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TRANSACTIONS
XAUviVLAZOO ACAD EM Z
OF THE
MEDICINE.
International Medical Congress.
NINTH SESSION.
EDITED FOR THE EXECUTIVE COMMITTEE
BY
JOHN B. HAMILTON, M. D.,
Secretary-general.
VOLUME IV.
WASHINGTON, I). C., U. S. A.
1887.
PUBLISHED BY AUTHORITY OF THE EXECUTIVE COMMITTEE.
PUBLICATION COMMITTEE:
JOHN B. HAMILTON, M. D.,
Secretary- General .
A. Y. P. GAENETT, M. D.,
Chairman Local Committee of Arrangements.
C. H. A. KLEINSCHMIDT, M.D.,
Librarian American Medical Association.
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ERRATA-VOL. IV.
Page IS. — French title, for “Laryngiennee” read Laryngiens.
Page 60. — French title, for “ Perfections ’’ read Perfectionnes.
Page 1U5. — Tenth paragraph, for “cette” read cet.
Page 170. — French title, for “Alimentation par rectum” read par le rectum. Page 225. — French title, for “Mercuriala” read Mereuriels.
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PRESENTED BY
DR.CHAS, W. HITCHCOCK.
FROM I HE LIBRARY OF
DR. H.O. HITCHCOCK.
Mn*
SECTION XIII— LARYNGOLOGY
President: DR. W. H. DALY Pittsburgh, Pa.
VICE-PRESIDENTS.
Dr. J. Baratoux, Paris, France.
Dr. Bouchut, Paris, France.
Mr. Lennox Browne, London, England.
Dr. J. Charazac, Toulouse, France.
Dr. Carl Deilio, Dorpat, Russia.
Dr. C. M. Desvernine, Havana, Cuba.
Dr. J. J. Kirk Duncanson, Edinburg, Scotland.
Dr. Joseph Gruber, Vienna, Austria.
Dr. J. H. Hartman, Baltimore, Md.
Dr. G. V. Woolen,
Dr. Prosser James, London, England.
Dr. B. D. Moura, Paris, France.
Dr. J. 0. Roe, Rochester, N. Y.
Dr. 0. Rosenbacii, Breslau, Germany.
Dr. A. Schnee, Nice, France.
Dr. John Schnitzler, Vienna, Austria.
Dr. E. L. Shurly, Detroit, Michigan.
Dr. McNiel Whistler, London, England.
Dr. F. Laborde de Winthuyssen, Sevilla, Spain. , Indianapolis, Ind.
Wm. Porter, m. d., St. Louis, Mo.
SECRETARIES.
| D. N. Rankin, a.m. m. d., Allegheny, Pa.
COUNCIL.
Dr. J. Dennis Arnold, San Francisco, Cal. Dr. H. Blaikie, Edinburg, Scotland.
Dr. S. N. Benham, Pittsburgh, Pa.
Dr. W. E. Casselberry, Chicago, 111.
1. Dr. Lester Curtis, Chicago, 111.
: , Dr. H. H. Curtis, New York, N. Y.
| i Dr. Andrew J. Coey, Chicago, 111.
Dr. Richard Ellis, Newcastle-on-Tyne, England. Dr. Herman E. Hayd, Buffalo, N. Y.
Dr. E. Fletcher Ingals, Chicago, 111.
Dr. Geo. Mackern, Buenos Ayres, Argentine Republic.
Dr. M. C. O’Toole, San Francisco, Cal.
Dr. S. W. Pearson, Baltimore, Md.
Vol. IV— 1
1
2
NINTH INTERNATIONAL MEDICAL CONGRESS.
FIRST DAY.
The Section was called to order promptly at 3 p. M. by the President, Dr. Daly.
The President announced that he had been informed that Dr. Morell Mackenzie was about to receive the honor of knighthood, and hoped, this Section would promptly authorize an expression of pleasure and congratulation by cablegram.
Mr. Lennox Browne, of London, moved a cablegram be sent at once. Motion seconded and carried unanimously.
Dr. J. Solis-Cohen moved, and motion seconded, “that no paper be read, if the author is not present, until those present shall have been read. ’ ’ Carried.
INAUGURAL ADDRESS OF THE PRESIDENT, W. H. DALY, M. D.
Gentlemen — It is gratifying to see so many of my American confreres here to redeem the pledge made for them at Copenhagen, Denmark, in 1884, that an American welcome should be given the International Medical Congress, at this its ninth meeting. It is also a source of highest pleasure to meet those present from foreign lands, many of whose familiar names in the growing literature of laryngology remind us that we are not altogether new acquaintances. With many of us, our memories revert at this time with renewed freshness and pleasure to our last meet- ing in the capital city of the kingdom of Denmark, the home, not only of the sturdy Norseman, but of the most accomplished medical scholars; where both King and Nation gave up their country to the good of the Congress during its meet- ; ings, and where every one, from ruler to peasant, united in showing their nation’s ] guests what the full meaning of the Norseman’s hospitality was, so earnest, so quiet, so restful, so complete, that it comes back to us at the end of three years as though it was a quiet, happy dream of ours in a Norseman fairyland.
We scarcely think that it is possible for us to be so successful; but if we can secure j a degree of the happiness and profit realized by all of us in Denmark in 1884, then I think we shall have been successful indeed.
To one and all, however, not only to personal friends from across the seas whose familiar faces I observe before me, and to whom I am so much indebted for early and valuable training in laryngology, but to all, I bid a heartfelt greetiug and cordial welcome, and although we may not attain the perfection of the great meeting in Copenhagen in 1884, yet I beg all of you to feel that the broad bosom of this j beautiful land is happy in being your resting place, and its people feel the high honor that is accorded them in being permitted to entertain the worthy representative medical men from foreign nations. We sincerely trust that none of you will leave 1 this our nation’s capital without inspecting its residential localities as well as its ; public buildings — The National Museum, the Museum of the Army, the Smithsonian and other institutions. None of these collections suffer by comparison with the famous collections of the old world. In fact, Washington City is placed in the front rank as a repository of scientific learning.
SECTION XIII — LARYNGOLOGY.
3
We ought to congratulate ourselves as laryngologists in this our second meeting as an independent Section of the International Medical Congress, and endeavor to have the work of this branch of medicine placed in every large medical body as an independent Section, as the importance and growing excellence of its literature and valuable practical work deserves.
When one looks back to the state of laryngology in 1876, and makes a comparison with the present status of it, it becomes a matter not only of the utmost interest, but of satisfaction and pride to those who have been engaged in its study and advancement, to note what, alone, its cognate branch, rhinology, has done for the successful and rational .treatment of hay fever. Before the appearance of a paper which I read before the American Laryngological Association in 1881, calling the attention of the profession to some observations I made during a few previous years, upon the local predisposing intra-nasal causes of this disease, the sufferers therefrom had spent a rambling sort of life in seeking immunity from what they can now, in a large percentage of cases, easily get cured, permanently and surely, at home, by a proper rational treatment.
I desire to say, however, that the lamented Hack, and some other able workers in the same field, claimed more for the plan of treatment I then advised than I ever did. What I then, in 1880, assumed to postulate, I still find, after seven years, strongly tenable, viz. , ‘ ‘ Whether we are warranted in believing any case of hay asthma purely a neurosis, without first eliminating the possible causation due to local, struc- tural or functional disease in the naso-pharynx. ’ ’ Therein clearly admitting that a proportion of cases were of the character of neuroses, but a far greater proportion still depended upon a chronic intra-nasal disease upon which the exciting cause, viz. , pollen, and other agents, act with effect ; and second, without this intrinsic nasal disease the exciting cause is innocuous.
I am firmly of the belief that the workers in our special branch will yet make the local treatment so complete that we will cure a still larger percentage, even to all the cases of hay asthma that present themselves. This is a hopeful and zealous view of the future of hay fever, but I nevertheless expect to see this realized.
There are few laryngologists but have constant opportunity of observing the rapid development and growth of puny children, after having been under the treat- ment of the throat specialist, and their noses and throats put in proper order, so that the filthy catarrhal discharges are no longer swallowed, and the upper air passages ; are opened up, so that during sleep they can get a plentiful supply of air ; hence physical thrift and comfort quickly change the weakly constitution to a strong one.
I think no working laryngologist can fail to note the growing importance of Rhinology, and I am free to say that the opinion I expressed in a paper before the Eighth International Medical Congress at Copenhagen, viz. , ‘ ‘ That the laryngologist of the future must be more the rliinologist, and the rhinologist more the surgeon than the physician, ’ ’ has been fully borne out by the evidence afforded by our literature alone.
There can be no question that a large proportion of the inflammatory diseases of the larynx are secondary to an initial disease of the intra-nasal cavities, of like inflam- matory character. This I have repeatedly verified by years of observation, and frequently publicly so stated in our deliberations, and I am pleased to say that the number of my colleagues who have since also verified this to their own satisfaction is an ever increasing one, comprising, as it does, some of the most successful and distinguished practitioners in this special branch of medicine. The aid modern rhinology has been in our successful prevention and treatment of internal and
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NINTH INTERNATIONAL MEDICAL CONGRESS.
middle-ear diseases alone is scarcely calculable. The fact is apparent that no aurist can be accomplished in his special work who ignores the facilities alforded him by a careful study of the concomitant, and too often initial, disease of the intra-nasal cavities.
But, gentlemen, time passes, and I must not further dilate on the advancement of our beloved specialty and its cognate branches ; the bright minds who are now devotees of its sendee, and future workers, will place it higher and higher, till it reaches its zenith of excellence and usefulness to humanity.
As you observe by the printed programme, there is an abundance of papers, from able writers from many lands, upon most attractive subjects, and the valuable time of the Section must not be taken up, either by your President or any one else, to the exclusion of others. I will, therefore, set the example of brevity by making my address short. I feel I have your kind wishes, and that you will aid me in expediting the work of the Section from day to day, confining ourselves strictly to the time per- mitted to each member under the rules, viz. , twenty minutes for the reading of a paper and ten minutes for each speaker engaging in the discussion thereof. I shall hope that each member will be promptly here at the hour to which we adjourn, so that we can begin our work and continue it without undue haste as the session advances.
But, friends, we are solemnly reminded in these living moments, as we enjoy our happy greetings of old friends and new “from lands of sun to lands of snow,” that there is an increasing number of the goodly names of our honored dead, who worked and won fame in the field we now cultivate ; while they are personally the silent members of this our Ninth International Medical Congress, yet through every one of you their names, and voices, and words of wisdom will be heard, as you speak from this, for the time being, the World’s Medical Forum, to your absent colleagues in every land and clime. Their names are on the lips of every student of laryngology, and their words will always stand a part of its growing and valuable literature ; and while then- fame is our pride, let it also be our aim to emulate the higher traits of character and the ability that won for our Elsberg, Krishaber, Foulis, Bruns, Walden- berg, Buro, Bocker and Hack, the distinction that made their teachings as beacon lights to guide their less gifted brethren in the fields of laryngological science. Oh honored dead, we in spirit strew flowers on your tombs, and join hand in hand while we bless the memory of your worthy lives and mourn the events of your too untimely deaths. A part of this number were young men, cut off in the growing beauty and strength of manhood, with all the zeal and enthusiasm of their scientific labors yet fresh upon them. May the earth rest lightly over them in the respective lands where their devoted bodies lie, the lameuted, the honored, dead of our ranks.
DISCUSSION ON EPISTAXIS.
Prof. E. Fletcher Ingals, of Chicago, opened the discussion on Epistaxis, it being one of the subjects, selected for special discussion. He remarked, this is an old subject, on which there is little to say, but we hope its discussion may call out some new thoughts from some of the many workers in this field. It is of much import- ance, because of the frequency of the affection, and therefore anything t hat may add to the general fund of our knowledge regarding it is valuable to the whole profession.
SECTION XIII — LARYNGOLOGY.
5
The ordinary cases of the disease occurring in children and young adults require no treatment whatever, as the bleeding is nature’s attempt to relieve plethora, or it is so slight that any of the many popular methods will check it in a few minutes; but when bleeding is persistent, or when it occurs frequently in such amount as to debilitate the patient, it must receive our careful attention.
In such cases constitutional remedies, such as ergot, gallic acid and iron, have been long recommended, and they may probably be tried, but I have little confidence in their efficiency. In most of these cases topical measures must be employed. Many times the bleeding may be checked by insufflations of cocaine, which is the most agreeable to the patient, or by tannin, gallic acid or matico, any of which may be used without causing great discomfort. If the insufflations do not succeed, plugging should be resorted to. The post-nasal tampon is efficient and is commonly employed, but it causes great discomfort, and is liable to set up inflammation of the middle ear, with serious consequences. A number of deaths have been reported from the inflammation which it has caused, therefore it should not be employed if it can be avoided, and in nearly every case equally good or better results can be obtained by tamponing the naris from in front. If the posterior plug is used, a short string should be left hanging down from it, behind the palate, to facilitate its removal. The method of tamponing which I have employed with most satisfaction is done with a strip of surgeon’s gauze, about an inch in width and three or four feet in length, which has been saturated with a mixture of tannin rubbed up in water to the con- sistence of thin syrup. The nostril being distended, the end of this strip should be folded over a flat probe and earned quickly to the back of the nasal cavity, and sub- sequently fold after fold is pushed in more slowly until the whole cavity is filled. It is important to carry in the first fold quickly, otherwise the blood will cause it to adhere to the walls before it has reached its proper position. As this plug must be kept in situ sometimes for many hours, it is well to make a free insufflation of iodo- form just before its introduction. In some cases it will be found very advantageous to tie several threads of strong silk, about two inches apart, to the end of the strip of gauze which is just introduced. These are allowed to hang from the nostril; the end of gauze to which they are fastened is pushed into the naso-pharynx, and after the naris has been partially filled the threads are drawn upon, one after another, so as to thoroughly plug the posterior naris. After the immediate danger is over, a careful inspection of the naris will, in the great majority of cases, reveal a small erosion or ulcer from which the blood has escaped. When this has been thoroughly cauter- ized a cure may be expected. For cauterization nitrate of silver may be employed, but the galvano-cautery is far preferable. In some cases, viz. , those depending on the hemorrhagic diathesis or extreme plethora, this may not effect a cure, but fortu- nately these cases are extremely rare.
Dr. I. Hermann, of Washington, D.C., remarked — I have listened with great interest to the discussion on this interesting subject. I should like to say a few words on a remedy for epistaxis which has not been mentioned among the different cures to-day. They are, of course, all very valuable, but we sometimes meet cases where they all seem to fail. Such, at least, has been my experience in a number of cases, and in one case particularly, which I will describe shortly. I had a lady under treatment for acute otitis media, and had to make the paracentesis tympani, using also the nasal catheter to remove the pus from the tympanic cavity. I am sure I did not produce a lesion of the nasal membrane with the catheter, but on the evening of the following day I was called to the lady, who had been bleeding at the
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NINTH INTERNATIONAL MEDICAL CONGRESS.
nose for several liours. I found her indeed in quite an alarming condition, as she was already quite anaemic from having injudiciously nursed a fifteen months old baby, and this loss of blood was rather too much for her. I applied cocaine in sub- stance and in bulk without effect, also Morell Mackenzie’s tannic and gallic acid mixture, as well as the anterior tampon; still the blood continued to flow in front as well as in the pharynx. Then I thought of a remedy I have sometimes used, and called for cracked ice, filled both nostrils with it, and put a small bag on the bridge of the nose. Then I made the anterior tamponade in both nostrils. This stopped the bleeding effectively, and another slight attack on the following day was also at once stopped by this application. I found also, on inquiry, that the bleeding of the nose was simultaneous with a flow of blood from the uterus. I have used this remedy for epistaxis before, on several occasions. I do not hesitate to commend it to the profession as a very superior and convenient remedy, where others fail.
Dr. Walton Browne, of Belfast, Ireland, said — I believe in the treatment of epistaxis; we should trust to plugging from the anterior nares by a strip of lint impregnated with powered alum ; remove it at the end of twenty-four hours by gentle syringing, and then plug with cotton wool saturated with hazaline. I would especially refer to the treatment of epistaxis by my friend Dr. Harkin, of Belfast, namely, counter-irritation over the region of the liver, with good results.
Mr. Lennox Browne, of London, related a case to show that it was sometimes unwise to arrest a disposition to epistaxis in persons past middle age, even when appearing to proceed from purely local causes in the nostril. He also drew atten- tien to recent experiments which tended to prove that the astringent properties of tannin have been much exaggerated.
Dr. M. It. Coomes, of Louisville, Ivy. related a case where a tampon had re- mained in the nostril by mistake for seven months; spoke of the plan of holding or compressing the nose, and the introduction of a piece of bacon in the nostril.
Dr. John M. Foster, of Richmond, Ky., related a case of epistaxis due to heart disease relieved by the use of digitalis, and spoke of the influence of scrofula in bringing about the hemorrhagic diathesis.
In closing the discussion, Prof. Ingals inquired of the other speakers as to whether ice or alum, as recommended by Dr. Browne, of Belfast, caused pain. He was answered in the negative, and therefore he thought well of both methods. He had no experience with bacon, recommended by one of the speakers. The method of compressing the nostrils until the blood had coagulated had been referred to as Dr. Roe’s method; but he was sure that his friend from Rochester, if present, would not father a method which had been in common use for five thousand years — since according to one of the speakers of the session, rhinologists first began their practice.
SECTION XIII — LARYNGOLOGY. 7
A CONTRIBUTION ON THE CAUSES AND TREATMENT OF SO- CALLED HAY FEVER, NASAL ASTHMA, AND ALLIED AFFEC- TIONS, CONSIDERED FROM A CLINICAL STANDPOINT.
UN RAPPORT SUR LES CAUSES ET LE TRAITEMENT DE L’ASTHME DE FOIN ET DES AFFECTIONS SEMBLABLES CONSIDEREES AU POINT DE VUE CLINIQUE.
EIN BEITRAG ZUR ATIOLOGIE UND BEHANDLUNG DES SOGENANNTEN HEU-ASTHMAS UND VERWANDTER AFFECTIONEN, VOM KLINISCHEN STANDPUNKT
BETRACHTET.
BY RICHARD HENRY THOMAS, M.D.,
Of Baltimore, Md.
Mr. President and Gentlemen of the Section. — In asking you to consider with me the subject of the nasal neuroses, I do so with the object of relating chiefly my own experience, with a hope of thereby contributing to the solution of some of the vexed questions in regard to this class of diseases.
There are those who claim that the occurrence of nasal reflexes depends chiefly upon a condition of neurasthenia, or some disturbance of the general nervous system; others, that they are due to obstructive disease of the nasal passages, or to some well defined intra-nasal disorder. Again, it has been urged that there exist in the upper air pas- sages certain special areas, such as “ the reflex sensitive area,” and that if these areas become diseased, or irritated by the presence of a polyp, or an opposing hypertrophy, etc., they will give rise to reflex phenomena. Others consider that the underlying cause consists in a congenital peculiarity of structure, either in the nerve centres or end- ings, that render them liable to take on perverted or excessive action when exposed to certain exciting causes; that this condition, though obscure, is pathological, and is greatly affected by the general health of the individual, and by various diseases of the upper air passages.
For reasons which I am about to submit, I incline to this last view, as opposed to the others I have mentioned.*
1. Neurasthenia. — While it is true that many of those in whom we observe the pres- ence of nasal neuroses are either neurasthenics or show evidence of some disturbance of the general nervous system, and while this general condition, when present, undoubt- edly is a very important factor in maintaining and increasing the violence of the attacks, yet the frequency with which we meet with the reflex phenomena as the only evidence of nervous disorder, shows that neurasthenia, or any condition of the general nervous system, is not of itself the necessary predisposing cause. This proposition is further sup- ported Jay the fact that we not infrequently see neurasthenics suffering from various forms of nasal disease, who present no evidence of reflex phenomena referable to the upper air passages.
