibits some special phenomena of severity or of mildness ; or is different in some other particular from every other case with the same general aspect. All that a writer can do is to mention the characteris-

Ylll PREFACE TO THE FIRST EDITION.

tics which determine the nature of the diseased action going on, to designate the elements of danger and of safety, and to indicate the methods of management which reason and experience have proven to be most adequate for relief, or best productive of cure. In attempting this, much has to be said which others have said already, and often in better language; but this repetition is sometimes necessary to complete the outline of a subject, or to convey intelligence for the first time to those who have not had access to original sources of information.

Due consideration has been given, in the subject-matter of the volume, to modern developments in the diagnosis and treatment of affections of the throat, especially those occupying the trachea, larynx, upper pharynx, and nasal passages. Here the author's experience has been ample; and if his record differs in some respects from the records of others, 'it does so by reason of an honest endeavor to interpret facts and observations as they appeared in the light of his own understanding. The articles on laryngoscopy, rhinoscopy, and surgical manipulations by their aid, are, with some additions, modifications, and omissions, essentially reprints of those contributed by the author, a few years ago, to the columns of The Medical Record, of Xew York, and to the second American edition of Mackenzie on the Use of the Laryngoscope.

The author has availed himself of the labors of his predecessors and contemporaries, in the production of this volume, as freely as he has resorted to them for his own instruction. He has endeavored, except in so far as certain general matters have long become the common property of the profession, to give due credit to his sources of information.

For the use of the studious and the curious, he has appended a bibliographical record, culled from his own index-rerum; and this has been distributed under catch-heads, as being more convenient for consultation than a purely alphabetical list of authors, or a mere chronological arrangement.

Acknowledgment is made to Mr. G. H. Gemrig, of Philadelphia, for many illustrations of surgical instruments; and also to Messrs. Otto & Reynders, and to Messrs. Tiemann & Co., of Xew York, for like favors. All the original woodcuts in the volume, and many of the copied ones, were engraved by Mr. Sebald, of Philadelphia.

Philadelphia, May, 1S72.

Table Of Contents

CHAPTEK I.

PAGE

Chapter II

Direct inspection of the throat. — Direct inspection of the nasal passages; anterior rhinoscopy. — laryngoscopy. — auto-laryngoscopy. — demonstro-laryngoscopy. — infra-glottic laryngoscopy and tracheoscopy. — (esophagoscopy. — pharyngeal rhinoscopy; retronasal rhinoscopy | posterior rhinoscopy. —

AUTO-RHINOSCOPY. — DeMONSTRO-JRHINOSCOPY. — PALPATION. — AUS- CULTATION.— Percussion.

Chapter III

Acute sore throat. — Common sore throat. — Phlegmonous sore throat. — Ulcerous sore throat. — Simple or common membranous SORE THROAT. — THE SORE THROATS OF THE FEBRILE EX- ANTHEMATA — Erysipelatous sore throat. — Acute tuberculous

SORE THROAT. — THE SORE THROAT OF GLANDERS. — THE SORE THROAT OF STOMATITIS.

Chapter VII

The pharyngo-palatine muscles. — Inflammation of the palate. — Lupus. — Morbid growths of the palate. — Deformatiye adhesions OF THE SOFT PALATE.— CLEFT PALATE. — WOUNDS OF THE

soft palate. — neuroses of the palate. — chronic elongation of the uvula. — 03dema of the uvula. — morbid growths of the uvula.— Bifid uvula.— Paralysis of the uvula.

Chapter VIII

chronic inflammation of the tonsils. — hypertrophy of the tonsils.— Atrophy of the tonsils. — Morbid growths of the tonsils.— Calculi.— Foreign bodies.

-

Chapter IX

Abscess of the pharynx. — Morbid growths of the pharynx. — Adenoma at the vault of the pharynx. — Naso-pharyngeal . tumors. — Wounds of the pharynx. — Foreign bodies in the pharynx. — Luxation of the hyoid bone. — Deformities of the pharynx. — flstule of the pharynx. — stenosis of the pharynx. — Pharyngocele. — Neuroses of the pharynx.