2. Obstructive Diseases of the Nasal Passages. — These are undoubtedly very frequently associated with hay fever, nasal asthma, etc., but that this condition is not in itself a principal factor in producing the attack is shown lay the following reasons: —
(a) In the majority of cases where I have observed this condition (whether arising from polypi, hypertrophies, deflected septum, etc.,) there have been no reflex phe- nomena at all, even in neurasthenic individuals. While this condition usually aggra-
* In the list of theories I have not included that which considers that a specific action belongs to the pollen of certain plants, as this doctrine is held by but few, and they are decreasing in number.
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NINTH INTERNATIONAL MEDICAL CONGRESS.
vates the attacks, it cannot be said to do so invariably, for in one of ray patients the symptoms are generally ameliorated when the nasal passages become occluded, either by swelling or secretion.
( b ) In typical cases of nasal asthma, I have observed patients in whom there was at no time nasal obstruction, though this condition is not so common as the opposite.
(c) Cases have been reported, though I have not seen any, where reflex phenomena of nasal origin were associated with an atrophic condition of the nasal tissues.
(d) It is generally possible in hay-fever patients to excite a temporary attack at any time, by touching the sensitive areas in the upper air passages with a probe, and this independently of the presence or not of nasal obstruction.
3. The same remarks apply to nasal and pharyngeal diseases generally, that can be detected by the ordinaiy methods of rhinoscopic examination. They all may or may not be accompanied by reflex phenomena.’ We may, therefore, conclude that the pri- mary cause of the nasal neuroses is not to be looked for in any of them, while it is undoubtedly true, both in regard to neurasthenic and non-neurasthenic individuals, that their presence may greatly aggravate and prolong the attacks, and perhaps even develop a latent tendency thereto.
4. The Existence of Sensitive Areas. — These have been variously defined by various 'observers. Some have been inclined to limit them to special places. Others have
admitted that any part of the upper air passages may be sensitive, but claim that there are special areas which are most generally sensitive, and on this claim they base their own theories as to the aetiology of nasal neuroses.
On this point I have instituted two series of observations. The first was to dis- cover the sensitive area, or areas, in those who were affected with some of the forms of nasal or pharyngeal reflex disturbance. The second was to discover any sensitive areas that might exist in cases where the upper air passages were normal, or, if pathological, not associated with reflex disturbance. Of course, I excluded all cases where there was any destructive disease. In carrying out these observations, I found that different individuals vary greatly, not only in the ease, but in the rapidity with which they respond to the touch of the probe. This makes it important to pause after touching one point before proceeding to another, for if this be not done, reflex phenomena really due to irritation of one part may be wrongly ascribed to another.
In the first series of cases, that is, those where the reflex phenomena were present,
I have found, as far as I have gone, that it is absolutely impossible to say positively that one part of the intra-nasal passages is more sensitive than another. In every case some area of special sensation was to be found, but this area would vary in every case, and in one or two instances could only be located in one nostril. In others, the sensi- tive area would be located in one nostril at one point, and in the other at another point not corresponding to the first. I find I have noted in different cases the floor of the nostrils, any portions of the turbinated bodies, the whole of the septum, partg of the pharynx. There is a slight predominance in favor of the middle and posterior' portions of the nasal passages, and of any part of the septum, especially that portion supplied by the olfactory. In two cases almost every portion of the intra- nasal tissues appeared equally sensitive. These observations were all carried on during the intervals between the attacks, no observation taken during an attack or in the hay-fever season having been noted in the preparation of this paper. The reflex phe- nomena brought out in these cases were : besides the usual laclirymation, violent parox- ysmal sneezing, disturbances of respiration, such as temporary asthmatic dyspnoea, headache, etc.
In the second series of cases, that is, in those where there were no reflex disturb- ances, I found, generally, that it was impossible by ordinary probing to produce any result beyond lachrymatiou, slight sneezing and, at times, a very slight expiratory effort.
SECTION XIII — LARYNGOLOGY.
9
The second was very often the last, generally absent. There was in some individuals of this class a very high degree of ordinary hypermstliesia in the nasal tissues, so that a slight touch of the probe would cause decided pain or great tickling. In these there was no reflex phenomena produced beyond laehrymation. In this class I have not been able to discover any area of special sensation, the slight phenomena produced being called forth about equally well from the various parts of the intra-nasal tissues.
While my observations are still in progress, the results thus far incline me to adopt the opinions of those who maintain —
(0) That, as a rule, there exists normally in the upper air passages no special “ reflex sensitive area.” This view is strengthened by the occurrence of polypi, etc., where they can irritate the so-called sensitive areas without producing reflex phenomena.
(b) When, under pathological conditions, such an area is present, it may exist in any part of the upper air passages. If this view be correct, we must accept the theory of Lublinski, that in the production of a paroxysm the olfactory, the trigeminus and the sympathetic may be involved.
5. Congenital Peculiarity of Structure. — As the other theories I have mentioned are not sufficiently sustained, we seem driven to the theory that there is a peculiar condi- tion, in the nerve endings (or perhaps in the nerve centres), that renders them liable to take on excessive or perverted action when exposed to certain forms of irritation. Idiosyncrasy is, according to Jonathan Hutchinson, “to a large extent a diathesis brought to a point.” I do not use the term as a means for hiding ignorance or dis- couraging research. But our knowledge is not yet sufficiently accurate to lay aside the expression. The existence of an idiosyncrasy always denotes a pathological condition which is still obscure. The pathological condition, however, occasions no disturbance until an exciting cause is present, and the readiness and violence with which it will respond to these excitants depends greatly upon the condition of the upper air passages and of the general nervous system . Why one irritant should produce an attack in one person and be harmless to another is, as far as our present knowledge goes, explicable only on the supposition of an idiosyncrasy.
The exciting causes may be classed as follows : (1) Inert substances floating in the
air, such as pollen, etc. (2) Psychical impressions. (3) Meteorological changes, and the effect of sunlight and wind. (4) Morbid changes and new growths in the upper air passages. (5) Irritation reflected from distant parts of the body.
(1) Substances Floating in the Air. — In the class of cases affected by this variety of irritants, the periodicity depends upon the return of the irritant. Thus, in the case of a colored man who presented himself at my clinic, the man would be free from attacks all the year round, working on a farm in the country, but could not for a moment enter a room where oysters were being opened without having a decided attack. In a medical student the odor of a dissecting room was found to have a similar effect. Among the external irritants, other than those just mentioned, floating in the atmos- phere, which I have noted as producing a paroxysm in my patients, are the following : The pollen of rag-weed, luxuriant vegetation generally, Indian corn in tassel, the smell of flowers, dust, wheaten and other kinds of flour and meal, the odor of tobacco, the dust of a preparation called “soapine,” the dust of a railway train, etc.
(2) Psychical Impressions. — These are at times sufficient to act as an exciting cause in a sensitive person, as, e. g., the production of an attack by the sight of an arti- ficial rose, reported by Dr. I. N. Mackenzie. This interesting case has, as Dr. Bosworth points out, no bearing on the question as to the power of the odor of flowers to pro- duce an attack without psychical impressions, as it is not at all likely that the result would have been brought about had it not been for the former experiences of the patient with real roses. I have seen a patient become affected by the presence of flowers in a room before he knew they were there. In my own person I have noticed
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NINTH INTERNATIONAL MEDICAL CONGRESS.
the effect of another form of mental impression. Although not subject to hay fever, I frequently have an attack of something like it for about half an hour after treating a severe case.
(3) Atmospheric Changes, etc. — The effect of these is so well known that I will merely refer to an interesting case that has lately presented itself to me. The patient suffers violently from asthma of naso-pharyngeal origin. The attacks only come on during the three summer months. The hotter the day the more comfortable she is, hut the sudden cooling of the atmosphere by a thunder storm, either where she is or in the near vicinity, will bring on an attack. The peculiarity in her case is that if a thunder storm occur in May, after never so hot a day, it will not affect her.
(4 and 5) New Growths and other Morbid Changes in the Upper Air Passages. — The influence of these has been so exhaustively discussed of late years, that it need only be referred to here. Neither will I take your time to dwell upon the power of irritation in other organs to produce reflex disturbance of the respiratory tract. Of the connec- tion between irritation of the genital apparatus and that of the nose, I have not had any experience as far as genuine hay fever cases are concerned. In a lady who suffered severely from migraine of nasal origin (which has since largely yielded to intra-nasal treatment) the first symptom would he occlusion of the nostrils and a simultaneous appearance of a leucorrhceal discharge from the vagina, which would abate with the abatement of the nasal symptoms.
If the views advanced in this paper be correct, it follows that, in the history of a paroxysm, the hyperasmia and swelling are secondary phenomena, the underlying cause being the excitation of the nerve endings (or centres), which are in a condition to respond to the irritant acting upon them.
I have noted, in common with others, the marked influence of heredity, but not to the same extent of race or station in life. While the majority of my patients have belonged to the more educated and intellectual classes, I have seen cases in every class of life, and not only in the Caucasian, but, in two instances, in the negro.
Treatment. — This may be palliative or curative. The palliative consists in various applications and internal remedies used at the time of the attack. Of these there are many, and none of them are of much permanent value. Their constant use is not without risk to the parts. This can certainly be predicated of local applications, such as cocaine and other powerful drugs.
Traveling is often a complete temporary relief. The precise cause for this is not always easy of explanation. A patient of mine, who for years was a sufferer, lived in a county in Maryland where the vegetation was luxuriant. One year he spent the season in another county where the conditions were the same, and where a number of the inhabitants are affected with hay fever. Yet he escaped entirely that year. The same individual would not be entirely free from attacks on a coasting vessel that kept within fifteen to fifty miles from shore, and this independently of the direction of the wind.
The proper course to pursue is the one that looks to a radical cure. To accomplish ' this we must use, in the majority of cases, both constitutional and local treatment. If we take Jonathan Hutchinson’s definition, above referred to, the presence of an idio- syncrasy should no more discourage treatment than a diathesis. The most important part of the treatment is the local, for the introduction of which we are indebted to our honorable President, Dr. W. H. Daly. This has two objects : 1st, to cure any coexisting disease in the nose or throat ; and, 2d, to search out carefully and locate the sensitive area or areas that may exist in the upper air passages and cauterize them, an operation rendered nearly painless since the introduction of cocaine. On the first indication it is needless to dwell. For the second I greatly prefer the galvano-cautery, although other caustics, such as glacial acetic acid, may be used instead. I have employed the galvano- cautery constantly for four years, and am more and more impressed with its adapt-
SECTION XIII — LARYNGOLOGY.
11
ability and safety, when used with the proper precautions. After the applications, the nasal passages should be carefully cleansed with some mild antiseptic solution (as Dobell’s), and the eschars removed as soon as possible, especially where the cauteri- zation has been made on a surface that nearly approaches the opposite wall of the naris. I frequently give iron and quinine internally after an application.
The most important rule to be observed in carrying out the treatment is to be thorough. So long as any sensitive area remains, the patient is not cured. The main treatment must be carried out betweeu the seasons for the attacks, and I prefer to begin as soon as the attack is over. It is important, also, to see the patient during the next season, as it is impossible to discover all the sensitive areas until the season arrives. The remaining sensitive spots are then to be cauterized.
I have seen the most gratifying results by following this method, though I have one case on record where the patient was cured without the use of any cautery, but only by simple applications of astringents and general treatment.
In cauterizing, my method is to destroy as little tissue as possible. The cavernous tissue is a normal one, and the process of engorgement and swelling which occurs in the varying states of the temperature and of the atmosphere is a normal one, and, in proper limits, preservative to the health. To attempt, then, anything like its entire extirpa- tion, even if that were possible, except where it is clearly required, is unwise.
At the same time, constitutional measures, chiefly addressed to the nervous system, are generally, though not always, indicated. The drugs I most frequently use are the valerianates of ii-on, quinine and zinc, arsenic or hydrobromic acid (Gardner’s syrup). In all cases of debility the general health must be built up by the usual tonics. Each case has to be made a separate study. If the treatment be properly carried out, the prognosis for a radical cure is decidedly good. Had time permitted, I should have illustrated this paper by more cases from my own practice, but, as it does not, I must be content to present these observations as a r6sum6 of my work up to date.
HAY FEVER.
ASTHME DE POIN.
HEU-ASTHMA.
BY ISRAEL P. KLINGENSMITH, M.D.,
Of Blairsville, Pa.
At no time in the world’s history, since the day Dr. John Bostock, in 1819, presented the first formal paper on this subject to the London Medico-Chirurgical Society, have more eager scientific workers been in the field in the pursuit of knowledge and its practical application to disease In no subject can you find a better proof of this fact, than in the disease now under consideration. I will not occupy your valuable time by giving a detailed history of the symptoms, course and duration of the disease, but will confine myself to submitting to your consideration the results of my investigations so far as they bear broadly and directly upon the method of treatment I propose to advo- cate. In very few diseases do we find such a diversity of opinion in regard to the cause, as in hay fever. Bostock attributed it to heat, while his contemporaries differed on
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NINTH INTERNATIONAL MEDICAL CONGRESS.
this point. Since that period many theories have been advanced, but considerable diversity of opinion exists even at the present time. Until within the last five or six years, inquiry has been directed to the investigation of the exciting cause of the attack, and the predisposing or more important causes of the disease have been overlooked. Most of the literature upon the subject of hay fever, hay asthma, autumnal catarrh, or by whatever name it may be designated, is devoted to the extraneous or exciting causes of the malady in question, and numerous remedies, which serve simply to divert the mind of the sufferer, without resulting in any practical benefit, are suggested. Each patient coming under our observation should be subjected to a thorough rhinoscopic examination, allowing all fine-spun theories and extrinsic causes to take care of them- selves. To Dr. W. H. Daly, of Pittsburgh, Pa., belongs the honor of first calling the attention of the profession to the important part which diseases of the naso-pharyngeal cavities play in the production of hay fever, who, in a paper read before the American Laryngological Association, in May, 1881, showed that the exciting causes of the disease are innocuous in those cases in which disease of the naso-pharyngeal cavities does not exist, and proved further, from clinical evidence, that the disease is a curable one, by removing the intrinsic local cause and restoring the parts to a normal condition. The succeeding year Dr. John O. Roe, of Rochester, N. Y., read a paper before the Medical Society of the State of New York, practically corroborating the investigations of Dr. Daly. In 1884, Dr. Hack, of Freibui-g, Germany, a special laborer in this field, made known the result of his investigations, also holding the view that pathological con- ditions of the nasal mucous membrane play the most important part in the production of the disease. The investigations of other observers substantially affirm the same theory. In reference to my own personal experience, I will simply say, that of the thirteen cases that have come under my personal observation, in each one of them has disease of the nose or naso-pharynx existed. The numerous exciting and extrinsic causes which have been supposed to bring on attacks of hay fever would occupy several pages, and I will therefore simply refer to a few of the more prominent. In those cases where local irritability or any deviation from the normal condition of the nasal cavities exists, an attack may be brought on by almost any exciting agent, an odor or vapor, dust, light or heat, the pollen of flowers or grasses. In some cases I have known the attack to date from a severe cold. In support of the view that almost any agent may produce a paroxysm, I will mention the case of a patient who is so susceptible to the influence of ipecac and Dover’s Powder as to be able to produce an attack at any time by their inhalation. More recently the case of a young man, a miller by profes- sion, has come under my observation, in [whom the paroxysms are produced by the inhalation of small particles of flour while following his occupation. During the past few years great advances have been made in bringing the treatment of hay fever within the radius of a more scientific standpoint, based upon a nearer approach to a rational pathology of the disease. Based upon my own investigations, as already stated, I am compelled to adopt the view that in each case of hay fever does a condition of the nasal or naso-pharyngeal cavities exist varying from the normal. When we view these facts and theories with a view of carrying out a rational plan of treatment, we should in every case make a thorough anterior and posterior rhinoscopic examination. In a great majority of cases a chronic nasal catarrh exists, with sensitive areas not confined to any particular portion of the mucous membrane. In other cases I find a true hypertrophic condition either anterior or posterior, or both. Polypi or deflections of the nasal septum may also act as a prominent factor in the propagation of the disease. Fully believing that hay fever is due to local irritatives brought in contact with a diseased con- dition of the nasal mucous membrane, I am therefore compelled to call attention to the radical treatment as the chief mode of relieving or curing the disease. This plan in the hands of Daly, Roe and others, beside myself, has been followed by the most
SECTION XIII — LARYNGOLOGY.
13
lasting and signal success. When nasal polypi exist I remove them by means of Allen’s nasal polypus forceps or Jarvis’ snare, always making sure to thoroughly cauterize the base with the galvano-eautery or glacial acetic acid. If large hypertrophies, either anterior or posterior, are found, they should be removed by means of the Jarvis snare. Smaller hypertrophies and sensitive areas I destroy by using the galvano-eautery, chromic acid or glacial acetic acid, giving preference in the order named. All surgeons have favorite instruments and appliances, giving preference to some, while discarding others. The battery in use by me now for several years was devised by Dr. Seiler, of Philadel- phia, and fulfills every indication required by the operator. The current cau be controlled by the foot of the operator, thus giving him the use of both hands, and the temperature of the knife can be regulated to any degree of intensity. In using the galvano-eautery I introduce an Allen’s hard-rubber nasal speculum, through which the electrode is placed on the spot to be cauterized, after which it is brought to a cherry-red heat; great care must be taken to have the electrode at the proper temperature when applied to the tissue about to be destroyed, as, when too hot, free hemorrhage may result, and when too cold great pain will be produced. As a certain amount of inflammation is necessa- rily produced, not too large an incision should be made at any oue sitting. My prefer- ence is given to the galvano-eautery, since it can be brought more fully under the con- trol of the operator than chromic acid, aud is less painful than glacial acetic acid. The pain produced, as a rule, is but momentary, except occasionally in persons of a highly nervous organization, when I apply a four per cent, solution of hydrochlorate of cocaine, either by means of the atomizer or an aluminium probe enveloped in cotton. The operation should be repeated about once a week, or as often as admissible, being governed by the degrees of inflammation produced, until all hypertrophies and sensitive spots are destroyed. During the intervals of the operations the patient is directed to use an insufflation, such as Dobell’s, or some other alkaline solution. In the application of chromic or acetic acid I use the Bosworth’s application. The treatment should be commenced about two months before tbe accession of the attack, and the nasal cavities should be restored to as nearly a normal condition as possible, relieving them of all hypertrophic conditions and sensitive areas. While I am of the opinion that treatment should be commenced several weeks prior to the expected attack, yet in no case do I desist from operating even when the disease is at its height. Iu several such cases have I known the intensity and duration of the paroxysms to be shortened. Of the thirteen cases upon which my observations are based, nine have been practically cured, and four, in whom the treatment could not be carried out perfectly, were greatly benefited. In conclusion, permit me to say, that I have tried to outline, in as brief a manner as pos- sible, the essential points of this method of treatment, but, as will be observed, much pertaining to the minor details has been necessarily omitted which is essential to a proper understanding of tbe subject.
DISCUSSION.
Mr. Lennox Browne, of London, Eng., expressed his general assent with the views expressed by the authors of the papers, and made a few rdmarks on details. He remarked the papers contained nothing new. He considered in some cases the pollen an exciting cause, in others the sole cause; the former generally held. He thought that often good might he done by gentle methods, as vaseline protection, etc. Cocaine, if long continued, might prove injurious. In using the galvano-eautery a dull-red heat is best, and least likely to produce hemorrhage.
Prof. E. Eletciier Ingals, of Chicago, thought nothing more could be said upon the two papers than had already been said by Mr. Lennox Browne, but he was interested in what the last speaker had said regarding the heat of the electrode. He thought if the naris was first treated with vaseline or fluid cosmoline, it made little
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NINTH INTERNATIONAL MEDICAL CONGRESS.
difference whether a red heat or a white heat were employed, provided the electric currents were not cut off before the electrode was removed from the tissues, except- ing in cases of deep incisions, in which hemorrhage was very likely to follow the use of an electrode at a white heat.