Chapter X. Special Affections Of The Cesophagus 282

oesophagitis. —Imperforate cesophagus.— Fistule of the oesophagus.— Stricture (stenosis) of the oesophagus.— Compression of the oesophagus. — dilatation of the cesophagus ; cesophagocele. — Morbid growths in the oesophagus. — Carcinoma of the cesophagus. — wounds and injuries of the oesophagus. — Perforation of the cesophagus. — Foreign bodies in the pharynx and oesophagus. — fancied bodies in the pharynx and cesophagus. — Neuroses of the oesophagus. — (So-called) progressive BULBAR PARALYSIS.

TABLE OF CONTENTS. XI

Chapter XI. Page

Acute coryza.— Gonorrheal coryza.— Idiosyncratic coryza.— Influenza. — Chronic coryza. — Nasal abscess. — Epistaxis. — Syphilitic affections of the nasal passages. — Stenosis of the nasal passages. — Congenital occlusion of the nasal passages. — Foreign bodies in the nasal passages. — Calcareous accretions in the nasal foss.e (rhinoliths).— Tumors of the nasal passages. — neuroses of the nasal passages.

Chapter XII. Affections Of The Septum Narium 407

Inflammation and abscess of the septum narium. — Submucous infiltration AT THE SIDES OF THE VOMER. — DEFLECTION OF SEP- TUM FROM MIDDLE LINE. — FRACTURES OF NASAL SEPTUM.— TUMORS OF THE SEPTUM.

Chapter XIII. Affections Of The Frontal Sinus 414

INFLAMMATION AND ABSCESS. — TUMORS OF THE FRONTAL SINUS. — FOR- EIGN BODIES IN THE FRONTAL SINUSES.

Chapter XIV

Acute laryngitis. — Phlegmonous laryngitis. — Erysipelatous laryngitis. — traumatic laryngitis. — abscess of the larynx. — (Edema of the larynx— Croup. — Tracheitis. — Chronic laryngitis. — Tuberculous laryngitis. — Syphilitic laryngitis. — Primary chondritis and perichondritis. — Lupus. —Lepra. — Hypertrophy of the larynx. — Morbid growths of the larynx. — eversion of the ventricle of the larynx. — morbid growths of the trachea. — tracheocele.— carcinoma of the larynx and trachea. — stenosis of the larynx and trachea. — flstulie of the larynx and trachea. — wounds of the larynx and trachea. — fractures of the larynx and TRAcnEA. — Contusions of the larynx and trachea. — Rupture of the trachea.— Foreign bodies in the larynx and trachea. — Neuroses of the larynx.— Spasm of the larynx.— Spasm of the trachea. — Irritative cough. — Spasmodic cough. — Motor paralyses of the larynx.

Xll TABLE OF CONTENTS.

Chapter XV. Page

Artificial openings into the larynx and trachea.— Catheterization OP LARYNX AND TRACHEA.— EXSECTION (EXTIRPATION) OP THE LARYNX.

Chapter XVI

AFFECTIONS OF THE LARYNGOPHARYNGEAL AND OF THE GLOSSO- EPIGLOTTIC SINUSES 686

Chapter XVII. External Affections Of The Neck And Throat

Diffuse inflammation of the connective tissue of the neck. — Tumors of the neck.— Mumps.— Bursal tumors of the thyrohyoid region.— Affections of the thyroid gland. —Affections of the hymus gland.

LIST OF ILLUSTRATIONS.