Prof. W. E. Casselberry, of Chicago, said — I am convinced that hay fever is primarily occasioned by local pathological lesions within the nose or naso-pharynx being acted upon by an irritant. It follows that thorough removal of the pathological condition will radically cure the disease, but it is essential that its cauterization be thorough, that all sensitive or diseased areas be removed. Many having been but partially treated and but partially or not at all relieved, speak adversely of the method, and unfairly so. Since the cautery cannot be applied oftener than once a week, to operate thoroughly requires not two months, the time mentioned, but often four, five, six or even more months; and it should be thoroughly understood with the patient, when treatment is commenced, that it is to be carried to a finish.
Dr. Stucky, of Lexington, Ky., thinks the majority of cases require gen- eral treatment. He summarizes as follows : In thirty-four cases the majority were neurasthenic, and required constitutional treatment. He never uses the galvano- cautery at white heat; has better results from dull red. If the sensitive area is hyper- trophied tissue, he uses chromic acid. He usually prefers glacial acetic acid, applied eveiy second or third day, and destroys every sensitive area, no matter how many or the location. His after treatment is soothing and protective, and consists of daily applications of vaseline. Three months was the longest time he had to treat a case.
Dr. John N. Mackenzie, of Baltimore, Md., remarked, in regard to Dr. Thomas’ reference to the sensitive area located by him some years ago, that he now maintained that the posterior end of the inferior or turbinated bones and septum were the sole spots from which pathological reflexes are obtained. Pathological reflexes may be gotten from any portion of the membrane, but the area indicated by him he believed to be the most sensitive. Dr. M. then related his experiments with artificial flowers, to counteract the criticism of Prof. Bosworth and Dr. Thomas. Gave a brief resume of his theory of hay fever and allied affections and criticised the various theories hitherto advanced.
Dr. J. Solis-Coiien, of Philadelphia, Pa. , believed that much of the difficulty in understanding hay fever was due to too much specialism. Iu pre-rhinoscopic days the general physician knew nothing of the condition of the nose, and recent workers in rhinoscopic fields seem to know too little of general medicine. His own opinion closely coincided with that of tbe preceding speaker, but he would attribute the con- stitutional conditions of the sympathetic portion of the nervous system, and the resultant conditions of its vasomotor terminals in the vessels of the nasal mucous membrane to a lack of equilibrium in the nervous strength of the patient. This might be due to hereditary conditions or to acquired ones, whether from deprivations, from excesses or from overwork. Hence, given a patient in this condition, the action of an irritant to which he is very sensitive will precipitate the attack of hay fever. If neurasthenic, his nervous system requires tonic treatment. If neurasthenic, it requires sedatives. This condition of system must be treated for long periods after the subsi- dence of an attack in order to get the patient into such a condition of his nervous system as would render him less susceptible to the irritation when the period for his hay fever recurs. This might take a very long time, and require the hay fever sub- ject to be under the observation of his physician during the entire interval.
SECTION XIII — LARYNGOLOGY.
15
Dr. Ridge, of Camden, New Jersey, believed, from his own experience, that hay fever was of sympathetic origin.
Dr. Yon Klein, of Dayton, Ohio, did not believe that the nose suffered from the constitution, but rather the constitution suffered from the nose. Hay fever is not a neurosis.
Dr. Mason, of Bloomington, 111. , related his personal experience of having his hay fever renewed on a railway train, after a supposed cold of two years’ duration. The cause appeared to be smoke from the locomotive. He cited two cases in which it was undoubtedly caused by mental impressions — one in which a child suffered by imitation of her father’s symptoms during several years, to be relieved when her father was cured; in the other case, a physician had aggravated symptoms of hay fever after hearing a paper read on the subject. Coughs are often produced by hypergestheuic areas in the naso-pharynx, which may be cured by using glacial acetic acid.
Dr. Frank 0. Stockton, of Chicago, 111. , remarked — To my mind the causes of so-called hay fever are three; namely, constitutional, local and external; and the fault with gentlemen who follow this specialty is that they seek to find one cause alone for this disease.
Dr. S. S. Koser, of Williamsport, Pa. , objects to the theory of the neurotic origin of the disease, from the fact that many of these people are attacked on a given day of the month in every year, and to conclude it is entirely constitutional is, to my mind, illogical. I know a lake far up in the Alleghanies to which persons resorted with perfect immunity until this year, and during this season they have suffered, though always heretofore they escaped.
Dr. R. H. Thomas, in closing the discussion, said that his object in preparing his paper had been largely to show that the theories which bring forward neurasthenia, or nasal obstruction, or the existence in the healthy upper air passages of areas of special sensation whose irritation would produce such reflex phenomena as asthma, etc. , were not supported by clinical facts. He was surprised to hear it asserted that only two views existed as to the aetiology of hay fever; the view she had referred to were all held, and, in fact, the discussion which was now closing had of itself been sufficient to bring out a great variety of opinion on the subject. His assertion that the occurrence of an attack of hay fever in a patient who had previously suffered from the disease, by the sight of an artificial rose, had no bearing on the power of a real rose to produce an attack, had been called in question. He thought his posi- tion a sound one. The instance merely proved the power of imagination. He had read of cases where individuals supposed to be very ill of hydrophobia had recovered at once on being told the dog that had bitten them was not rabid. All the symp- toms in such cases were due to imagination, yet few doubted the existence of •genuine hydrophobia. One of the gentlemen who had taken part in the discussion had spoken as if the results obtained by him (Dr. Thomas) in endeavoring to locate the sensitive areas had been carried out during the hay fever season, when all parts of the nasal passages were hypersensitive.
The paper had distinctly said that the observations had been exclusively carried on between the seasons. The result of these observations, as far as they had gone, told against the theories that were based on the special sensitiveness of any particular parts of the naso-pharyngeal tract.
In regard to the use of the term ‘ ‘ idiosyncrasy, ’ ’ he did not consider that the
*
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NINTH INTERNATIONAL MEDICAL CONGRESS.
present state of our knowledge rendered it possible for us to drop the term, or some equivalent of it.
He strongly endorsed what had been said as to the importance of constitutional as well as local treatment, and the necessity for a prolonged and thorough course in order to accomplish satisfactory results.
Dr. D. N. Rankin, of Allegheny, Pa. , read a paper entitled —
SOME REMARKS OK THE HISTORY OF RHINOLOGY.
QUELQUES REMARQUES SUR L’HISTOIRE DE LA RIIINOLOGIE.
EINIGE BEMERKUNGEN UBER DIE GESCHICHTE DER RHINOLOGIE.
BY D. N. RANKIN, A.M., M.D.,
Allegheny, Pa.
Until a comparatively recent date the nasal cavities have been sadly neglected. This neglect is more surprising in face of the fact that the nares furnish the natural medium for respiration; that they are the organ of smell, thereby protecting the lungs from the inhalations of deleterious gases, and assisting the organ of taste in discrimi- nating the properties of food ; and as an adjunct to the vocal apparatus in making a pleasant voice, they are indispensable.
It is certainly very desirable to have an acute sense of smell, though it is not so important as some of the other senses.
Of its pleasures, let me here mention a few: Every hill, and vale, and shore is trib- utary to the sense of smell. There appears to he a scale in odors with respect to the pleasures which they excite in the organ of smell. The rose appears to be at the head of this scale, the shrub next, the pink, the jessamine, the tuberose, the honeysuckle, the sweetbriar, all gradually descend from it. The pleasure derived from odors is much increased by mixture. There can be little doubt that these odors are so related to each other as to produce from different mixtures greater or less degrees of harmony analo- gous to the vibrations of musical sounds.
The odor of flowers, certain vegetables, and meats in the process of cooking, is not only pleasant, but nutritious and medicinal, from the stimulus it imparts to the whole system through the medium of the sense of smelling. Country air owes one of its beneficial effects on invalids to this cause.
The sense of smell is liable to be perverted, as we see in the artificial pleasure which some people derive from the fetor of the civet, musk, asafoetida, and even of the snuff of a candle.
Who that never saw or experienced it, would believe that the odor of the rose could produce fainting, or that the heliotrope and the tuberose have made some persons asthmatical. The smell of musk, so grateful to many people, sickens some.
It is well known that the sense of smell guides many of the lower animals to their food, or warns them of danger, as is exemplified in the hunting dog. The distance at which a dog tracks his master is scarcely credible.
The acuteness of the sense of smelling in animals is such that in many instances our observations have been deemed fabulous. Birds of prey will scent the battle field
SECTION XIII — LARYNGOLOGY.
17
at prodigious distances, and they are often seen hovering instinctively over the ground where the conflict is to supply their festival.
Ancient historians assert that vultures have cleft the air one hundred and fifty leagues to arrive in time to feast upon a battle field.
Whence comes it that the red-wing, that passes the summer in Norway, or the wild duck, that summers in the woods and lakes of Lapland, is able to track the pathless void of the atmosphere with the utmost nicety, and arrive on our own southern coasts uniformly in the beginning of October.
It has been observed that animals which possess the most acute smell have the nasal organs the most extensively developed. The American Indians are remarkable for the acuteness of this sense, which accounts for their wonderful power of tracking their enemies.
By a glance over the text-books, you will find in the chapter on nasal diseases that they do not receive that attention they deserve. It is an undeniable fact, that perhaps no department of medicine has been so much invaded by quacks. It is true they often acquire reputation and wealth, but this must be ascribed to the credulity of their patients, and to the zeal with which they exaggerate and advertise their cures, or palliate or deny their mistakes.
It has been said, and well said, that quacks are the greatest liars in the world, except their patients. “ Quacks and impostors,” said Lord Bacon, “ have always held a com- petition with physicians.”
Galen observed that patients placed more confidence in the oracles of Esculapius and their own idle dreams, than in the prescriptions of doctors.
No science has been cultivated with more difficulty than that of this specialty. Sir Astley Cooper used to complain that a knowledge of the nasal cavities is by no means general in the profession, and still less are their diseases understood.
Compare the armamentarium of thirty years ago with the outfit of the nasal special- ist of to day. What was it previous to thirty years ago ? Literally nothing ; no perfect rhinoscope, no insufflator, no inhalers, no galvano-cautery, no incandescent light, no sponge holders, no guillotine, no ecraseur, no snares. A single pair of polypus forceps and a cumbersome nose speculum constituted the set. While visiting the mountainous districts of western Pennsylvania, some years ago, I went into the office of the village doctor to
I pay my respects. He was a man of perhaps seventy years of age. In conversation I inquired if he had much nose and throat disease to treat. He said he had considerable of that class of disease to look after. He then exhibited his nose and throat instruments, which consisted of a tongue depressor and polypus forceps. He informed me that the tongue depressor was made by the village blacksmith. Our forefathers depended principally upon general treatment and snuffs, as then treatment locally was not thought of. If a person was unfortunate enough to have any of the many forms of disease of the nasal cavities, it was allowed to progress uninterruptedly, short of a constitutional treatment.
It appears from historical accounts that the ancients, especially the Egyptians, made rhinoscopic examinations, but with what success is not stated. Since Prof. Czermak, of Pesth, conceived the idea of, and introduced to the attention of the profession, the rhinoscope, wonderful indeed has been its utility in diagnosing affections of the nares which previously had been very unsatisfactory and obscure. The usefulness of the rhinoscope, however, would have been greatly lessened had it not been for the ingenuity of other eminent rhinoscopists, who have devised many useful surgical instruments as well as means for making therapeutical and electrical applications to the nasal cavities, whereby local applications can as readily be made to the posterior nares as to the pharynx. Czermak has done for the nasal organs what the illustrious Laennec has done for the organs of respiration.
The therapeutics of the nares have kept pace with the surgical and electrical pro- Vol. IV— 2
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NINTH INTERNATIONAL MEDICAL CONGRESS.
cedures of that organ. Among the many excellent remedies that have been locally utilized, I would merely mention four — iodoform, bismuth, chromic acid and cocaine.
The general practitioner, when summoned to see a case of nasal disease, is too often satisfied with a too superficial examination. Generally, he raises the point of the nose somewhat, and then the vague pronunciations are uttered : “ high up in the nares,” or “ deep down in the nares,” or, in the case of a child, ‘‘let it alone, it will grow out of it.” Therefore, it cannot be wondered at that the diagnosis and treatment of nasal diseases have been in a mixed condition.
We live, gentlemen, in a revolutionary age; our science has caught the spirit of the times, and more improvements have been made in this specialty within the past twenty- five years than had been made in a century before. From these events, so auspicious to our department, we may cherish a hope that advancement may draw nearer perfection.
Great Britain is entitled to a large share of the influence in the advancement of this specialty. It has contributed much to this movement by careful clinical observations of diseases of the nose, and by numerous contributions to our anatomical and physio- logical knowledge of nasal diseases. The German spirit, recognizing the importance of this new era, joined in, hand in hand. Austria, Denmark, Russia, France, Spain and Italy are all well represented by men eminent in this specialty.
America, never behind in anything that conduces to the benefit of mankind, is rep- resented by men of marked ability as writers and teachers, as well as successful practi- tioners in this department.
The American Laryngological Association and the American Rhinological Associa- tion are institutions we feel proud of. The former, with a fellowship of over fifty members, is composed of the very best talent in this country, who have already made their mark, and are still actively engaged in prosecuting their valuable labors. The American Rhinological Association, being of recent origin, is composed of excellent material and doing good work. It was my good fortune, during the last meeting of the International Medical Congress at Copenhagen, Denmark, to meet most of the gentle- men of the Laryngological Section, and without a single exception those I met were persons of the highest medical attainments, and gentlemen in every sense of the word.
Here permit me to say a word in memory of the father of Rhinology and Laryn- gology in America. I refer to the late Lewis Elsberg, a man whose memory we should all revere, as not only a gentleman and scholar, but most eminent in Rhinology and Laryngology. He unquestionably did much to advance these specialties.
To America is due the credit of bringing rhinology to its present status. Dr. Daly has doubtless done more to accomplish this end than any man in this country.
The ample means we now possess of investigating diseases of the nares, and the facility with which the true nature of these diseases is arrived at, is certainly very encouraging.
Comparing rhinology to a house, the different stories of which have been erected by different architects, Czermak, Elsberg, etc., have a large claim to our gratitude for having, by their arduous and successful labors, advanced the building to its present height. It belongs to the rhinologists of the present and future generations to place a roof upon it, and thereby complete the fabric of rhinology.
DISCUSSION.
Dr. M. F. Coomes, of Louisville, Ky., remarked: In 1859, Dr. Troupe Max- well, of Kentucky, had a mirror constructed, and obtained a view of the vocal cords, not the posterior nares. He was certainly the first American to use a mirror for looking at the vocal cords.
SECTION XIII — LARYNGOLOGY.
19
SECOND DAY.
The Section was called to order at 11 A. M., the President in the chair.
Mr. Lennox Browne, of London, read a paper entitled —
RECENT VIEWS ON THE PATHOLOGY AND TREATMENT OF TUBER- CULOSIS OF THE THROAT AND LARYNX.
APERfU RECENT SUR LA PATHOLOGIE ET TRAITEMENT DE LA TUBERCULOSE
DE LA GORGE ET DU LARYNX.
NEUE ANSICHTEN UBER DIE PATHOLOGIE UND BEHANDLUNG DER TUBERKULOSE DES
SCHLUNDES UND XEHLKOPFES.
BY MR. LENNOX BROWNE, F. R. C. S. , EDIN. ,
London.
At the present time it is almost universally accepted that the tuberculous process is initiated by the settlement of a specific bacillus on a suitable nidus, or, as it was form- erly called, at the spot of least resistance. This bacillus is of the nature of a fungus, and partakes of the special characteristic of all fungi, in that it requires for its growth a soil in which organic decay is taking place. Bacilli gain access to the lungs by means, primarily, of the main air passages; they may he deposited at a portion of the lung, for example, an apex, which is ill supplied with blood and especially with air, or in the altered pulmonary tissue which invariably exists after an acute lung disease ; of this we see an example in the case of tuberculosis following basal pneumonia.
Like all parasites, bacilli are highly irritating, expression of which quality is evi- denced in the formation of the miliary tubercle, a tissue of very low vitality, prone to break down. As to whether the bacilli reach the tissue through a break of epithelial continuity, by diapedesis or otherwise, is a question which cannot now be entered on. What we do know is that the bacilli, having once established themselves, multiply in large numbers, and this circumstance leads not only to a local increase in the morbid process, but also to access of bacilli to the general circulation by the lymphatic system. When the tubercles are broken down so as to form cavities, bacilli are more or less abundant in the sputa. It is thus evident that bacilli may arrive at the region of the larynx by at least two routes.
Taking into account the fact that tuberculous infiltration usually invades the deeper tissues of the larynx at an early period of the disease, and before any breach of con- tinuity of surface, I am inclined to the conclusion that when laryngeal phthisis follows a pulmonary disease of the same nature, the tubercles are transplanted through the systemic circulation. Without doubt, however, it occasionally happens that there is direct infection by the sputa through a breach of surface, the result of a coincident catarrhal laryngitis more or less acute. But, as a general rule, there must be in the larynx, as in the lungs, a condition of local receptivity. One factor, at least, of this predisponent is that of anajmia. This is manifested preferably at marginal and apical
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regions of the larynx, as of the lungs, and we thus find that the general seats of earliest infiltration are the inter-arytenoid space, the coverings of one or both of the arytenoid cartilages, the ary-epiglottic folds and the epiglottis. On the other hand, in those cases in which functional abuse is an exciting cause of the local process, the tumefaction may first occur in the vocal cords and the ventricular bands. In this last class of cases, and in some few others not due to functional causes, the first condition is one of per- sistent hypenemia instead of anaemia, and instances will occur to every practitioner illustrative, in its special application to the throat, of Trousseau’s dictum, that a neglected catarrh is often a consumption commenced. There is, in fact, a condition of the larynx predisposing to tuberculous deposit very analogous to that of an unresolved pneumonia.
Ulcerations of laryngeal phthisis are characterized by their small size, their mul- tiple character, and their tendency to coalesce and to extend laterally rather than to penetrate deeply. As before mentioned, erosions non-tuberculous in character may appear in the larynx of a tuberculous patient the subject of a fortuitous catarrh. Doubt- less, some of those that heal under treatment are of this nature. It remains to say a few words as to the mode of origin of tuberculous manifestations in the fauces. A long experience has assured me that disorders of absorption, assimilation, and digestion generally play a far more important part in the production of faucial, tonsillar and pharyngeal inflammations than any faults of atmosphere, climate or even exposure to cold and damp, these last preferably and mainly affecting the respiratory tracts. When the pharynx is attacked in the case of an advanced pulmonary or laryngeal phthisis, we may not presuppose a breach of surface to be absolutely necessary for infection of this region by bacilli contained in the sputa and oral fluids, but we may postulate that the absorption of the liquid portions of the contaminated oral secretions must lower the vitality of the faucial and pharyngeal mucous membrane; in fact, a nidus is formed for the settlement of bacilli brought thither by the general circulation. When the fauces are primarily attacked we must admit the probability of a previous breach of continuity. I have reported a case in which the local irritation of diseased teeth, as evinced by marked improvement following their extraction, was the exciting cause of a tuberculous ulceration of the gums and mouth.
In my experience, evidence of the tuberculous process is manifested later in the fauces than in the larynx, but, as I could show by relation of many cases, this region may be attacked at any stage of the disease; several circumstances, especially the now well known case of Demme*, have confirmed the opinion long entertained, though until recently unsubstantiated, that laryngeal phthisis may precede the pulmonary disease, | and it is quite possible that similar evidence will be afforded regarding the fauces and pharynx. At present we are not in a position to do more than assume its probability.
Some six and a half years ago I reported, in conjunction with Dundas Grant, two cases — one arising, as just recorded, from direct irritation of decayed teeth, in which the first manifestation in the mouth and fauces had occurred between two and three years previously to any chest attack, or even before the suspicion of pulmonary disease.