FIG. PAGE

1. Folding tongue-depressors 9

2. Tuerck's tongue-depressor 10

3. Author's hard-rubber tongue-depressor 11

4. Palate elevator 12

5. Examination of nasal passage anteriorly, with hair-pin retractor 14

6. Duplay's nasal speculum 14

7. Elsberg's trivalve nasal speculum 15

8. Thudichum's nasal speculum 15

9. Fraenkefs nasal speculum 15

10. Laryngoscopic mirror of circular form, with thick stem, as used by the

author 20

11. Circular mirror, with stout shank and flat handle 21

12. The laryngoscopic mirror in position, stem to one side 22

13. Manner of holding laryngoscopic mirror preparatory to its introduction. ... 24

14. Relative relations of larynx and its image in the laryngoscopic mirror (stem

uppermost) 25

15. Diagrammatic representation of the reflection of the glottis in the laryngo-

scopic mirror (altered from Mandl) 20

1 6. Dobell's tongue-holder 29

17. Bruns' pincette for holding up the epiglottis 33

18. Examination. by reflection of solar rays (altered from Moura) 3G

19. Examination by diffuse daylight reflected from concave mirror attached to

forehead : 37

20. Perforated reflector attached to Kramer's head-band by a ball-and-socket

joint. Shown in position for covering one eye 37

21. Examination by direct artificial light (Moura) 38

22. Krishaber's illuminator 39

23. Mackenzie's rack-movement illuminator and bull-eye condenser 39

24. Tobold's illuminator and reflector adjusted to a student-lamp (Tobold) 40

25. Author's arrangement of Tobold's illuminating apparatus; fed with gas;

supported from floor; with arm of reflector above the lenses; the whole moving in mass up or down, right or left, by means of a supporting rod sliding in the socket of the stand 41

26. Examination by means of Tobold's pocket illuminator (Tobold) 42

27. Tobold's fenestrated tracheal canula, with small metallic mirror, for infra-

glottic laryngoscopy 49

28. Enlarged sketch of normal laryngoscopic image in respiration, slightly forced

to exhibit the chief cardinal points of observation in detail 53

XIV LIST OF ILLUSTRATIONS.

"<*■ PAGE

29. Arched epiglottis 55

30. Indented epiglottis 55

31. Assy metric epiglottis 55

32. Depressed epiglottis 55

33. Omega-like epiglottis 55

34. Pointed and depressed epiglottis of children 55

35. Normal larynx during inspiration 08

36. The ventricular bands in approximation (Tuerck) 59

37. Normal larynx in phonation (jO

38. Normal larynx of the female in respiration 01

39. Normal larynx of the female in the formation of head-tones 61

40. View of the left side of the larynx (Tuerck) 67

41. View of right bronchus (Tuerck) 67

42. View of posterior wall of trachea, and bifurcation of the primitive bronchi. 68

43. Rhinoscopic mirror with curved shank . 72

44. Rhinoscopic image 74

45. Rhinoscopic image in a case of cleft palate 76

46. Case of cleft palate from which rhinoscopic image (Fig. 45) was obtained . . . 76

47. View of left Eustachian orifice 76

48. Author's caustic pencil 96

49. Syphilitic ravages in the soft palate, tonsil, and lateral pharyngeal wall. . . . 125

50. Syphilitic ravages in the epiglottis and lateral laryngeal wall (in same case

51 . Folliculous pharyngitis 184

52. Chronic folliculous pharyngitis 186

53. Author's forceps for local applications to pharynx 194

54. Dr. Mears' toothed f orceps 194

55. Author's arrangement of metallic spray-producer on Bergson's principle,

with duck-bill tubes and reservoir on top ; for use with compressed air from air-press or rubber bulb 1 97

56. Author's arrangement of duck-bill glass tubes for sprays, driven by steam,

on Siegle's principle 197

57. Anterior view of the musculature of the pharynx and palate after removal

of tongue, hyoid bone, and larynx, as far as the posterior segment of

its thyroid cartilage (Luschka) 205

58. Posterior view of the palatine muscles (Luschka) 206

59. Separate investment of the palato-glossi muscles 207

60. Gemrig's uvula scissors - 219

61. Elsberg's uvula sector 219

62. Mouth-distender 229

63. Physick's amygdalatome 230

64. Fahnestock's amygdalatome 230

65. Charriere's amygdalatome 231

66. Adenoid tissue of vault of pharynx (Luschka) 254

67. Pharyngeal bursa (Luschka) - . 254

68. Glandular tissue at vault of pharynx, in a case of cleft palate 256

69. Pharyngeal extremity of left Eustachian tube, as visible in a case of cleft of

hard and soft palate 257

70. Rhinoscopic view of glandular vegetations at vault of pharynx 259

71. Naso-pharyngeal syringe 261

LIST OF ILLUSTRATIONS. XV

FIG. PAGE

72. Author's (retro-nasal) pharyngeal cutting forceps 262

73. Rhinoscopic view of glandular hypertrophy at vault of pharynx 202

74. Author's pharyngeal forceps for seizing naso-pharyngeal tumors 266

75. Author's naso-pharyngeal electrolytic needle 270

76. Graduated oesophageal dilator 21)3

77. Oesophageal dilators 294

78. Enormous dilatation of oesophagus (Luschka) 297

79. Bond's oesophageal forceps 315

80. Burge's oesophageal forceps 315

81. Horsehair snare and probang for the extraction of foreign bodies from the

oesophagus 317

82. Pomeroy's nasal inhaler 339

83. Living parasites from nasal excreta (Cutter) 345

84. Syphon nasal douche 356

85. Syphon douche with compression-bulb . 356

86. Manner of arranging syphon nasal douche 356

87. Bottle nasal douche 357

88. Thudichum's nasal douche (Thudichum) 357

89. Author's posterior nasal syringe 358

90. Fullgrafs retro-nasal douche 359

91. Lewin's apparatus for generating nascent chloride of ammonium, as modi-

fied by the author, for forcing the nascent vapor forward by compressed air 371

92. Canula of Bellocq, for tamponing the posterior nares 381

93. Gross's instruments for removal of foreign bodies from the nasal pas-

sages 389

94. Gross's polypus-forceps , 396

95. Rhinoscopic image of oedema of nasal septum 409

96. Rhinoscopic image of oedema of nasal septum 409

97. Submucous infiltration of posterior nasal septum, supposed to be due to

mycelium 409

98. Gaping of glottis from incomplete tension of vocal cords (Ziemssen) 426

99. Gaping of arytenoidal portion of glottis (Ziemssen) 426

100. Erysipelatous laryngitis (Tuerck) 437

101. CEdema of the larynx 449

102. CEdema of the epiglottis 450

103. Sub-glottic oedema of the larynx 456

104. Enlarged glands at base of the tongue 478

105. Chronic tumefaction of the lower surface of the vocal cords, and of the

posterior wall of the larynx (Tuerck) 479

106. Same case as Fig. 105, eight months after tracheotomy; showing the

tracheotomy-tube in position, projecting just beneath the posterior portion of the image of the glottis (Tuerck) 479

107. Laryngeal douche 487

108. Tobold's laryngeal syringe 488

109. Mackenzie's brush holder 490

110. Sponge-holder with bayonet-catch 490

111. Author's lateral-spring laryngeal forceps for securing minute fragments of

sponge or amadou 492

112. Rauchfuss's laryngeal powder-insufflator 493

XVI LIST OF ILLUSTRATIONS.

FIG. PAGE

113. Pyriform tumefaction of supra-arytenoid structures in tuberculous laryn-

gitis ; showing- also linear ulceration of vocal cords, and ulceration of inter-arytenoid fold 501

114. Ulceration on posterior wall of larynx (Tuerck) 503

115. Ulceration of epiglottis, ventricular bands, vocal cords, and external face

of one supra-arytenoid eminence, with denudation of vocal process of same side 503

116. Ulceration of epiglottis, ventricular bands, and interior of larynx 504

117. Growths on vocal cords and inter-arytenoid fold in a case of phthisis .... 506

118. Membranous adhesions between ulcerated growths on vocal cords ; same

case 506

119. Ultimate formation of web of membrane between vocal cords in same case. 506

120. (Edema of larynx in tuberculous phthisis, with central ulceration of lingual

face of epiglottis, and linear cicatrix marking previous ulceration of its free edge 507