Last December I exhibited a patient at the Medical Society of London, and I have
* Demme’s case is that of a boy aged four and a half years, who died of tubercular menin- gitis; the neoropsy showed the prosonco of laryngeal ulceration with tubercle bacilli; the thoracic and abdominal organs being at the same time free from tubercular disease.
•j- Zichl has also related a very pertinent example, in which a woman was tracheotomized for laryngeal stenosis. The pulmonary secretions, which could thus be perfectly separated from those of the larynx, were free of bacilli, while those taken directly from the laryngeal ulceration con- tained them.
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reported it in full in the recently published second edition of my work, “The Throat and its Diseases;” as far as clinical evidence could go, it clearly establishes the proba- bility of a primary tuberculous ulceration in the upper throat.
The subject was a young woman, aged twenty, the mother of three children, the youngest of whom was fourteen months old. She applied for treatment on account of extreme pain in swallowing, not only food, but even saliva. There was no distress of breathing, no night sweats nor diarrhcea. Physically there was seen to be ulceration of the left tonsil and of the back wall of the pharynx along its whole length, with slight extension to the posterior border of the larynx. Beyond very moderate conges- tion of the coverings of the arytenoids, and hardly preceptible thickening of the inter- arytenoid fold, there was no other laryngeal disease, and the stethoscope revealed nothing beyond slight harshness of respiration and somewhat impaired resonance at the right apex. Tubercle bacilli were abundantly manifested in the sputa. Under treat- ment— by scraping and lactic acid — the patient lost all her symptoms, and beyond some adhesion of the left posterior faucial pillar there could be detected no signs of her former disease, but whenever the saliva was examined, as was done for many weeks after all functional and physical signs had disappeared, tubercle bacilli could be detected. It may be mentioned, en passant, that this circumstance well illustrates the limit of use- fulness of bacillary evidence. It is an important factor of diagnosis of the presence of tubercle, but of uncertain value in prognosis, since bacilli are often as abundant in mild and chronic cases as in those of an acute and advanced character. However, a very careful and thrice repeated search failed to detect any bacilli on the last occasion on which I saw her, namely, one week before I left England. The patient has gained weight and is really in fair health; the lung symptoms have not in the least degree advanced since the first examination.
Having thus indicated some of the more important of the local pathological circum- stances on which we are to base our treatment, and necessarily excluding from the present discussion pulmonary conditions, let us proceed to consider the means at our command for combating the tuberculous process in the pharynx and larynx, and, for the sake of still further confining my observations within available limits, I shall suppose that we have a case before us in which, though the morbid process is well established in some portion of the throat, the general system has not yet broken down, or the lung disease advanced so far as to preclude the hope of restoration to comparative health and a prolongation of comfortable and useful life.
The basis of our treatment must be : First, by certain climatic, hygienic and general measures, to place the patient in the most favorable position for resisting the baneful influence of the bacilli, and, if we can, of rendering their life impossible. Under this head I have a preference for sea voyages and mountain air over residence in very hot climates, and especially at health resorts where the air is unduly moist, though, of course, such circumstances must be regulated by the particular character and stage of the case. The advantages of sea air and mountain elevation are generally allowed to arise from the greater rarity of morbific germs and the larger amount of oxygen and ozone present in such atmospheres. The only satisfactory case of actual cure of laryn- geal phthisis that I have seen has been the result of two sea voyages and a residence for two years in New Zealand. The subject, when first brought to my notice, was a lad of fifteen. The nature of the case was undoubted, and was confirmed by others. Lung disease was hardly to be detected. The patient is now twenty-two years of age, and a hale farmer in the west of England. Hunter Mackenzie, in a recent article, has deprecated high altitudes as too irritating for patients suffering from throat consumption, but such an objection does not apply to the earlier stages or to cases in which the lungs are but slightly implicated. On the contrary, I have seen the happiest effects from
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residence on mountainous plateaus. There are, of course, many circumstances not possible to at present consider, which may modify our advice on this head.
Supplementary to these climatic measures may be considered those of inhalation, and I have only here to state that for some years I have ceased to advise those of medicated steam. I cannot agree with a recent author, Massei, that oro-nasal inhalers have at all fallen out of fashion. My daily experience convinces me more and more of their value. The particular mixture I employ for general use is one composed as follows : Oil of pine and oil of eucalyptus, of each a drachm ; alcohol and ozonic ether, of each eleven drachms. I have also found benefit from the inhalation of menthol, as advised by Rosenberg. This remedy is particularly valuable in the stage of anaimia and infiltration, i. e., before the occurrence of ulcerations. Under its use I have seen perceptible and increasing improvement in the shape of recovery of normal color of the mucous membrane and diminution of submucous infiltration. In the hyperaemic type I have witnessed resolution by means of the same remedy. The patients get to like the treatment so much that there is no necessity to encourage them, as is advisable, to wear the inhaler as long as possible, both waking and sleeping. I have found the cheap inhaler of Squire, devised by Burney Yeo, answer as well for general hospital purposes as any of the more elaborate apparatus.
There is no doubt that the tuberculous process, when once thoroughly established, is one of septicaemia, and it is probable that the colliquative sweating and diarrhoea, the general asthenia and cardiac failure, often manifested by the phthisical patient in whom there is no actual cardiac disease, may all be explained as results of ptomaine poisoning. Many of these general symptoms are relieved by the oro-nasal inhaler ; but the particular alkaloid which seems antidotal to many of these evidences of ptomaine toxaemia is atropine. In any case, apart from theory, it is a symptomatic remedy of acknowledged value.
Of further general measures I need only allude to the hypophosphites, but I may mention that while I often employ them in combination, as in Fellows’ svrup, I have a preference for the salt of calcium as more likely to bring about a beneficent (calca- reous) degeneration of diseased tissues. I have also witnessed the excellent results to be obtained by administration of small doses of arseniate of soda or potash. Arsenic appears, indeed, to act on the tuberculous dyscrasia much in the same specific way — though perhaps less powerfully — as does mercury in syphilis.
The second indication is to annihilate the bacilli by germicides. These remedies may be divided into two classes — those which, while acting as germ destroyers, may also powerfully affect the general system, and those of a more purely local character. Among the former are to be mentioned perchloride of mercury, aniline, and perhaps in a less degree sulphureted hydrogen and dioxide of carbon.
Looking to the injurious effects of mercurial combinations when internally admin- istered to a tuberculous patient, I cannot recommend either sprays or injections of cor- rosive sublimate. My own conviction is, that as germs are killed with more difficulty than are normal cells, especially in persons of tuberculous tendency, the remedy might but aggravate the disease. Nevertheless, Massei states that he has found the effect so satisfactory that he now employs it in daily practice to the strength of 1 in 2000. The aniline treatment by Kremianski has had but a short life and is generally condemned.
The sulphureted hydrogen treatment, introduced by Bergeon aud administered per rectum , is yet on its trial. Its special office seems to be to check bronchial secretion and to diminish night sweats, but it is doubtful if the process is in any sense truly microbicidal. I have no especial experience of this remedy at present beyond one ease, in which the effect appeared at first to be very favorable — profuse brouchorrhoea and night sweats being both arrested almost as by a charm; but on the patient leaving his
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physician, Dr. Sinclair Cogliill, whom I am happy to see present, and continuing the treatment himself without medical supervision, such alarming symptoms of dyspnoea occurred that I was summoned to perform tracheotomy. The operation was, unhappily, of no avail, although I made the opening as low as possible in the trachea, we having diagnosed, prior to operation, that there was, in addition to a mechanical laryngeal stenosis, a further considerable obstruction of the left bronchus near its bifurcation. After death, Dr. Montague Ball, of Hounslow, who was the practitioner in attendance, found that the vocal cords were greatly thickened and congested, the whole trachea and bronchi also very much congested and the left bronchus almost entirely blocked by a plug of thick, fibrous mucus. There was also great enlargement, with caseation of the glands surrounding the left bronchus to such an extent as to considerably diminish the diameter of the tube. In the light afforded by the autopsy, it would be unreason- able to say that the fatal result was due to the treatment; nevertheless, it should warn us, in cases favorable for its adoption, against allowing a patient to undertake it himself, as has been advised and countenanced by several writers on the subject.
Of the germicides producing local effects may be mentioned —
1. Galvano-cautery.
2. Lactic acid.
3. Menthol.
4. Iodoform or iodol.
The first I have employed with success in tuberculous ulceration of the tongue and tonsil, and I have reported cases in support of its adoption.
The second has proved of great service in the practice of myself and my colleagues in pharyngeal and faucial manifestations. It is preceded by an application of a ten per cent, solution of cocaine and a scraping of the surface to which the acid is to be applied. Its effect is to stimulate healthy reaction, and, as Krause has said, pain is no contraindication to success ; for on recovering from inflammation, the parts generally cicatrize healthily.
I have been so satisfied with this treatment that I have not employed the remedy by means of the syringe, as was first recommended by Hering, of Warsaw. Moreover, I have a distinct preference for a cotton-wool brush over the spray; for, as Roe, of Rochester, has shown, remedies introduced by the latter method do not penetrate to the ventricles and other chinks and crannies of the larynx so well as when the sphincter glottidis squeezes the fluid from a brush. This author believes that the continuous use of sprays is injurious to the cilia of the mucous membrane of the air passages, but that there is no such danger in soft brushes. In this respect the solution carrier made of absorbent wool possesses advantages over those of camel hair or sponge. Whatever form of applicator is employed, it is important to clear away the excess of frothy saliva and other tenacious secretion that always overloads a tuberculous throat. Neglect to take this precaution may account for many instances of failure of local treatment. The circumstance itself explains why fine sprays and insufflations are often inert, whereas the slight friction inseparable from the use of the brush is really beneficial.
As to the third method, our experience at the Central London Throat and Ear Hos- pital, of lactic acid in the larynx, has not been so favorable as in the upper throat, and we have frequently employed menthol, 20 per cent., as advised by Rosenberg. Although at first rather pungent, its application is quickly followed by a distinctly anaesthetic effect. 1 am not sure that ulcerations often or ever heal under this treatment, but I have no doubt that infiltration is frequently resolved, that in the case of anaemia the tissues gain color, while, when the condition is one of congestion, the hyperannia is reduced.
The fourth is that of iodoform or iodol, which it is recommended to apply in either ethereal or alcoholic solutions or as insufflations. These remedies have many warm
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advocates among practitioners of repute, particularly of Lubinski, but have failed to give satisfaction in my own practice. It is to be noted that, according to recent inves- tigations, not only is the germicidal action of this drug doubted, but, as Watson Cheyne states, germs may even be cultivated in its presence.
Although in no sense curative, insufflations and other remedies of a purely anodyne character demand at least passing consideration. For myself, I limit insufflations to cases in which it is desirable to apply sedatives and to keep them in contact with an elevated or otherwise painful. spot; but, as I have already said, I am not an advocate of insufflations as a general method of conveying topical remedies, for I have not unseldom seen them coughed away as a thick cake a second or two after their introduction, and if I wish to have a sedative retained I prefer a semi-fluid or emulsive medium of traga- cantli. Cocaine has, of late years, taken preeminence as a pain destroyer, and is of undoubted value lor allaying sensibility of the throat to the passage of food when adyn- phagia is a prominent symptom ; but morphia, whether in powder or in semi-fluid medium, and balsamic applications containing some preparation of opium or belladonna, are of more service in diminishing continuous pain and in allaying cough, since, the action of these drugs is far less transitory than in that of cocaine. Cocaine lozenges are useful in tuberculosis of the tongue and fauces. They are of no avail in laryngeal cases.
Before the introduction of cocaine, I found great comfort was experienced from appli- cation of a mixture of compound tincture of benzoin and paragoric, each an ounce, and a drachm of tincture of belladonna mixed up with the yelk of one egg. Patients were allowed to apply it themselves before food taking and on occurrence of cough. I still employ this mixture, substituting cocaine in place of the belladonna, for allaying actual pain.
Surgical Measures. — These are, for the most part, heroic, and are not pursued by me further than to the extent of scrapings prior to the application of lactic acid or menthol. It is hardly necessary to speak in detail of incision into the thickened laryngeal tissues, as advised seven years ago by Schmidt and also advocated by Hering. It is true that general periostitis has been treated successfully by stabbings and incisions ; neverthe- less, my experience of quite slight scarification of the larynx of a tuberculous patient, even where the swelling of the tissues seemed to be due to true oedema, has not encouraged me to further extend the practice. Such points rarely, if ever, heal, and are only too likely to become the seats of fresh infection. I doubt if there are many practitioners who have longer any faith in the treatment. Neither do I advise removal of the granulomata and other papillomatoid excrescences so frequently observed in the course of a tuberculous laryngitis, unless they are in such situation as to seriously interfere with respiration. Nor have I yet seen my way to the advocacy of tracheotomy, either as a prophylactic or as ameliorative of the distressing respiratory symptoms so often evidenced in laryngeal phthisis. My main objection is that the theoretical indi- cation on which the operation is based — namely, the giving functional rest to the larynx — is but very rarely attained in practice. On the contrary, a tracheotomy tube is almost always a source of extreme irritation and increased discomfort in the case of a tubercu- lous patient. Added to this, the physiological duties of the upper air passages are entirely abrogated, and the air is taken into the lungs impure, cold and dry. In this manner the operation is actually capable of inducing an aggravation or recrudescence of pulmonary disease, unless the patient is confined to a room and made to inhale an atmosphere charged with steam and antiseptics.
Nor can I speak favorably of the prospects to be afforded by the recently revived procedure of intubation of the larynx, which has the additional objection of causing increased irritation by constant contact of a foreign body with tissues already ulcerated or highly prone to become so. The risk of blocking of the very small tubes used in these operations, by tenacious secretions and sputa, constitutes an adverse argument
SECTION XIII — LARYNGOLOGY.
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that must not be overlooked. For fear of bringing valuable surgical measures into disrepute, I go so far as to never remove even an elongated uvula in a tuberculous subject without most explicitly warning both the patient and his friends that the operation is but, at best, a palliative. Far less could I approve the suggestion to remove a portion of thickened epiglottis or arytenoid body. But to show the length to which surgical measures may be extended, I need only mention that Massei has recently suggested that “the history of many successful cases of extirpation of glands, kidneys, ovaries and other organs for tubercular disease warrants us in entertaining the idea that, were early diagnosis of primary laryngeal phthisis possible, extirpation of the larynx in such instances would come within the pale as the most efficacious of all remedies. ’ ’ It is hardly necessary for me to say that I do not share such an opinion.
After all is said and done, are we in a position to-day to claim that we can cure laryngeal phthisis? I personally doubt it, and although I have alluded to two cases occurring in my own practice, in which there has been apparently complete arrest of all diseased processes, I am unable to report one in which I have seen what could fairly be called a cure, by either physic or surgery, of a case of well-established laryngeal phthisis. I could present you with a table of many carefully- watched observations, by which it could be shown that, under treatment such as has been indicated as that generally adopted in my practice, the following gratifying results have taken place : —
1. Food taking has been rendered painless or less painful, and regurgitation of fluids has been especially obviated. As a consequence, weight has been gained.
2. Expectoration and secretion have both been lessened.
3. Erosions have healed, but rarely ulcerations, except in the fauces and pharynx. In this respect I am able to concur heartily with the dictum of Hunter Mackenzie, that success in treatment is in proportion to the accessibility of the seat of the lesion. When the vocal cords are implicated, I have but rarely witnessed material improvement in the vocal symptoms.
4. The pulmonary condition has remained in some cases stationary, in others the morbid process has been retarded, and in a third class, although lung disease has been far advanced, and has continued active, improvement of throat symptoms, especially of pain and difficulty in food taking, has been really considerable.
5. Hectic sweats have in many cases been diminished, even where the chart has not shown great variations of temperature.
On the whole, I have to confess that evidence of local relief has been more satisfac- tory than that pointing to any real arrest of the disease, and we must still admit that faucial or laryngeal tuberculosis, being rarely primary, is but partially amenable to therapeutics, and that its existence in the throat as a complication of a pulmonary tuberculosis must always influence our prognosis most unfavorably, whether we calcu- late on the chances of an arrest of the disease or on the probable duration of a life.
But while I am precluded from reporting such a happy experience as those of Schmidt, tiering, Bosworth and others, who claim to have quite a long list of cures, I am far from denying such a possibility. On the contrary, I feel sure that each year we are encouraged in the belief that there is at least equal hope that such a result may in time be attained, when the disease attacks the throat, as is at present held out regarding its manifestations in the chest.
For this desirable end what is required is: First, earlier diagnosis and treatment of premonitory morbid conditions.
Secondly, greater reticence in advertising the infallibility of new remedies, and adoption only of such as are based on sound pathological data.
Thirdly, abstinence from “useless activity,” as Paget has called it, especially in advanced cases, and a recognition of the fact that an attempt should be made to heal the nidus as well as to destroy the bacillus which is settled thereon.
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Lastly, and above all, to again quote the words of Sir James Paget, “The chief need seems to be the collection of facts well observed by many persons. I say by many, not only because many facts are wanted, but because, in all difficult research it is well that apparent facts should be observed by many; for things are not what they may appear to each one’s mind. In that which each man believes that he observes there is something of himself, and for certainty even on matters of fact we often need the agreement of many minds, that the personal element of each may be counteracted.”
DISCUSSION.
Dr. J. Sinclair Cogiiill, of London, opened the discussion on this paper by say- ing— I have listened to Mr. Browne’s communication with the same pleasure and instruction I always receive from that gentleman’s contributions to the literature of that branch of medicine which he has cultivated so successfully. There is no form or complication of phthisis which causes so much distress to the patient and embar- rassment to the physician as tubercular laryngitis. It is of first importance to dis- tinguish between tubercular laryngitis as a primary and as a secondary lesion. This is more especially important as a basis of opinion in prognosis. As a secondary affection, the physician must content himself with relieving symptoms with a view to alleviate the evident and distressing sufferings of the patient. As a primary affec- tion we can hope to decrease, in the light of modern discoveries, the prognosis is vastly less grave, and at least we can regard a pause in the progress. It was long before I could convince myself that laryngeal phthisis was ever other than a lesion secondary to pulmonary tuberculosis. I have no doubt whatever, now, that it does occur as a primary disease from infection. It would indeed be strange if this were not to occur occasionally if the lungs are infected through the air passages, as they most undoubtedly are. One case recently under my care threw a most instructive light in this connection. A young lady contracted a tubercular ulceration of the left side of the pharynx, extending down to and involving the margin of the epi- 1 glottis. Repeated examination of the chest revealed no pulmonary mischief. The disease was contracted while nursing a brother who died of chronic pulmonary phthisis involving both lungs. The patient in question had all the usual symptoms of tuberculosis. Iodoform applied locally, with extreme care, in association with apropriate general treatment, entirely cured the case. I know no remedy equal to iodoform, but it is a potent one, and must be used sparingly and cautiously. I have seen toxic effects repeatedly developed from comparatively small doses. I cannot tell what its mode of action may he ; it is possible, as Mr. Cheyne says, that ‘ ‘ the tubercle bacillus perishes in the purity of iodoform;” but there is no topical remedy I have employed with so much confidence and satisfaction in tuberculosis, nay, indeed, in any foul ulceration, as iodoform. I must confess I am not sound on the tubercle bacillus. • My heterodoxy, however, only goes the length of referring the processes in which it may be recognized as more due to its nidus or environment, than to the bacillus itself. This is most important to bear in mind, as the importance of general treatment in such cases take this foreground in one regard. Tuberculosis is essentially a parasit- ical disease, and this fact must be continually borne in mind. I might illustrate this from what is so familiar to us in the vegetable world. When a tree has deficient air and light, its roots cramped in by barren soil, it gets sickly, looks ill, gets out of con- dition and speedily becomes the prey of every parasitic pest. Remove the unhealthy condition, let in air, light and sunshine, loosen the roots and furnish rich soil, and the change for the better begins, health is restored, and the parasites cease to flour- ish. This is seen in phthisis in states of arrest ; bacilli may be found, but the condi-
SECTION XIII — LARYNGOLOGY.