121. (Edema of larynx with ulceration, in the latter stage of phthisis 507

122. Extensive destruction of epiglottis (Tuerck) 508

123. Perichondritis of arytenoid cartilage in tuberculosis. Ulceration in inter-

arytenoid fold 509

124. Abscess from perichondritis of arytenoid, projecting above the glottis 509

125. Perichondritis of right arytenoid and right side of cricoid cartilage, with

necrosis of latter, and protrusion beneath the displaced vocal cord ; ulceration of left vocal cord, and fungus vegetation in the inter-arytenoid fold 510

126. Multiple gummata (Mandl) 520

127. Gumma on inter-arytenoid fold 520

128. Primary perichondritis of cricoid cartilage, abscess unopened. Anchylosis

of left arytenoid (Tuerck) 528

129. Perichondritis of cricoid, with loss of right arytenoid, in a case of typhoid

fever (Tuerck) 528

130. Lupus of the larynx ;Tuerck) 529

131. Lupus of larynx (Ziemssen) 530

132. Syphilis of larynx (Ziemssen) 530

133. Appearance of larynx in leprosy (Elsberg ) 532

134. Appearance of larynx in leprosy (Elsberg) 532

135. Tumors on both vocal cords, producing sudden death 540

136. Tumor on left vocal cord, producing sudden death 540

137. Tobold's concealed holder, for molten caustic (Tobold) 550

138. Excrescence on left vocal cord (destroyed by caustic) 550

139. Excrescence on right vocal cord (destroyed by caustic) 550

140. Epithelial growths on both vocal cords, in a case of phthisis 551

141. Appearance of cords after destruction of growths with chromic acid 551

142. Tobold's laryngeal forceps (Tobold) 553

14:!. Fauvel's laryngeal forceps 554

144. Cuzco's laryngeal forceps 554

145. Luer's laryngeal forceps 554

146. Mackenzie's laryngeal forceps (Mackenzie) 555

147. Mackenzie's laryngeal tube-forceps and scissors (Mackenzie) 556

148. Durham's flexible forceps 557

149. Papillary growths in phthisis 557

LIST OF ILLUSTRATIONS. XV11

FIG.