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tions for their development are absent. This question of raising and restoring the general health is not only true with respect to the recovery from disease, but also in resisting morbid influences. Note the different fate of twelve robust, well-fed and vigorous men, and a similar number of feeble and starved men, exposed to the infection of sewer gas. I must refer, before sitting down, to Bergeon’s treatment. I believe it has no specific action in tuberculosis of lungs or larynx. It is only improving in the general health through the gastro-intestiual mucous membrane, improving action of liver, digestion and assimilation, just as sulphureted waters have been doing for ages, when taken by the stomach. The case Mr. Lennox Browne has referred to was one that improved marvelously under treatment. Indeed, it encouraged me vastly to believe in its efficacy. No case could have presented a greater consensus of unfavor- able conditions, both as regards the morbid history and the inherited cachexia, but that the patient seemed to revive miraculously, profoundly impressed me with the benefit he had derived. I think he confirms the treatment too energetically with the results stated.
Dr. J. Solis-Cohen, of Philadelphia had frequent occasion to corroborate mostly the views of the reader of the paper, especially those of the last speaker, with whom he had seen much advantage from the topical use of iodoform, and with whom he thought the great elements in treatment are to improve the general con- dition of the tissues so as to disfavor the development of bacilli, and render them more innocuous, and to depend upon nutrition as the main resource in treatment.
Prof. E. Fletcher Ingals, of Chicago, said — Like the preceding speakers, I fully agree with nearly all that has been said by the author of the paper, and I desire to call special notice to some of the points which have been made, with a view of emphasizing them. I was especially pleased to learn that the author had given up the use of steam inhalations, and I wish every one else would give them up, for I believe that in most cases they do more harm than good. Regarding climatic treatment, I am uncertain what cases of laryngeal tuberculosis are benefited by a high altitude. I now think that those in which the disease is recent may be bene- fited, but I am confident that many cases of advanced ulceration are greatly injured by it. I fully agree with the author that the salts of calcium seem most beneficial. I do not know that it matters materially what salt be used, but from several years’ use I have come to like best the chloride, which is readily soluble and easily absorbed. Bergeou’s treatment I have tried, and in one case of laryngeal phthisis found it beneficial for a few days, but afterward it caused such severe pain that the treatment had to be suspended. I have had little experience with the superficial application of lactic acid, and, fortunately, but little with the submucous injection. In only two cases have I tried the latter ; in both the effects were not good, and the patients went rapidly “to their reward.” I have had very little satisfaction from the use of cocaine for the relief of pain, either when applied by myself or when used as an insufflation by the patient shortly before eating. I have had better results in these cases in relieving pain from the application of a pigment of morphine, carbolic acid and tannin in glycerine and water. I believe that the combination of the tannin with the glycerine hardens the tissues, and thus materially aids in preventing pain. As to the prognosis, I can now recall four cases, in two of which there were ulceration, and in the others erosions, in whom recovery had taken place. In these the diagnosis was not made by the aid of the microscope, but in all of them were pronounced pulmonary lesions. These cases are of from four to seven years’ duration. The two of whose present condition I am certain have pulmonary scars. With the second speaker I fear I am not orthodox on the subject of bacilli, but
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believe that the bacillus is not of so much importance as the soil upon which it thrives. This recalls the case of a brother physician suffering from laryngeal tuber- culosis iu which the number of bacilli are greatly increased by the occurrence of cold.
It seems as though in this case it must surely be the soil that causes the increase. Finally, as I said many years ago, I believe that constitutional treatment is of great- est importance, though I also believe that local treatment is of much value. If the < condition of treatment can be improved, we may hope to benefit the larynx, but local i treatment can hardly help other cases, excepting as they prevent pain and thus allow of proper nutrition.
Dr. Coomes, of Louisville, Ky. , said that a few years since he was in doubt as to the possibility of phthisis of the larynx occurring without involvement of the lungs, J but at present he was satisfied that the larynx might be involved without the exist- ence of tubercle iu other portions of the body. He reported four cases in which the j disease of the larynx was arrested during the existence of the lung complication. In two cases the epiglottis was almost completely destroyed, but the open surface in each completely healed ; one of the patients is still living, the other died eighteen months after the throat lesion was cured, from pulmonary hemorrhage. He pre- ferred iodoform insufflations to all other local applications ; was careful to apply it in small quantities, two grains being quite sufficient. Had seen two cases of severe poisoning from its use in large doses.
Dr. Max Thorner, of Cincinnati, Ohio, said — I think that tuberculous ulcer- ation in early stages may heal, even if only temporarily. The presence of bacterii tuberculosis seems not to be necessary, since other symptoms often will prove the ' presence of tuberculosis. Dr. Bryson Delavan, of N. Y. , reported in the last meet- ing of the American Laryngological Association cases of tuberculous ulcers of the tonsils, where he did not find bacilli. I have seen two cases of laryngeal phthisis in which tuberculous ulceration was present, though I admit of not having found bacilli tuberculosis. One gentleman had ulcers on the vocal cords; he complained of pain | radiating from the left side of larynx to the ear. The apices of the lungs showed | acute bronchitis. After using iodoform and boric acid for about two months, the ulcers healed. Six months afterward the patient came with the same symptoms ; the same treatment had the same effect.
In the second case, a young, emaciated man was exceedingly hoarse, complained of severe pain radiating from both sides of the larynx to the ears. The vocal cords were superficially ulcerated. The left arytenoid cartilage had the pathognomonic pyriform shape. There was no active process in the lungs ; both apices had a dull percussion sound. The ulcers healed twice, in intervals of about six months after, with the application of iodoform and lactic acid. When he appeared the third time with the same symptoms, I treated him alone, according to Bergeon’s plan ; after six weeks there was no improvement at all in the laryngeal symptoms. I then again treated him with forty per cent, solution of lactic acid ; the ulcers healed in about eight weeks. These two cases seem to prove to me that laryngeal tuberculous ulcers i may heal temporarily.
Dr. McGeagh, of London, reported one case under observation at University Hospital, London, remarkable for the marked improvement during the exhibition of iodide of potassium, ten grains three times a day, with the local application of equal parts of iodoform, boric acid and starch by insufflation, after having the throat first ; of all thoroughly cleansed by a camel’ s-hair brush saturated with an antiseptic solu- 1 tion. This case gained at the rate of five pounds a week for a period of several
SECTION XIII — LARYNGOLOGY.
29
weeks; finally he left with his throat partially healed and his general condition mani- festly improved.
Prof. Casselberry, of Chicago, remarked — There are formidable cases which tax. our utmost resources. Lactic acid has been highly lauded, and as strongly con- demned. Rational selection of cases is necessary to obtain good results. The treat- ment is accompanied by considerable after pain and cough, which is badly borne by debilitated subjects. Comparatively sthenic subjects, with circumscribed laryngeal lesions, so treated, are the ones which recover.
Thorough cleansing of the parts is an essential preliminary to all local applica- tions. An alkaline spray, to which a small percentage of thymol may be added, is useful for this purpose; iodol by insufflation is a useful substitute for iodoform. It is lighter, and consequently more diffusible. Ethereal solutions of iodoform are irri- tant, because of the irritant qualities of ether. Liquid vaseline probably is a better vehicle. Morphine is a better local sedative for continuous use than cocaine, the reaction from the latter maintaining congestion of the parts. I have observed spon- taneous recovery of the vocal laryngeal lesions during the progress of the pulmonary tuberculosis.
Prof. Stockton, of Chicago, said — I am quite in accord with Mr. Browne, that mountain and ocean air are only applicable to recent cases. Lactic acid I have used, but found that the cases must be selected. Iodoform I consider the medica- tion par excellence; the ulcer must be carefully cleansed, and then only a small quantity of iodoform is necessary, as it should be localized to the ulcer. Cocaine is only useful for examinations, and must not be used for any length of time. I cannot see how iodide of potash can be of use in this disease, unless it is one of those com- plicated cases such as I have had the pleasure of seeing in Vienna, from one of the rare cases on the post-mortem table.
Dr. John N. Mackenzie, of Baltimore, Md., shared the skepticism shown by some of his colleagues in regard to the bacillus theory of tuberculosis. If the bacilli be inhaled, why is it that tuberculosis of the nasal passages is not more fre- quently met with. While he believed that laryngeal ulcers tubercular in nature occasionally heal, the probability is not to be overlooked that the so-called tubercu- lar ulcer can be none other than the diphtheritic ulcers of the windpipe, so common in general tuberculosis. Dr. M. insisted on general treatment, commended the local use of iodoform and a weak spray of bichloride of mercury. The question of pri- mary laryngeal tuberculosis can only be settled by the scalpel; that had already been done by Orth.
Dr. Lester Curtis, of Chicago, remarked that he had been listening to the dis- cussion in the hope of hearing mention of a line of treatment that he had followed in the case of a lady with a large cavity of one lung and extensive consolidation of the other. She had a temperature of 103° Fahrenheit or over, and the other usual symptoms of advanced phthisis. On the use of quinine in pretty full doses, the temperature fell to somewhat near normal, and all her symptoms improved to such an extent that she considered herself nearly well, and continued so for nearly a year. In regard to tuberculosis of the larynx, some eight or ten years ago, a case came to him with ulceration of the arytenoid cartilages, with great difficulty of swallow- ing. He was put upon a treatment of a spray of nitrate of silver. In a very short time the difficulty diminished greatly; he continued much better for a month or two, when he passed out of observation. In this case there was a considerable
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consolidation of both apices. Another case of advanced phthisis, cavities in both apices, ulceration at the base of both arytenoids and great difficulty of swallowing; j on treatment by nitrate of silver the dysphagia nearly disappeared, continued absent : for three or four weeks, when he died by the natural progress of the lung lesion.
Dr. Coghill, of London, closed the discussion by remarking — In view of the limited time at my disposal, and the very thorough manner this subject has been threshed out by the various speakers, I shall close the debate in a very few words, | The number of speakers and the very interesting views and experiences brought for- j ward testify to the importance and value of Mr. Lennox Browne’s paper. It is ! satisfactory to note how agreed all are with the correctness of the views enunciated j and the principles for treatment, general and local, so precisely and fully laid down by Mr. Lennox Browne. I must conclude by expressing the great pleasure with which I have taken part in this extremely interesting and valuable discussion.
Mr. Lennox Browne, of London, commenced his reply by thanking the i Section for the generous reception of his communication, and by congratulating him- self on the discussion that had been raised. He expressed himself in entire agree- ment with those who had dwelt on the primary importance of climate, hygiene and • general treatment, both medical and dietetic. In fact, he had discussed these ; subjects first in his paper. But he also urged that though, in many cases, a pharyngeal or laryngeal tuberculosis was but a complication of a similar lesion in the j lungs, the pain and distress which it occasioned called for all our energies, and he ; expressed his belief that in no disease of the throat had the specialist done more ; serviceable work or more thoroughly justified his position than in the great advances ; that have been made in the palliation, and possibly even cure, of the evidences of this malady in the throat. This had been done, not by general therapeutic meas-| ures, to improvement of which laryngologists have contributed little, but by remedies j applied locally. It was therefore fit that local means of treatment should occupy the most prominent place in a discussion on this subject, in a Section devoted to laryngology. With regard to climate, he concurred with the speakers who con- sidered high altitudes most suited to early stages and deleterious in the later ; the criteria for judgment on this head were in no sense different from those regulating • advice in general pulmonary disease. He was forced to the conclusion that the result of the case treated successfully by iodide of potassium was one of syphilis, for, ! from his experience with the drug which had been so ardently advocated by Moretz Schmidt, of Milan, in 1880, its effects in a tme tuberculosis were actually harmful.
In response to the doubts expressed by many speakers as to the part played by bacilli as primary factors of tubercle, the author expressed himself as by no meaus indissolubly wedded to the view. He had given it as the most recent, and as one almost universally accepted in the present day. It certainly offered one of the best; data for treatment that has yet been afforded. He thought it quite possible that many remedies, such as iodoform, so generally extolled by all who had spoken, might act, as suggested by Dr. Coghill, in such a way on the soil in which the bacteria were manifested as to hinder their growth and multiplication, even though the drug might not be germicidal; and doubtless the tendency of the day was to pay too much attention to the bacilli, to the neglect of the nidus. Against such neglect he had spoken in his paper. With regard to local treatment, as Prof. Casselberry had wisely drawn attention to the importance of selecting cases for particular remedies, his remarks were important as emphasizing a point only lightly attended to in the paper.
SECTION XIII — LARYNGOLOGY.
31
Lastly, as to cure of the ulcer, it was largely a question of opinion as to what was recognized as a truly tubercular ulcer. Without doubt such lesions were healed in the fauces and supra-glottic region. He personally doubted if the same happy result occurred, save as au exception, in the larynx, and he was pleased to find that Drs. Cohen and John N. Mackenzie agreed with him, that those that did best were, in the majority of instances, not truly tuberculosis.
Dr. A. G. Hobbs, of Atlanta, Ga., read a paper on —
THE NERVOUS PHENOMENA OBSERVED IN A CASE OF EXPO- SURE OF THE ANTERIOR COLUMN OF THE CORD FROM SYPHILITIC ULCERATION OF THE UPPER PHARYNX.
LES PHENOMENES NERVEUX OBSERVES DANS UN CAS D’EXPOSITION DE LA COLONNE ANTERIEURE DE LA CORDE PAR SUITE D’ULCERATION SYPHILITIQUE DU PHARYNX SUPERIEUR.
DIE NERVOSEN PHaNOMENE BEI EINEM FALL VON BLOSLEGUNG DER RUCKENMARKS- VORDERSTRANGE DURCH SYPHILITISCHE EITERUNG DES OBEREN PHARYNX.
BY A. G. HOBBS, M. D.,
Of Atlanta, Ga.
In October last a young man was brought to my office to be treated for “ulcerated sore throat,” as his father expressed it. He had been a cowboy in Texas for two years, strong and robust, weighing 140 pounds. When he reached me he was thin, pale and anaemic, weighing only 104 pounds.
He denied ever having had syphilis, nor had he any evidence of this disease other than the ulcer about to be described, and, according to his own history, there never had been any other symptom of syphilis.
A posterior rhinoscopic examination revealed an ugly sloughing ulcer in the poste- rior and superior wall of the pharynx, about the size of a silver quarter. Ey the use of a soft palate retractor a direct view of a greater part of the ulcer could be obtained. A bent probe discovered necrosed and detached bone at the depth of about half an inch, a piece of which I succeeded in extracting at the first sitting. At each succeeding daily visit, for two weeks, small pieces of bone, from the size of a pin head to a small pea, were either washed out with the cleansing syringe or extracted with the probe or scoop. My index finger would now enter the cavity as far as the first joint, by which means I could discover either detached or jagged undetached bones.
The treatment had from the beginning been based upon the assumption that it was a syphilitic ulcer, notwithstanding his repeated denials of ever having contracted the disease, and his father’s assurance that he had been healthy from infancy and could not, therefore, have inherited the taint.
He began on forty grains of iodide of potash, three times a day, in a menstruum of succus alterans ; this dose was afterward doubled. The ulcer was daily cleansed with cotton probes, syringes and sprays. Sprays were applied, not only directly, but through the nose, on account of the discharge being partly expelled through that channel.
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Listerine was used, for its disinfectant and cleansing properties, and nitrate of silver, full strength, was applied to the bottom of the cavity by a cotton probe, after which the cavity was packed with iodol.
About this time, after four or five weeks of daily treatment, the nervous phenomena first occurred.
For a week or ten days he had been complaining of constant pain in the hack of his head and neck, which caused him to carry his head to one side, and rigidly. During this latter period — the fourth and fifth weeks — he had been unable to sleep, except for a few minutes at a time, and in a sitting posture.
After the cavity had been thoroughly cleansed, at one of the treatments, I pressed the nitrate of silver probe to its bottom, when, as suddenly as if he had been shot, one- half of the patient’s body became paralyzed ; his head fell to the right, his right arm dropped to his side, his right leg turned outward, and he would have fallen from the chair if I had not caught him. Without losing consciousness at any time, this hemi- plegic condition lasted about thirty seconds, when, as he expressed it, ‘ ‘ he felt a tingling in the right half of his body,” and in another half minute he slowly raised his right side into position. The next day the same phenomenon was repeated, but on the opposite side. The pupil on the side affected became slightly dilated, but the perspiratory glands did not seem to be affected during the paralysis.
He was now so reduced in weight (to 96 pounds) and in strength, by the loss of sleep and constant pain, that he could not walk to my office. The extreme insomnia lasted about ten days, during which time his attendants thought he did not sleep one hour in twenty-four. But from this time healing began at the bottom of the ulcer, the discharge became less, and examinations with the finger did not discover any more rough bones ; he slept better, and complained less of the pain in the back of his head and neck.
He naturally did not desire that a paralysis should be deliberately produced now, because he was not certain, nor could I with much confidence assure him, that it would only last one minute if repeated . A week passed on with all of his symptoms gradually improving, when I could no longer resist the temptation of making another pressure with the probe.
Paralysis of the side pressed upon was again exhibited, but in a much milder degree than before,' ending in the same tingling sensations as described before.
As only the spray and powder blower were used from this time onward in dressing the cavity, no more pressures with the probe were made till healing had well progressed, probably ten days or two weeks after the last test.
To my surprise, when the probe was now pressed into the cavity, a condition just the opposite of paralysis was exhibited ; the arm aud leg jerked and jumped similar to a case of chorea. These choreic muscular contractions, uulike the paralysis, lasted only during the pressure of the probe. In repeating the probe pressures at intervals during the next few days, the same choreic symptoms Avere produced, always on the corre- sponding side of the pressure, but in a less aud less degree, requiring a still firmer pressure to produce the effect.
Finally, when the healing process had been thoroughly established, and cicatricial tissue had in a measure closed up the cavity, only a “ tingling or pricking ” sensation followed the probe pressure, a sensation similar to that which followed the hemiplegia in the first instance. After the cicatricial tissue had thoroughly hardened, no mani- festation folloAved the pressure of the probe.
At the time of writing, ten mouths since I first suav the patient, he is entirely recovered, aud presents a perfect picture of health. His weight is 37 to 40 pounds more than he weighed in November of last year. He was kept on a lessened dose of iodide of potash and succus al tenuis until last J uly.
SECTION XIII — LARYNGOLOGY.
33
I cannot state accurately as to the total amount of dead bone taken from the cavity, but I should say that its area would about equal that of a medium-size almond.
The sequel, it would seem, proved my diagnosis to he correct, since the ulcer had gradually increased in size and virulency for six months prior to the beginning of the anti-syphilitic treatment ; and though he did not improve at once, healing did begin as soon as the local treatment succeeded in cleansing the ulcer of necrosed hone.
The case is of even greater interest to the neurologist than to the laryngologist, and had more systematic experiments been made, and closer observations been taken of the nervous phenomena, something of greater interest might have been gained.
I will confess that I had not the temerity to risk many experiments at the time in the progress of the case when they would have been available.
Some important points may be noted : —
1. The necrosis must have occurred in the spinous process of the second cervical vertebra ; hence the spinal cord was exposed either between the first and second or the second and third vertebra.
2. The probe pressure always produced its effect on the corresponding side of the body.
3. The pressure that produced the paralysis must have wounded the anterior column by pressing a jagged piece of bone against the cord, and the pressure that produced the convulsions must have only irritated the anterior column, since it is well known, by experiments on the lower animals, that a wound of the anterior column produces immediate paralysis, and an irritation immediate convulsions.
RHEUMATIC LARYNGITIS.
LARYNGITE RHUMATISMALE UBER EHEUMATISCHE LARYNGITIS.
BY E. FLETCHER INGALS, A.M., M.D.,
Of Chicago, 111.