PAGE

150. Papilloma occupying posterior laryngeal wall 557

151. Pedunculated neoplasm on vocal cord, in a case of phthisis 558

152. Pedunculated fibroma beneath vocal cord 558

153. Cyst of vocal cord 558

154. Laryngeal growths 559

155. Same case as Fig. 154, after removal of growths , 559

156. Tobold's concealed knife (Tobold) 560

157. Tobold's lancet-pointed probe (Tobold) 560

158. Tobold's knife, with single cutting edge (Tobold) 561

159. Tobold's knife, with double cutting edge (Tobold) « 561

160. Tobold's horizontally cutting scissors (Tobold) 563

161. Tobold's perpendicularly cutting scissors (Tobold) 563

162. Stoerck's universal handle for guillotine, etc., with two forms of guillotine

shown below 563

163. Gibb's wire-snare for dividing laryngeal growths (Gibb) 564

164. Tobold's wire-snare for dividing laryngeal growths (Tobold) 564

165. Guarded wheel ecraseur (Mackenzie) = 565

166. Tobold's chain ecraseur (Tobold) 566

167. Voltolini's laryngeal galvano- cautery 566

168. Author's galvano-cautery for the larynx 566

169-174. Von Bruns' instruments for galvano-cautery (Bruns) 567

175. Neoplasm on epiglottis 568

176. Fibroma on right vocal cord, removed after thyrotomy without tracheotomy 569

177. Laryngeal growth, for the removal of which thyrotomy was performed

after tracheotomy 570

178. Appearance of the parts some months after the operation 570

179. Appearance of the parts some years after the operation 570

180. Tumor of the trachea (Schroetter) 577

181. Involution of trachea by an aneurism of arch of aorta 579

182. Medullary carcinoma of larynx, in early stage 583

183. Schroetter's method of dilating stenosis of the larynx (Labus) 591

184. Mackenzie's dilator, for laryngeal stenosis 592

185. Bilateral paralysis of thyro-arytenoids in acute laryngitis (Ziemssen) 640

186. Unilateral paralysis of (right) thyro- arytenoid (Ziemssen) 640

187. Bilateral paralysis of thyro -arytenoid, with paresis of arytenoid (Ziemssen) . 641

188. Bilateral paralysis of recurrent nerve, caused by cancer of the oesophagus

(Ziemssen) 644

189. Cadaveric position of the vocal cords, drawn from a larynx removed from

a recent cadaver (Ziemssen) 644

190. Mackenzie's laryngeal electrodes 646

191. Ziemssen's double and single electrodes (Ziemssen) 647

192. Paralysis of left vocal cord in a case of aneurism of the aorta, appearance

during respiration 651

193. Paralysis of left vocal cord in a case of aneurism of the aorta. Appearance

during attempted phonation , 651

194. Crossing of the supra-arytenoid cartilages (Ziemssen) 651

195. Paralysis of left vocal cord in a case of phthisis. Appearance during res-

piration 652

196. Paralysis of left vocal cord in a case of phthisis. Appearance during x

attempt at phonation 652

XV111 LIST OF ILLUSTRATIONS.

FIG. PAGE

197. Paralysis of the arytenoid in acute laryngitis ( Ziemssen) 653

198. Bilateral paralysis of the posterior crico-arytenoids. Patient wearing the

canula 656

199. Bilateral paralysis of the posterior crico-arytenoids ; in the same case as

Fig. 198, at a later stage of the affection 656

200. Trousseau's double tracheotomy-tube 663

201. Howard's extemporaneous tracheotomy-tube 065

20'2. Howard's extemporaneous tracheotomy-tube 665

203. Trousseau's dilator 673

204. Author's rigid conductor, for facilitating introduction of tracheotomy-tube . 673

205. Trousseau's forceps for the tracheal canula 676

206. Luer's pea-valved tracheotomy-tube 679

207. Great displacement of larynx and trachea by cervical tumor 693

208. Laryngoscopy view of horizontal displacement of larynx to the extreme

right by cervical tumor 693

DISEASES OF THE THKOAT.

Chapter I. Diseases Of The Throat In General

Diseases of the throat do not differ materially in pathology from diseases of like tissues or tissue-elements elsewhere. Inflammations, idiopathic, deuteropathic, and traumatic, occur in various grades, or occur as constituent manifestations or results of systemic affections, such as tuberculosis, scrofulosis, syphilis, cancer, rheumatism, gout, erysipelas and the exanthemata, continued fevers, diseases of the large glands, chronic cutaneous affections, and other maladies. Then we encounter the various products of inflammation— adhesions of tissues, fistulse, strictures, glandular enlargements, tumors benign and malignant, aneurisms, etc. ; likewise wounds and other local injuries, mechanical and chemical ; foreign bodies, introduced by accident or design ; local results, such as oedema, pustular inflammation and destructive ulceration from the use of certain drugs, such as mercury, antimony, iodine and bromine, belladonna and stramonium, and some others; and, finally, various disorders of nervous origin.

The mucous membrane of the throat is exceedingly prone to become diseased, partly from its exposure as an inlet to extraneous influences, partly from a special proclivity, the nature of which is but imperfectly comprehended, and partly from extension of disease in adjacent structures, not infrequently the skin, with the affections of which it has much in common, in consequence, likely, of analogous construction, and perhaps of ultimate nervous distribution.