Rheumatic laryngitis is a painful affection of the vocal organ, attended by more or less hoarseness and fatigue of the parts after talking, and sometimes by grave or even fatal obstruction of the glottis. The affection may be either acute or chronic. The acute disease, from having been associated with articular rheumatism, has been recog- nized for several years, but it has been hut little studied, and the literature of the sub- ject is very meagre. Through the kindness of Dr. J. S. Billings, the library of the Surgeon-general’s office has been searched for me, but we have succeeded in unearthing only two articles upon the subject. The first of these, from a thesis of Dr. E. J. R. E. Emery-Desbrousses,* 1861, relates to a case of acute febrile articular rheumatism, with laryngeal localization, which terminated fatally. The patient was a young woman, twenty-four years of age, suffering from acute articular rheumatism and pericarditis. On the fourth day the larynx became involved, causing aphonia and severe pain, with suf- focative attacks, which continued, with varying severity, until her death, from slow
* “ Rheumatisme articulairo aigu, febrile localisation laryngfie pericardite et pneumoni6 mort.” 4to. Strasburg, 1861— 25. No. 544.— ( Thiae.)
Vol. IV— 3
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NINTH INTERNATIONAL MEDICAL CONGRESS.
asphyxia, on the twentieth day. At the autopsy the arytenoids were found bare hut not necrosed, and on the left side a reddish, serous fluid was found in the articulation, which demonstrated the rheumatic laryngeal arthritis. This seems to have been the first case placed on record, though brief references to the affection have been made by Besmer, Chomel, Lieberman, Dechamb and Prof. Jaccoud, and cases have also been recorded by Fauvel, Coupard and Joal.
The second paper is a very complete article on the subject by R. Archambault. ( Th csis, Paris, 1880.) He gives a careful history of the literature of the subject, and has collected five cases, one by Emery Desbrousses, just referred to, one by Fauvel and two by Coupard ; to these he adds the history of one which came under his own obser- vation. From these cases he draws the following conclusions —
“1. Acute laryngeal manifestations of rheumatism are more common than is gener- ally supposed.
“2. These manifestations may affect separately the various parts of the larynx, mucous membrane, articulations, muscles, nerves.
“3. The congestions of mucous membranes are the most frequent as well as the most easily determined of the lesions.
“ 4. They may give rise to accidents of suffocation grave enough to necessitate sur- gical intervention.
“5. The other manifestations are too uncommon and too little known to make a thorough and separate study of them.”
Treatment. — “Care should betaken to prevent the frequent occurrence of the laryn- geal congestion in individuals predisposed to it, by taking care to avoid exposure to cold and dampness.
“ The abnormal susceptibility of the larynx should be combated by fomentations of cold water upon the neck, and at the same time general bathing.
“At the commencement of an attack absolute rest should be enjoined, the use of diaphoretics to keep up activity of the skin, and the use of emollient gargles and inha- lations of steam, with or without aromatics.
“ If the case is very severe, a more energetic medication is advisable. Hot fomenta- tions and application of tr. iodine externally. If necessary, the use of vesicants should be resorted to, applied in front, over the larynx. Leeches may often be applied to advantage. If pain is very severe, applications of solution of muriate of cocaine by means of a sponge carrier will give relief. The administration of salicylate of soda is at times beneficial, but not so much so as in simple rheumatism. When suffocation is imminent, tracheotomy must be performed as the only means of avoiding a fatal ter- mination.”
Of the chronic rheumatic laryngitis to which I would call your attention I can find no mention in medical literature.
For many years past I have from time to time observed chronic painful affections of the larynx, attended by no erosions or ulcerations and by but little congestion and swelling of the part. At first I was inclined to consider these merely cases of neuralgia, but several years ago I became convinced that they were not all of neurotic origin, and during the past two years several similar cases have been under my care, which have confirmed me in the opinion that they are rheumatic in character.
At the last meeting of the American Laryngological Association, in May of the pres- ent year, Dr. S. H. Chapman, of New Haven, Conn., read a paper on “ Myalgia of the Pharynx and Larynx,” in which he described cases that seemed at first similar to those to which I refer. He thought them to have been caused by malaria. A careful perusal of his article will show that they were quite different from the cases I would term rheumatic.
The affection to which I wish to direct attention usually occurs in persons of a
SECTION XIII — LARYNGOLOGY.
35
rheumatic diathesis, but ofteu the laryux or the tissues about the hyoid bone present the only evidence of the constitutional disease. In this affection, as in the chronic rheumatism of a mild character, which often affects the joiuts, or as in muscular rhematism, the paiu is not constant, but may frequently disappear for a few days, especially during fine weather, to return again on slight exposure or with changes in the temperature. Its course is erratic, but nearly always obstinate. The patients frequently have an inherited or acquired predisposition to rheumatism, and it is not unusual for them to complain of rheumatic pains in other parts of the body, but, singu- larly, they never suspect the true nature of the disease.
Several of the cases I have seen have complained of hoarseness or aphonia. Most of them have been troubled with the pain for several months before coming to me, and I have usually found them filled with apprehensions of cancer. In no case has pain been very severe. In certain cases it has been most noticeable on using the voice, but it is often more troublesome when swallowing, and in some it is aggravated by every
■ attempt at deglutition, even of saliva. However, it varies much in intensity from day I to day or from week to week, being nearly always worse in damp or chilly weather.
Patients commonly refer the pain to one side of the larynx when this organ alone is involved, but in some cases it is also referred to the trachea, the region of the greater cornu of the hyoid bone, to the base of the tongue, or to the lower part of the tonsil on the corresponding side. In similar cases we sometimes find the pain confined to these • latter regions, there being little or no involvement of the larynx, but even in these the i patient is liable to experience fatigue of the vocal organ after talking. Hoarseness or loss of voice are also frequent symptoms. Upon inspection of the parts, one or both ; arytenoids may be slightly congested, or the redness may be confined to one side of the I fauces or to the pharynx. The vocal cords remain clear, and the inflammatory symp- . toms seem altogether inadequate to account i'or the discomfort. In some cases the i parts involved are slightly swollen, but in others no change of form is noticeable.
The diagnosis of chronic rheumatic laryngitis must be based on the history and i symptoms, and the exclusion of neuralgias and the various affections which cause
■ organic change in the parts. Acute catarrhal inflammations, chronic syphilitic laryn-
■ gitis and abnormal growths may be easily excluded. Tubercular laryngitis, in its inception, is often attended by fatigue of the larynx after talking, and sometimes by
i paiu, even before there is ulceration or swelling ; but it has a different history from the rheumatic affections. In tubercular laryngitis the parts are usually paler than in health, while they are slightly congested in the rheumatic affection. In the tuber- > cular disease the constitutional symptoms are marked ; not so in the rheumatic.
Fully developed tubercular laryngitis cannot be mistaken for the affection under . consideration.
In malignant affections of the larynx pain is often present, but from my observa- . tion I conclude that it does not often precede pronounced organic changes. Therefore,
' they are not likely to be confounded with the affection under consideration. Eheu- I matic laryngitis is most likely to be confounded with neuralgia or paraesthesia of the i organ. In distinguishing between these, the history must be carefully scrutinized,
I and rheumatic or neuralgic pains must be looked for in other parts of the body. In
■ the rheumatic affection there is usually slight redness and swelling ; not so in neuralgia. For confirmation of the diagnosis, we must sometimes await the result of treatment.
Rheumatic laryngitis usually runs a chronic course, extending over periods varying I from two months to one or more years. In most cases, if not in all, there are periods I of immunity from the soreness, but at other times there are quite severe exacerbations of pain. I recall one case which was troublesome at times for four or five years. Recovery may be expected ultimately, and the patient may and should be assured that ; the disease does not endanger life.
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In the treatment of chronic rheumatic laryngitis, I have derived considerable bene- fit from the local application of stimulant and astringent sprays, or pigments, and in some cases galvano-cauterization of the congested surface seems to have aided much in recovery. However, I have relied mainly upon internal remedies suited to the diathesis. Iodide of potassium, salicylate of soda, guaiac, colehicum and cimicifuga have all been tried with more or less success. Extract of phytolacca has been given with apparent benefit, and oil of gaultheria, in doses of fifteen minims, three times a day, has at times given satisfaction.
By way of illustration, I have selected from my note books records of a few cases that demonstrate the characteristics of this affection.
Case I. — Mrs. W., aged thirty-two ; general health perfect. About four years ago this lady complained of almost constant pain in the larynx, which, however, varied greatly from time to time. Upon examination the whole throat as well as the 1 irynx was found congested ; but the pharynx was so exquisitively sensitive that she could scarcely tolerate inspection, and therefore declined any local treatment. This patient’s father had been almost a cripple from rheumatism for many years ; other ancestors had suffered greatly from it, and the patient herself had frequently been subject to rheumatic pains, but at the time referred to there was no manifestation of the disease, excepting the pain in the larynx. She was not subject to neuralgia. Anti-rheumatic remedies were ordered and taken for a short time, but were not persisted in, as she had lost all faith in remedies for rheumatism, excepting the waters of a certain so-called magnetic spring, which had at times relieved her father.
Whether or not she visited the spring I do not know, but the soreness continued at intervals for about two years, when it, with other rheumatic symptoms, gradually dis- appeared, and she has since been perfectly well.
Case ii. — Mr. H. G., farmer, aged forty -seven ; general health good ; but he was morbid on the subject of cancer of the throat. He had been complaining for two months of pain and sense of fullness in the larynx, which he feared would choke him. The soreness was not constant, but would come on quite suddenly, last three or four days, and then gradually subside.
The sensations, when I first saw him, were referred to the upper part of the left side of the thyroid cartilage. When the attacks were at their worst his voice was husky, and occasionally he had been aphonic for a short time. He had been frequently anuoyed by muscular rheumatism, and he stated that he felt lame and tired all over his whole body when the exacerbations came on.
Laryngoscopic examination revealed moderate congestion of the epiglottis and left wall of the larynx, with very slight swelling of the latter ; also very slight congestion of the vocal cord, but nothing more. On touching the parts with a probe he claimed that the sensitive spot was either on the inner surface of the left wall of the larynx, or else just external to the left wing of the thyroid cartilage, but he was not quite certain which.
I placed the patient on twenty-grain doses of bromide of potassium, four times a day, and fifteen-minim doses of oil of gaultheria. I also applied a sixty -grain solution of nitrate of silver to the left side of the larynx. Eight days later it was noted that he was almost well, and was to have returned to his home, but the soreness had reappeared, lower down, at the upper portion of the trachea. During the next few days the pain shifted to the larynx again, and then to a point beneath the sternum. Sixteen days after I first saw him he returned to his home, free from pain, with directions to take iodide of potassium, grains vijss, and oil of gaultheria, ffb xv three times a day. I learu that the pain returned, subsequently, from time to time.
Case iii. — Miss F. G., aged twenty-two ; general health good. Her voice had been weak l'or four years, whenever she attempted to shout, but this gave her no special dis-
SECTION XIII — LARYNGOLOGY.
37
comfort. Fora month before consulting me she had been complaining of aching in the : tonsils, larynx, trachea and sub-sternal region whenever she used the voice for a few minutes. The soreness was always worse in damp weather. Examination of the larynx showed paresis of the right vocal cord, which moved through only about one-third its normal excursion, but there was neither swelling nor redness.
In this case there was no previous rheumatic history, and there were no signs in the larynx excepting those of paresis.
Her principal symptoms were of only a month’s duration, and I therefore concluded that the paresis was either of recent origin, or that it had nothing to do with the present s attack. She complained of other pains which seemed rheumatic ; she had always been - worse in damp weather, and under the influence of salicylate of soda, acetate of potas- , sium, and oil of gaultheria she improved rapidly, so that I think the diagnosis was i fairly established.
Just as I was completing this paper the patient returned, after several months’ . absence, complaining of severe and constant pain in the same regions as before. She had been free from pain for several weeks during the interim, but it had recently t. returned with increased severity. No abnormal signs could be seen in the larynx, even [ the paresis having disappeared, and the evidences of rheumatism were more pronounced c than ever before.
Case iv. — Mr. J. C. R., aged thirty-nine. Patient complained of pains in the i shoulders, chest and back of the head, and of aphonia of four months’ duration. He had suffered several attacks of inflammatory rheumatism, and had been frequently t, troubled with slight attacks of sore throat. General health good. Weight, pulse and temperature were normal.
On examining the larynx I found bilateral paralysis of the lateral crico-arylenoid muscles, with inability to close the glottis on attempted phonation, but there was no congestion or swelling.
In this case the pains, and possibly the paralysis, seemed to be of rheumatic origin. I saw the patient only once, and have not heard the result of treatment.
Case v. — Mr. C. F. M., aged twenty-nine. General health perfect. Had complained of soreness of the throat much of the time for four months, of occasional hoarseness, and of rheumatic pains in the back and chest, and in the regions of the trachea and hyoid bone. These pains were always aggravated by damp weather and by exposure to night air.
Under the influence of stimulant applications to the throat and anti-rheumatic remedies internally he speedily improved, but every four to six weeks, with some renewed exposure, his symptoms have returned. He is at present well, but I expect renewed attacks.
Besides these, several other such patients have been under my care, and I am confident that similar cases have presented themselves to other laryngologists, but we have been accustomed to class them with the cases of neuralgia or paraesthesia, with no very defi- nite idea of their etiology and but little hope of benefit from treatment.
I am confident that, with more critical observation, we shall find many cases similar to those I have described, which are due to the same causes as muscular or articular rheumatism, and in which we will obtain far better results from treatment than we have been accustomed to if we bear this in mind, and prescribe constitutional remedies accordingly.
DISCUSSION.
Dr. J. A. Stucky, of Lexington, Ky. , remarked — This Section is greatly indebted to Dr. Ingals for the timely, practical and valuable paper just read. I have no doubt but many of us have had cases of rheumatic laryngeal trouble and
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NINTH INTERNATIONAL MEDICAL CONGRESS.
failed to recognize it. I remember of having only one case, and that of such interest and so instructive to me, I beg leave to report it. Patient was a lady aet. 26; had been bedfast for eleven days, I first saw her, with inflammatory articular rheumatism of violent form. I was called to see her on account of pain over the larynx, sensi- tive to the touch, and patient said her neck pained her as much as her joints. Deg- lutition and phonation were very painful. The laryngoscope revealed marked hyperaemia, with oedematous swelling of right arytenoid. Epiglottis slightly cedem- atous. A diagnosis of the rheumatic poison affecting the laryngeal muscles and articulation of the cartilages was made. And the dose of anti-rheumatic remedies was increased ; soothing applications, consisting of neutral oleate of cocaine in vaseline, were applied at short intervals, by means of the spray. The symptoms increased, with very little amelioration of the pain in the larynx, and by the four- teenth day the dyspnoea was so urgent that tracheotomy was advised. While on my way to my office for the instruments to perform the operation, the patient died, whether from suffocation or heart involvement I am not able to say. Since then, whenever a patient complains of pain in the laryngeal region, I look out for rheu- matic troubles. If these symptoms are detected, the line of treatment is easily decided upon.
Dr. Stockton, of Chicago, 111., said — I think Prof. Ingals’ paper very timely, and I am very glad to hear it. I have met with a number of cases that I am confi- dent are rheumatic, being unwilling to class them as neuralgic.
Paper by Dr. J. A. Stucky, of Lexington, Ky., owing to his paper being destroyed by fire, was read by title. “ Clinical Report on the Treatment of Laryn- geal Phthisis. ’ ’
THE DIAGNOSTIC DIFFERENTIATION OF RECENT TUBERCULOUS, 1 SPECIFIC AND RHEUMATIC LARYNGEAL DISEASES.
LA DIAGNOSTIQUE DIFFERENTIELLE DES MALADIES LARYNGIENNES RHUMA-1 TIQUES SPECIFIQUES, ET TUBERCULEUSES RECENTES.
DIE DIFFERENTIALDIAGNOSE DER PRIMAREN TUBERKULOSEN, SPECIFISCHEN UND RHEUMATISCHEN KRANKHEITEN DES LARYNX.
BY DR. E. S. SHURLY,
Detroit, Mich.
The differentiation of recent tuberculous, specific and rheumatic disease affecting the ] larynx, as we all know, is a topic of very wide range. I shall endeavor, however, to 3 present the subject as concisely as possible, by confining myself rigidly to the laryngeal j region. You will, therefore, notice the omission of many things which, were time aud I circumstances favorable, might be included.
While there is much similarity in the symptomatology of the three diseases whose -1 local expression we are about to consider, there is that variation, in even typical cases,* which will allow very often of distinction.
Without further generalization, I will call your attention, first, to the laryngoscopic I appearances, second, to the objective symptoms, and third, to the systemic symptoms accompanying the three diseases.
Hyperaemia, or congestion and inflammation of the laryngeal mucous membrane, is,
SECTION XIII — LARYNGOLOGY.
39
of course, one of tlie earliest manifestations in each of the conditions under considera- . tion, unless we may sometimes except phthisis. In recent syphilis, whether secondary or tertiary, it is apt to be diffuse and persistent, the color varying according to the individual. In phthisis, although a majority of cases present a paleness of the mucous membrane, yet this may soon be succeeded by congestion more or less diffused. In rheumatism, when the hypersemia is general, it seems less intense and more disposed ( about the upper larynx — especially in the muscular variety — constituting so-called rheumatic laryngitis; while in the arthritic form the congestion seems to take place i at first along the lateral wall up as far as the faucial pillars, either in streaks or quite diffused. The surface is not granular, as is the case sometimes with either of the other i diseases.
Anaemia, the opposite condition, rarely occurs in recent diseases of either affection, excepting phthisis, unless as an oedema, which may then accompany either syphilis or rheumatism, especially the latter, if an active inflammation be seated in one of the arytenoid joints.
Tumefaction, or infiltration, either quickly or slowly, succeeds congestion in tuber- culous laryugeal phthisis, although not always. All of us have, I think, met with i cases of tuberculosis where the tumefaction was quite diffuse, and beginning even in the lower laryux, which seemed more like real hyperplasia than mere infiltration. Of i course, when the characteristic swelling of the arytenoid eminences and epiglottis — so i common in this disease — is present, the diagnosis is about determined. In syphilis, either secondary or tertiary, when recent, the tumefaction comes slowly, while the ■ thickening is not so great or regular. The surface may, and often does, show a papular ; character and very uneven surface, but when certain regions of the submucosa contain the principal exudation, a careless inspection might lead one to regard the nature of the case as tubercular. In some cases of rheumatism and gout — especially the latter — the tumefaction is not diffuse, hut, on the contrary, distinctly localized at the posterior part of the larynx on either side, according to the arytenoid joint affected, and is of such consistence in subacute or chronic cases as to appear like an organized hyperplasia.
! Later on, if the joint undergoes organic change or perichondritis supervene, the thick- ening becomes firm and corrugated. In my opinion, it is very difficult, indeed, in such eases — early stages — to differentiate between a local manifestation of syphilis aud rhuematic gout or gout.
In the muscular variety of rheumatism the tumefaction is usually very slight, and 1 disposed in lines or patches.
Ulceration soon supervenes in recent tuberculous disease, and less rapidly, as a rule, in syphilitic, while never in rheumatic, excepting in advanced states of rheumatic : perichondritis.
Regarding syphilis, it is considered doubtful by many observers if condylomata or gummas or ulceration ever occur in the larynx early or primarily ; while, on the other ; hand, there are cases reported in medical literature with descriptions of such appear- ances. When ulceration occurs, it comes on quickly and often symmetrically ; the i ulcers are solitary, deep, with sharp-cut edges, irregularly round, surrounded by a bright i areola of congestion and swelling, and having a predilection for the aryepiglottic folds and upper surface of the epiglottis. It is, however, very rare to find ulceration in recent syphilitic disease primarily occurring in the larynx. The ulceration of laryngeal phthisis or tuberculosis comes on slowly. It is more apt to ‘occur primarily in the larynx than in the structures above. The ulcers are small, numerous, scattered, super- ficial, edges irregular, in some cases described as like worm tracks ; while in others they are smooth, oval excavations, generally seated on the under side of the epiglottis, ary- tenoid and aryepiglottic folds, ventricular bands, and less frequently on the vocal cords.