The treatment of diseases of the throat is rendered more 1

2 DISEASES OF THE THROAT IN GEXEUAL.

protracted than the treatment of diseases in most other portions of the body, by reason of the difficulty encountered in protecting the affected structures from the contact of the air, and the impracticability of keeping up continuous local medication; circumstances which compel a course of management differing from that which would be employed in analogous affections manifested elsewhere, where we avail ourselves of the plaster and the compress, the poultice and the embrocation. Topical treatment being required in many affections of the throat, the exercise of great care is essential in the selection of local remedial agents, inasmuch as some of them are capable of being promptly absorbed by the nasal and bronchial mucous membrane, and may thus produce objectionable systemic effects ; while, for similar reasons, caution is necessary to prevent the deglutition of the local remedy when of such a nature as to induce any deleterious influence from its ingestion, or its presence as a foreign or toxic body.

In almost all diseases of the throat, the secretion from the mucous membrane is affected. Sometimes it is simply diminished in quantity, sometimes it is simply increased ; most frequently, however, it is altered in quality as well as in quantity.

The normal secretion of the epithelial cells of the mucous membrane of the throat is seen to be a transparent, slightly viscous, aqueous exhalation, equably diffused over the surface, and giving little or no refractive evidence of its presence. It just serves to keep the parts in the moist, pliable state requisite for comfort ; and it protects them from the irritating influence of extraneous matters, whether present in the air, or brought in direct contact under special circumstances of avocation or exposure.

The most common effect of simple irritation of the mucous membrane is the collection of this exhalation into globules or drops, which present, according to their volume and the direction of light under which they are viewed, the appearance of either minute vesicles or papules ; and although this is not an evidence of active or serious disease, throats exhibiting this appearance are often denominated granular, not in the sense of description merely, but with the conception that the mucous membrane is deprived of its epithelial coat, and that the globules, papules, or granules are the prominences of enlarged follicles or muciparous glands — a condition which sometimes

DISEASES OF THE THROAT EN- GENERAL. 3

exists under circumstances mentioned later in the volume. Under this misapprehension, throats are unhesitatingly cauterized and re-cauterized, and therefore heedlessly subjected to the chance of sustaining permanent injury ; a result, however, which fortunately does not always follow in this class of affections, inasmuch as reparation is prompt, owing to the usually good state of the general health, and the innocuousness of the agent, nitrate of silver, most frequently applied upon the healthy mucous membrane. Sometimes, indeed, it must be acknowledged that such treatment, if not repeated frequently, as is too often the case, seems to rouse up the sluggish vascular action of the part, and conduce to prompt resumption of function.

One of the earliest and most persistent indications of inflammation of the mucous membrane is the secretion or development of mucus. The researches of physiologists teach that healthy mucous membrane does not secrete typical mucus, such as we are accustomed to so term it in diseased conditions of the membrane.

"When mucous membrane becomes diseased, the newly formed nuclei, which would normally have been developed into epithelial cells, take on the prolific cell-growth of an organization lower in the scale, and adhere to each other in masses which, with the fluids in which they are suspended, are described as mucus. This increased cell-action is very great, often producing material in much larger abundance than could be furnished by the extent of mucous surface involved, were the entire mass of mucus a mere secretion from that surface. Physiologists account for the copious collections of mucus sometimes encountered on mucous membranes, by the continued development of the nuclei and their offspring, after their deposition upon the exterior surface of the membrane.

In the absence of epithelium from mucous membrane, a superficial excavation is noticed, a mere erosion or abrasion, liable to be mistaken for ulceration involving the proper tissue of the membrane itself. The uneven prominences observed upon the surface of the mucous membrane in the inflammatory condition, is due to the rapid and unequal proliferation of immature epithelium cells, which, in their transformation into mucus, are progressing through the membrane to the surface, pushing it outwards from behind, as it were ; and as this process continues in the localities in which it first set up, the enlargements become more or less permanent, until the action is changed by treatment or otherwise. There is by no means a necessary destruction of the superficial epithelium of mucous membranes secreting mucus, as met with even in severe catarrhal inflammations, and even though these may be purulent in character. In fact, experience shows that this condition is exceptional, antecedent to such cases only as evince a disposition to ulceration from their commencement, whether arising from special diathesis, atony of constitution, violence of action, or lack of proper attention at an early period of the disease.