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It has been said that tubercular deposit might be recognized in the edges of the ulcers of some cases.
Of course there are many departures from the typical appearance, as, for instance, when the case is a mixed one ; then the ulceration may be rapid and serpiginous, or deep and confluent, even in the early stages. I remember a case of this sort in my own practice, with well-marked ulceration, confined to the larynx, and with a history of both tuberculosis and syphilis, which went on from congestion to extensive destruction of the laryngeal membrane in two weeks.
Laryngeal hemorrhage is rarely a symptom of laryngeal phthisis or syphilis, excepting as a result of erosion, but it is sometimes an accompaniment of rheumatism.
The mobility of the parts may very early suffer impairment in the course of these diseases, whether syphilitic, laryngeal or rheumatic. Immobility of one or both cords would be due either to tumefaction, hyperplasia or paralysis. The immobility due to rheumatism can be easily confounded with paralysis or immobility from totally different causes, as when a rheum-arthritis affects one of the arytenoid joints. The distinguishing feature, aside from the history, in cases where the articulations are involved, is the location of swelling or fullness toward the base of the cartilage and about the attached portion of the ventricular bands, together with the pain of larynx and neck muscles ; and when the laryngeal muscles are the seat of the trouble, the swelling may be insignificant and the mobility be incomplete, but the pain or soreness is excessive.
The objective symptoms belonging to the early stages of these diseases may be mentioned as hoarseness, aphonia, dysphonia, odynphagia, dysphagia, pain in the throat and adjacent region, cough, secretion and expectoration, varying in degree according to the case. Hoarseness is generally present in laryngeal hyperaemia from any cause, unless confined to the upper part of the larynx, and is due either to functional disturb- ance or the different conditions of tumefaction affecting the mucosa or submucosa or the interarytenoid fold. Though generally present, it is not invariably in recent tuber- culous or syphilitic disease ; but dysphonia, especially accompanied by soreness of the neck, is a marked symptom of rheumatism. In gout, however, the pain and soreness is more limited and less fugitive than in the acute or subacute variety of rheumatism. Cough of peculiar character is almost always present in syphilis and laryngeal phthisis, but not so in rheumatic disease, except, perhaps, the occasional attempts at clearing the throat, which hardly amount to laryngeal cough.
Waiving any remarks upon the secretions of the mucous membrane in syphilitic and tuberculous disease, with which all are familiar, I would state that in rheumatic it is usually a glairy mucus, excepting in gouty cases, associated with more or less bronchial catarrh, when it is muco-purulent. Microscopic examination of sputum never shows bacilli or elastic tissue, excepting in cases complicated with chronic bronchitis or phthisis.
The shortness of breath, which I have seen mentioned as one of the signs of rheu- matic laryngitis, occurs only in those cases where there is mechanical obstruction from tumefaction, immobility of the glottis or concomitant bronchial catarrh, but occasion- ally it may depend upon implication of the muscles of respiration. In the other two affections it is, of course, due to structural changes. Odynphagia and dysphagia occur early in rheumatism, but later in syphilis and tuberculosis.
Spasm of the glottis', while occurring at times in laryngeal phthisis and syphilis, is much more frequent in the early stages of rheumatic disease, but after a time, if the disease becomes general, this symptom disappears. Chorea of the vocal cords, or paraes- thesia, may also be the principal symptoms of rheumatic disease.
The clinical history connected with these manifestations is certainly an important
SECTION XIII — LARYNGOLOGY.
41
, factor in the diagnosis, and oftentimes must be our main dependence in differentiation, i As it would be a matter of supererogation as well as a waste of time to enumerate in detail the clinical history of laryngeal phthisis, syphilis and rheumatism, I will, of i course, pass them with the mere mention.
I am fully aware that the existence of rheumatoid disease of the larynx, as well as condylomata, gummata and primary tuberculous deposit, are denied by many competent observers ; hence great dissimilarity of ideas attach to the respective terms used in giving expression to these various local appearances. In some of the mixed cases, such as present a clinical history of all three of these diseases, differentiation in the earlier : stages becomes almost impossible.
Concerning the rheumatic affection, which is not as common as the others, I think we ought to recognize two varieties at least — the one a genuine arthritis, occurring in a gouty subject, perhaps with the local lesion confined to the neighborhood of the joint, mainly ; and the other, seated for the most part in the nervo-muscular apparatus of the larynx, and also affecting the neck or chest muscles more or less. In both forms the attending pain in the parts and neighborhood is apt to be severe.
In conclusion, permit me to offer a summary in the form of a tabular statement of the marked signs of each of these diseases.
TABLE SHOWING PRINCIPAL SIGNS AND SYMPTOMS OF RECENT TUBERCULOUS, SYPHILITIC AND RHEUMATIC DISEASE OF THE LARYNX.
|
Laryngeal Phthisis. |
Syphilis. |
Rheumatism. |
|
Hypercemia or congestion often not so marked. |
Hypercemia and congestion al- ways persistent and extended. |
Hyperoemia and congestion always present but not intense, and often localized. |
|
Tumefaction or infiltration quite consta nt and peculiar, affect- ing epiglottis and arytenoids. |
Tumefaction not marked. |
Tumefaction rare, excepting in arthritic rheumatism, when it is local. |
|
None. |
Condylomata and gummata sometimes. |
None. |
|
Ulceration, common, slow de- velopment, scattered, irregular, small, roundish or oval, commonly situated on under surface of epi- glottis and arytenoids. |
Ulceration may be rapid, but rare in larynx ; when occurring is rapid and apt to he solitary or symmetrical, surrounded by areoia. |
No ulceration. |
|
Mobility o f cords slightly affected. |
Mobility slightly affected. |
Mobility out of proportion to st ructu ra 1 change, especially arth- ritic variety. |
|
Hemorrhage rare. |
Hemorrhage very rare. |
Hemorrhage common. |
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NINTH INTERNATIONAL MEDICAL CONGRESS.
TABLE SHOWING PRINCIPAL SIGNS AND SYMPTOMS OF RECENT TUBERCULOUS, SYPHILITIC AND RHEUMATIC DISEASE OF THE LARYNX. — Continued.
OBJECTIVE SYMPTOMS.
|
Laryngeal Phthisis. |
Syphilis. |
Rheumatism. |
|
Hoarseness. |
Hoarseness , dysphonia , slight. |
Dysphonia, aphonia , or hoarse- ness. |
|
Dysphagia and odynphagia only when epiglottis and arytenoid eminences are principally affected. |
Not marked, unless pharynx is involved. |
Quite persistent and constant. |
|
Pain in larynx absent. |
Pain in larynx absent. |
Pain in larynx, quite constant, and about neck. |
|
Expectoration of mucus contain- ing bacilli often. |
Expectoration of mucus, no bacilli. |
Little or no expectoration, no bacilli |
|
Cervical glands not enlarged. |
Cervical glands enlarged. |
Cervical glands not enlarged. |
|
No spasm of laryngeal muscles, as a rule. |
No spasm oflaryngeal muscles. |
Spasm frequent, also chorea. |
|
Sensation not perverted. |
Sensation not perverted. |
Sensation often perverted, par- sesthesia. |
DISCUSSION.
Dr. Ingals, of Chicago, El., had been much interested in the paper, especially because it contained much on rheumatic laryngitis, of which affection very little could be learned from medical literature. The author has mentioned some points which had not come under his observation, of which he could find no mention in medical literature.
Dr. Shurly, in closing the discussion, remarked — I would like to call attention to rheumatic disease of the larynx because Dr. Ingals says the literature of the sub- ject is meagre, and because I believe cases of this sort are often passed as laryngeal phthisis or other diseases.
THE TREATMENT OF LARYNGEAL PAPILLOMATA.
LE TRAITEMENT DES PAPILLOMES LARYNGIENNES.
UBER DIE BEHANDLUNG DER LARYNXPAPILLOME.
BY PROF. W. E. CASSELBERRY, M.D.,
Of Chicago, 111.
A discussion of the treatment of laryngeal papillomata naturally resolves itself into a consideration of the best means of eradicating these growths. Their removal, by whatever method, has been much facilitated by the introduction of cocaine, and for the sake of brevity we will suppose that this local anaesthetic be applied in all cases, so as to permit of instrumental manipulation within the larynx. The laryngeal forceps are
SECTION XIII — LARYNGOLOGY.
43
commonly employed to grasp the tumor or portions of it and cut or pull it from its base. A great variety of these have been devised, of which those of Mackenzie, Schriitter, Stoerk and Cusco are familiar examples. There are many cases in which one or other of these is unquestionably the simplest and best means at our disposal. This is true when the papilloma is single, with a narrow and circumscribed base, which is not too deeply inserted, and when it is in a position accessible to the forceps.
There are other cases, however, in which I am convinced the forceps are not only slow, but ineffective, and perhaps even worse than useless. I have in mind two cases; in one the papilloma was sessile, flat, with a broad base covering the anterior two-thirds of the superior surface of the right vocal cord and spreading in half its extent around the free border of its cord on to its inferior surface. I tried forceps, but succeeded in detaching only small pieces at a time. Each operation was followed by inflammation, and by the time I could again operate the growth was as large as before. I despaired of effecting a cure in this way. It was like pulling pieces from a cutaneous seed wart — the more I pulled, the faster it grew. Moreover, a part of the tumor, being beneath the vocal cord, could not be reached by forceps.
In the other case the entire larynx, at first sight, seemed filled with papillomatous growth. Forceps were used to clear away the grosser portions, when it was found that the warts sprang from the edges of both vocal cords along their entire extent and from the inter-arytenoid space. They had a seedy aspect, i. e., the appearance of a common seed wart as it grows on the hands. Again the same difficulty was encountered. I could not by means of forceps exterminate the roots, and stimulated apparently by the extraction of piece by piece, their growth was such that after a certain point no progress was made.
This brings me to another method of removal — cauterization. Rut with what? Nitrate of silver is too superficial. Chromic acid is often uncontrollable. The galvano- cautery in the form of the apparatus which I here exhibit answers every indica- tion. The apparatus is Sajous’ handle and laryngeal loop electrode, with its loop bent to one side. A perfect cure, with restoration of voice, was effected in one case. In the second case, restoration of voice has been produced, but the case is yet under treatment.
A curette has been devised by Dr. Rossi, of Italy, cited by Ferreri, of Rome, the application of which is to be followed by scarification of its base and cauterization with a chemical caustic. I should be pleased to hear this method discussed.
DISCUSSION.
Dr. J. Solis-Cohen, of Philadelphia, referred to two methods of removing laryngeal growths not mentioned, one by employing the snare so successfully used by the Chairman, and the simple sponge probang by means of which white, soft growths can be nibbed off from the lower surface of the vocal bands. In many cases, how- ever, it is necessary to incise the crico-thyroid membrane in order to get direct access to growths in that position. He also called attention to a modification of the jaws of the forceps by which a broad surface is supplied, instead of the pointed end of the ordinary oval jaw, which facilitates catching hold of minute growths on the superior surface of the vocal bands.
He likewise called attention to the importance of leaving the wires of the electric cautery as thick as is compatible with convenience in manipulation, in order the better to confine the heat in the platinum terminal, and avoid unnecessary heat in the handle. In cauterizing growths on the edge of the vocal bands, he recommended protection by layers of asbestos and ivory in the opposite side, so as to avoid injuring the sound tissues in the sphincter-like action following interference in the larynx.
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NINTH INTERNATIONAL MEDICAL CONGRESS.
Prof. E. Fletcher Ingals, of Chicago, 111. — Referring to the statement that chromic acid is uncontrollable, he thought there could be no difficulty whatever in controlling its action if it were fused on a probe in proper quantity.
Dr. William Porter, of St. Louis, Mo., uses chromic acid, and carefully applies it as a safe remedy. The curette has been efficacious in two cases, and the sponge method of Yoltolini in one. He applies the chromic acid in cases of small growths where it is difficult to apply the forceps. He uses a probe, on which is fixed a small glass bulb with a depression upon one side, in which is placed a single crystal of chromic acid.
Mr. Lennox Browne, of London, while expressing his interest in the cases considered by Prof Casselberry, who had initiated the discussion, felt some regret that the field of debate had not been extended to consideration of the important question of recurrence. Without doubt, functional abuse of the voice, and a state of chronic and persistent hyperaemia, were main factors of the aetiology of papillomata ; and in certain instances in which the hyperaemic state persisted after removal of a neoplasm, there would be a liability to recurrence, not necessarily in the same situa- tion, but possibly so, or in some other part of the larynx. This fact constituted a serious element of consideration when forming a prognosis, and accounted for the disappointment often experienced by the operator, who, sometimes having cured his patient as he thought, heard of the case coming under the care of another confrere as uncured. In one such case of obstinate recurrence in fresh situations, Mr. Lennox Browne had experienced a good result from enjoining absolute silence for two months, and the application during that period of continuous cold over the larynx, by means of a Leiter coil.
Prof. W. E. Casselberry closed the discussion by remarking — All methods of treatment were not mentioned by me, as I expected they would be elicited by the discussion. The sponge method of Voltolini I have not tried. The snare would have been inapplicable in the two cases cited. That the galvano-cautery will burn but superficially is not my experience. I think it can be made to burn more deeply than other caustics. The electrode might be protected on one side, but the shield increases the bulk of the instrument, and in my hands has not been necessary. I have not searched the opposite side of the larynx, because I have carefully located the part to be cauterized, pressed the electrode into it and away from the opposite side before applying the current. With the parts thoroughly cocainized and in com- parative quietude, I can see no reason why the galvano-cautery should not be used as well below as above the epiglottis; although, as a matter of course, it must be by skillful hands. My galvano-cautery is not fickle, but quite reliable, if kept in proper repair.
SECTION XIII — LARYNGOLOGY.
45
RECURRENT HEMORRHAGE OF THE UPPER AIR PASSAGES.
L’HEMORRIIAGIE RECURRENTE DES VOIES RESPIRATOIRES SUPERIEURES.
UBER RECURRENTE BLUTUNG DER OBEREN LUFTtVEGE.
BY WILLIAM PORTER, M. D.,
Of St. Louis, Mo.
Mr. President. — You have asked me to speak upon a most interesting topic. I will not attempt to present it fully, but rather to make some suggestions along which the line of an argument may run.
First let me limit the geographical boundaries of the term upper air passages. Epistaxis forms the subject of another discussion, and we will not include that at this time. Bronchial hemorrhage is rare except as a complication of pulmonary involve- ment, and when found is discovered by the use of the stethoscope rather than the laryn- goscope —by hearing rather than by sight.
While many of us include diseases of the chest in our field of work, it is proper here that we should, as far as possible, confine our remarks to laryngological topics only.
Excluding, then, for these reasons, epistaxis and hemorrhage from the bronchial tubes, let us turn our thought to recurrent hemorrhage of the larynx and pharynx. Again, I think we need consider those cases only in which the hemorrhage is of idio- pathic origin. Interesting essays have been written upon such themes as hemorrhage following uvulotomy (Morgan) and tonsillotomy (Lefferts), but such phenomena as these and other writers upon kindred subjects have mentioned can scarcely be called recurrent, but rather persistent and constant.
Two cases may be used as illustrations of our subject. The first was recurrent hemor- ; rhage from the larynx.
Miss K., about eighteen years of age, with good family history, consulted me because of frequent bleeding, which she feared originated in the lungs. She had had some hoarseness and at times soreness in the glottic region, but not constantly. A careful examination of the chest did not enable me to locate the lesion. At that time I could not discover any abnormal condition suggesting hemorrhage in the upper air passages, although there was a chronic laryngitis and pharyngitis.
A few days later she again called. She had been bleeding slowly for some hours, and was still expectorating blood at intervals. This time the source of the hemorrhage was found. A small perforating ulcer, which had escaped my attention at first exami- 1 nation, was seen on the right ventricular band, and, after removing all the exuded blood i by absorbent cotton, the fresh blood could be observed coming from the ulcer. A solu- tion of iron and glycerine promptly controlled the hemorrhage. There was recurrence of the hemorrhage several times, and the ulcer healed slowly. Rest was enjoined, phonation restricted, and after two weeks there was no return of the bleeding. There t has been entire absence of this symptom for two months, and the laryngitis under i treatment has improved, though not entirely relieved.
Where there is extravasation of blood into the submucous tissues of the larynx, i serious complications may ensue and death may quickly occurfrom obstruction. One of the most interesting monographs upon this subject was published by Dr. Gleitsman in the 1 American Journal of the Medical Sciences, April, 1885. After recording a typical case of his own, he mentions a number reported by others (Mandl, Fraenkel, Lewin, Hart- i man, Wagner, Jngals, Knight, Morgan). Some of these gentlemen being present, will ‘ doubtless recall the cases to which I refer.
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Hemorrhage from the larynx is not a disease, it is hut a symptom, and must he treated as such. Generally resulting from some form of laryngitis — simple tubercular or, in rare instances, syphilitic — yet a prominent factor in its production may he a faulty heart action. In one case, at least, topical applications were insufficient until the heart, unable to do its work through mitral lesion, was aided by rest of the body and digitalis.
Hemorrhage from the pharynx may easily be mistaken for haemoptysis. In 1882 I reported two cases to the American Medical Association, in the Section on Laryngology. In each of these cases there was some slight pulmonary lesion, and when the hemor- rhage appeared, it was but natural to think that its origin should have been in the lungs, and in each the true site was in the pharynx. Since then I have seen several similar instances, the following case being typical : —
Mr. N., a young attorney of St. Louis, having had during previous years several attacks of bronchitis, was one day surprised by the rapid discharge of blood from the mouth. He was sure the hemorrhage came from the right middle lobe, where he had had some pain during the attacks of bronchitis mentioned.
The bleeding had ceased when I saw him, and although there was evidence of a slight chronic bronchitis, the percussion note, vesicular murmur and rhythm were normal. Some days afterward, Mr. N. again came. He had had slight bleeding several times during the day. In my search for the source, I passed a bent cotton-covered probe into the upper pharynx, and was rewarded by the reappearance of the hemorrhage, the blood trickling down from behind the soft palate.
Suffice it to say, that a small ulcer was found on the posterior wall of the velum, a little to the right of the median line, and I need scarcely add that, with this dis- covery, all fear of lung complication speedily passed from the patient’s mind. There was no further hemorrhage, the ulcer rapidly disappearing under slight treatment. The thought which I would offer, in submitting these condensed histories, is that hemor- rhage from the upper air passages, is not infrequently a complication of chronic inflam- mation of the larynx or pharynx, and that it may be mistaken for haemoptysis or even haematemesis. This being admitted, in all cases of hemorrhage from the respiratory tract, of doubtful origin, there should be careful examination of the upper air passages.
DISCUSSION.
Prof. Stockton, of Chicago, 111. , remarked — I wish to add one more case to those already reported. A young lady, an opera singer, one day, in practicing, sud- denly lost her voice, and in a few minutes coughed up some bright, frothy blood. On examination I found the larynx coated with blood, and on wiping it away, I dis- covered a small pulsating vessel from which hemorrhage was taking place. ‘I succeeded in controlling the flow of blood by the galvano-cautery. In two weeks’ . time the lady was able to sing.
Dr. J. Solis-Cohen, of Philadelphia, does not think the occasional hemorrhages from rupture of vessels in chronic inflammations of the larynx and pharynx of much importance, and has never seen any extreme hemorrhage. In those instances in which the hemorrhage is submucous, there may be considerable trouble from stridor, especially in that of oedema of the larynx, termed hemorrhagic oedema. He does not approve of the term laryngitis haemorrhagici, sometimes applied to these conditions, and does not use the term himself
Mr. Lennox Browne, of London, desired to bear testimony to the value of discussing the somewhat uncommon tut important class of cases included in the interesting communication which had opened this debate. Personally, he doubted
SECTION XIII — LARYNGOLOGY.
47
the occurrence of laryngeal hemorrhage in the course of an uncomplicated laryngitis, and would always give a grave prognosis in any case presented to his notice. Laryn- geal hemorrhage was not a frequent complication of tuberculous laryngitis; it was more common in his experience in syphilis than was believed by Dr. Porter, and was one of the causes of death to be foretold in cases of laryngeal or rather pharyngo- laryngeal carcinoma. A very common but unrecognized cause of slight hemorrhages iu the throat was varix of the vessels at the base of the tongue. This condition was often manifested to such an extent as to constitute a truly hemorrhoidal state of affairs. The aetiology was in many respects similar to that of rectal hemorrhoids; it was often associated with varix in other parts of the body, and required for successful j treatment a local eradication by electric cautery of the diseased veins, and a careful • search for and correction of all general and functional causes that might have led to the complaint.
This subject was one which had been treated by the author and his deceased col- league, Llewelyn Thomas, at Milan, in 1880, but the communication, having been somewhat buried in the Comptes Rendus of that Congress, had not attracted much notice. It was fully discussed in Mr. Lennox Browne’s recently published new i edition of his work on ‘ ‘ The Throat and its Diseases, ’ ’ and the attention of the members present was invited.
48
NINTH INTERNATIONAL MEDICAL CONGRESS.
THIRD DAY.
Meeting called to order at 11 a.m. by the President.
In the absence of Dr. H. H. Curtis, of New York, Dr. S. N. Benham was appointed by the President to read Dr. Curtis’ paper, entitled —
NASAL STENOSIS.
RETRECISSEMENT NASAL.
UBER NASENSTENOSE.
BY H. HOLBROOK CURTIS, M.D.,
Of New York.
The exact function of the nose, from a physiological standpoint, has, as yet, not been definitely demonstrated, though great advances have been made in rhinology since 5, the last meeting of the International Medical Congress.
The important relationship between pathological conditions of the olfactory and respiratory nasal tracts and diseases alfecting their continuity in the pharynx and larynx well deserves the amount of labor and research which has been devoted to rhinological laryngology during the past three years.
The advent of intra-nasal surgery has not only compelled an entirely new classifi- ,j cation of nasal diseases, but also admits of the elucidation of many previously obscure pathological problems. The surgery of rhinology had its origin and a greater part of its development in the United States, and the compliment paid by Mr. Lennox Browne to the American Laryngological Association, in his valuable work just issued, well shows the recognition American laryngology obtains abroad.
The various deformities of the bony and cartilaginous framework of the nose, and their surgical relief, together with the altered structure or function of the turbinate | bodies and their mode of treatment, will illustrate the purport of this thesis, and the title, Nasal Stenosis, will embrace all these conditions.
NASAL STENOSIS MAY BE OF TRAUMATIC, HYPERTROPHIC OR REFLEX ORIGIN.
1. Traumatic Stenosis comprises deviations of the septum, either bony, cartilaginous, or both, resulting from direct injury, improper mode of lying during sleep in infancy, j congenital deformity or unequal cranial development.
2. Hypertrophic Stenosis includes exostoses, enchondroses, thickened ridges along one or both sides of the septal articulations, hypertrophy of the turbinate bodies, erectile tumefactions, polypi, neoplasms, tumors, etc.
3. Temporary or Reflex Stenosis includes the reflex neuroses and those conditions in which the erectile tissues are temporarily enlarged, either by increased nutrition, by vasomotor paresis or by irritation.
The term Nasal Stenosis we employ in its generic sense.
SECTION XIII — LARYNGOLOGY.
49
The descriptions of diseases under the names “Post-Nasal Catarrh,” “Granular Pharyngitis,” “Hypertrophic Lateral Pharyngitis, ” etc., will soon he done away with, and the near future of pathological research, combined with better physiological kuowl- s edge, will cause a reflex impairment of function in these cases to be classified as such, rather than as diseases per se.
Post-nasal catarrh is a symptom of nasal stenosis, so also is ethmoiditis, eustachian [. catarrh, otitis, adenoid growths, pharyngitis, laryngitis, hay asthma, spasmodic asthma, .enlarged tonsils, bronchitis, etc. When we say bronchitis we do not include, neces- sarily, all bronchitis, any more than when we say otitis do we include every otitis; but nasal stenosis includes as symptoms some of the above conditions in a very large pro- ! portion of cases. Hence the relief of nasal stenosis becomes an essential factor in the ' treatment of these conditions, and at present has assumed an importance in laryngology not dreamed of in the past.
Some of the best literature of to-day — the works of Mackenzie, Cohen, Lennox Browne, etc.— dismiss the subject of deviation of the septum with a page or two in five hundred, and, with the exception of Lennox Browne, make but passing reference to i stenosis of the nostrils from so-called hypertrophies and catarrhs resulting therefrom,
1 while to thoroughly cope with the seriousness of the trouble, and the magical effect of the restitution of the lower nasal air passages, would rightly deserve a quarter of the subject matter of their respective works.
The study of stenosis is as important an attribute to laryngology as the consideration of stricture of the urethra is to genito-urinology.
For several years the writer has been waiting to see a case of “ Post-Nasal Catarrh ” unaccompanied by enlarged turbinates or deviated septum. Writers on the subject . maintain that the catarrh causes the erectile tumefactions. If this is so, why, then, do we never see a catarrh in its initial stage ?
Rhinitis is a vasomotor phenomenon, with its stages of shock, dilatation and secre- : tion. Catarrh may result from chronic rhinitis only when the dilatation has persisted long enough to produce oxygen starvation and changed secretion ; for by relief of the stenosis and reestablishment of free oxygenation the altered secretion of a catarrh will lose its tenacity and become normal. A catarrhal secretion is, then, the normal secretion of the nostril rendered viscid by want of oxygenation.* It is a matter of sincere regret ; that certain writers have made of late rather extraordinary claims for their ability to j cure all conditions of catarrhal implication by the simple procedure of sawing off the 1 angle of a septal deflection or the free use of chromic acid to the erectile tissues of the 1 turbinate bodies, without taking into consideration possible ethmoidal complications ;
for the writer has had the opportunity of seeing several cases of anterior ethmoidal r. catarrh, periostitis and caries which have preseuted themselves for treatment after i having been positively assured entire freedom from their symptoms, following a relief i of nasal stenosis. It seems proper to consider ethmoiditis to result either from con- •I tinued colds, causing chronic congestion of the inter-ethmoidal mucous membranes, or I from stoppage of the orifice of ethmoidal secretions by pressure f from an enlarged ( turbinate body. There is no doubt that many so-described catarrhal conditions of the tantrum are, in reality, but an anterior catarrhal ethmoiditis. The condition rarely I occurs but on one side. It is frequently seen, but I do not find it described in any text-book. If the ethmoiditis has become carious, the slender probe introduced into
* See paper by writer, read before Am. Soc. Sci. Ass., and published in American Social Science Journal. Report of meeting September 7th, 1886, at Saratoga.
f See paper entitled “A Few Points Concerning Laryngologieal and Rhinological Work,” read by Dr. II. Holbrook Curtis before the New York Academy of Medicine. ( New York Medical Record, April 30th, 1887.)
Vol.IV— 4
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NINTH INTERNATIONAL MEDICAL CONGRESS.
the anterior orifice of the ethmoid cells will at once give the bony touch. This is done with great facility as the result of a little practice.
It is due to the apparent lack of appreciation of the existence of this interesting con- dition, that the differential diagnosis of nasal catarrhal diseases has been so hopelessly at fault, and though it does not directly concern the subject of nasal stenosis (except when it occurs from hypertrophy of the middle turbinate body causing pressure, and retention of ethmoidal secretions), it is important to understand the difference between an ethmoiditis and a simple nasal catarrh.
Having outlined the principal causes of nasal stenosis, and touched upon the symp- toms, let us, for a moment, take up the consideration of the traumatic and hypertrophic subdivisions.
1. Traumatic. This variety occurs as deviation of the nasal septum from the median line. These deviations have been classified by the writer as —
(а) Vertical (V).
(б) Horizontal (H).
(e) Oblique, ascending and descending (OA) (OD).
(d) Sigmoidal (S).
(e) Pyramidal (P).
The vertical deflection has an anterior and a posterior plane, with the line of the ridge or intersection perpendicular to the floor of the nasal cavity.
The horizontal deflection consists of two planes or faces, with the ridge or intersection parallel with the floor of the nasal cavity.
The oblique ascending consists of two planes, the ridge or intersection rising obliquely upward and backward, usually corresponding to the line made by the articulation of the vomer with the cartilage of the septum.
The oblique descending ridge will make either an acute or right angle with this line.
The sigmoidal is represented by a right (or left) horizontal deflection in the middle meatus, and a left (or right) horizontal deflection with the inferior meatus of the oppo- site side. Sigmoidal deflections may be horizontal or vertical.
The pyramidal deflection presents three or more planes, whose apex points either to the right or left. This method of classification has been adopted, to keep a record of operations with the saw or nasal trephine.*
Thus, if an operation with the saw or trephine has been performed on a nasal deflec- tion of the septum, we write —
It. H. D. I. M. f in. Trephine, or,
L. P. D. M. M. Saw, or,
E. V. D. total occlusion, Trephine No. 3.
In other words, we have operated with the trephine on a right horizontal deflection, which caused stenosis of the inferior meatus, and extended for two-thirds of an inch.
In the second case the letters express an operation with the nasal saw, on a left pyramidal deflection projecting into the middle meatus.
In the third formula we read that a complete stenosis was over- ly come by making an artificial meatus with a T\ in. trephine.
It will be seen that the deflections, except the sigmoidal and pyramidal, approximately correspond (considered geometrically) to the diameters of an octagon, and are most conveniently referred to in this manner.
* See paper, “ The Nasal Trephino and its Advantages,” read by the writer before the Section of Laryngology, New York Academy of Medicine, March 23d, 1S87. — A etc York Medical Journal, May 28tb, 1887.
SECTION XIII — LARYNGOLOGY.
51
Tbe deflections we are most frequently called upon to deal w ' tli are cartilaginous ; r they usually present themselves as horizontal or oblique ascending in the anterior nasal chambers.
Next in point of frequency occur the same deflections of greater extent, with bone in the posterior portion. Then follow in order of frequency of occurrence the vertical,
; pyramidal and sigmoidal. The oblique descending is most seldom encountered.
Rarely do we find a horizontal deflection which implicates the posterior border of the u vomer ; and bony deflections without implication of the cartilage are infrequently met with.
2. Hypertrophic.— The bony exostoses should be considered, though we do not find many cases of importance ; occasionally the middle or superior turbinated bone assumes an arborescent growth, causing pressure in the adjacent parts. The most frequent bony
: growth we encounter is a spinous process, which arises from the superior maxillary bone, and projects into and causes obstruction of the inferior meatus. This must not > be confounded with the nasal maxillary spine, which is frequently seen on one side.
with a dislocated cartilage in the other nostril. The septum immediately at its origin,
) at the anterior floor, often becomes thickened by cartilaginous proliferation, and may - present prominences, the size of a large pea, on either or both sides. These processes are made up often of a union of osseous and cartilaginous material, of the same con- 3 sistency as the ridges above alluded to, which form at the septal articulations. These ;. ridges are found to exist most frequently in the noses of those of a rheumatic or gouty J diathesis, and are generally associated with enlarged tonsils. There is always an i enlarged turbinate body in the inferior meatus, obstructed by such a tumor, the direct Tesult of the anterior stenosis. The tubercle of Zukerkandl must not be mistaken for a deflection or an exostosis, though it is often largely developed, and errors have arisen from its appearance. Far more often than the septal deflections and thickenings do we find nasal stenosis to result from enlargement of the turbinate bodies, and more especially the lower turbinate. This enlargement may be due to excitation of the erectile tissues for a considerable period, as we observe in workers in acid, wood sawing and metal filing, and also from exposure to certain dusts and pollens. This stimula- tion, as with snuff-takers, goes on until the contractile power of the tissues becomes lost, and we have a resulting enlarged turbinate body, either soft or hard, according to the amount of hyperplastic metamorphosis which has gone on. This condition, com- mencing with a dilatation, ends in true hypertrophy. These hypertrophic conditions are seen most frequently in middle life, and it is to be presumed that the decreased nutrition which supervenes on the development of true hypertrophy causes later a certain shrinkage, with consolidation of the material. Some nasal irritants, as acid fumes and pollens, tend to cause a primary excitation of the erectile tissues ; while others, such as snuff and menthol, cause contraction. But whether it be either con- tinued dilatation or contraction of the erectile tissues, the secondary effect will be an hypertrophy, as evidenced by the snuff-taker and the patient who has used cocaine for some time to counteract the disagreeable effects of a stenosis, as in hay fever.
3. Reflex. — Various reflex conditions have been proved to be the direct result of hypertrophies and erectile tumefactions in the nostril ; and, on the other hand, we may find the nasal erectile mucous membrane to be acted upon and enlarged by an excita- tion or irritation of a co-related area. In the female the erectile tissues ai'e distended during menstruation. By the irritation of the peripheral ends of the pneumogastric nerve in children suffering with worms, we also have a nasal excitation. These forms of nasal stenosis are not, however, origo malorum, and do not require our attention here.
Symptoms. — Nasal stenosis causes first a diminished air current in normal respiration, and is widened by a general malaise in the individual, from want of proper blood oxygenation. Sooner or later, to remedy the defect of improper oxygenation of the
52 NINTH INTERNATIONAL MEDICAL CONGRESS.
pulmonary air tracts, the subject becomes a mouth-breather. From the moment a person becomes a mouth -breather, two diseases, as at present classified, announce themselves; viz., a subacute catarrhal rhinitis, and a subacute pharyngitis, afterward becoming glandular. These in course maybe complicated with subacute laryngitis, Eustachian catarrh, bronchitis, hypertrophy of the tonsils, adenoid growths, caseous degeneration of the tonsils, catarrhal pulmonalis, etc., etc.
So many of the commonly encountered diseases of the ear, nose, throat and lungs have a symptomatic association with nasal stenosis, that it would be almost necessary to include an index of throat diseases. Why the profession at large do not and have not grasped this great truth is surprising. In many of the medical schools of this country the examination of the nasal passage is untaught, and among men with acknowledged ability in the practice of their profession, in New York City, many an error in diagnosis is corrected in the offices of our laryngologists. It seems a disgrace to scientific teaching, that patients suffering from a condition as apparent as nasal polypi, or almost complete stenosis from deflection of the septum, should he almost daily advised to go to Colorado or Florida to avoid phthisis. More good will be done to suffering humanity when the stethoscope is made secondary to laryngo-rhiuoscopy in the investigation of pulmonary affections. While briefly stating the symptoms of nasal stenosis, it is important to consider the fact that 50 per cent, of the cases which present themselves in our throat and ear hospitals are fit subjects for undergoing an operation for the relief of nasal stenosis. In looking over the reports of three of the large throat hospitals in London, we find that among 20,000 patients treated during the year 1886, less than one patient in 1000 was operated upon for deviation of the septum, and with t ie exception of one institution, viz., the London Throat Hospital, there was no attention directed to the use of escharotics to reduce enlarged turbinate bodies. At the London Central Throat Hospital, where Lennox Browne is making his name famous, the gal- vano-cautery takes the place of chromic acid, but the work accomplished is not as thorough. Woakes, though the first to recommend the free use of the nasal saw, seldom employs it in his clinic. It is easily comprehended, when one sees the thick- ness and clumsiness of the instrument, as compared with the saw of Bosworth, or the even more delicate saws manufactured for the writer, and known under his name. Notwithstanding the brilliant results obtained by the use of the nasal saw, in the cure of catarrhal symptoms from stenosis, nasal, pharyngeal and laryngeal, it requires some skill to properly manipulate the same in order to produce the best effects. Two distinct cuts are frequently necessary, and the angle of union must be carefully determined often in the presence of considerable hemorrhage. The saws which are most easily used, are the long, probe-pointed but very thin saws, with the bayonet handle parallel to the blade, the teeth on the upper or under side, as one wishes to cut either up or down; also the straight knitting-needle saw with double teeth.
These three saws will enable one to do all the work necessary upon the nasal septum, the needle saw being useful in making crescentic cuts. A very large experi- ence with the saw has taught the writer that the region of the inferior meatus is the important seat of operations, and in many cases, the reestablishment of the lower channel will be enough to give relief from nasal, pharyngeal and aural troubles, with- out attempting to reconstruct the entire septal anatomy. For those whose opportuni- ties for operation are frequent, and time is an essential factor, an instrument which is vastly superior to the saw is the nasal trephine of the writer, operated by means of a flexible cable communicating with an electric motor, water motor, or revolving wheel worked by an assistant. This instrument has been employed by me for several months, to the exclusion of all revolving knives, burr drills, etc., and has proved extremely satisfactory. By means of the nasal trephine, one is enabled to do many an excavation to relieve astenosed inferior meatus, when the ridges appear as a thickening to which
SECTION XIII — LARYNGOLOGY.
53
oue would hardly apply the saw, on account of the difficulty of making a good opera- tion. The instrument has been thoroughly described by me in the New York Medical Journal of May 28th, 1887, and thus i'ar, with a history of 75 operations, there is no i. modification which I can at present suggest. To any one who has had the continued j disappointments with the stellate punch of Steele, and Adams’ nasal forceps, that the | writer has experienced in the operation of septal deviations, the trephine must he hailed ) with delight. With trephines of this kind, varying in size from one-sixteenth to one- I iourth of an inch in diameter, one is enabled to do an operation in a few seconds.
which by other methods would take a much longer time. The free use of cocaine ; renders the operation absolutely painless, bleeding never obscures the view of the operator, and the result is always better than when the saw is employed. The cut being circular, a concave surface results, which permits more space than when a straight j -cut is made with the saw. It is possible to make an artificial meatus in case of total occlusion of the nostril, where the saw cannot conveniently be introduced. When the i perforation is complete, the core remains within the cylinder of the trephine, and is withdrawn with the instrument. Iu regard to the use of chromic acid for the treat- ment of those enlargements which occur, either as the result of a hypertrophy of the turbinate bodies, or as a dilatation of the same from a lack of vasomotor resiliency, I have no desire to retract the somewhat criticised assertion made by me' in a paper t read before the New York Academy of Medicine last April, in reference to nasal stenosis i from turbinate hypertrophies or enlargements, in which I said that so great was the importance, iu my estimation, of a reestablishment of the air current through the upper air passages, and particularly through the inferior meatus, iu the treatment of all affections of the pharynx and larynx, non-specific or non-tubercular, that I would not exchange the flat probe aud chromic acid, for the combined douches, sprays and therapy of the most complete laryngological establishment. There has been much t comment upon the claims put forth for chromic acid, but those who are adverse to it are those who do not use it properly. The acid should be permitted to remain in an open- < mouthed bottle and allowed to deliquesce; a drop of glycerine or a few drops of water i arrests this. The partially deliquesced acid should be reduced to a pulpy consistency, i containing fragments of the crystals, by rubbing up with a glass pestle. The thick mass t is then spread upon one side of a flattened copper applicator aud introduced. A good I rule to observe, is to only apply the acid to the pendulous portion of the turbinate bodies, i being careful not to touch the septum or floor of the nasal cavities; disagreeable symp- i toms often follow if the soft palate is touched.
Much more frequently are we called upon to treat in this manner erectile dilatations than true hypertrophies, our aim in these cases being to produce a cicatricial bandage i for the dilated erectile structure. That the turbinate bodies possess a normal erectile function is conclusively proven, but the word hypertrophy, used to express au altered I condition of this function without hyperplastic deposit, is, in my opinion, a misnomer The presence of a true hypertrophy is ascertained by the application of cocaine and chromic acid, neither of which contracts the hypertrophied turbinate body, but either drug causes the dilated plexus to contract at once. A true hypertrophy often needs the trephine for its removal ; it is hard and gristly to the probe touch, and is difficult of removal by chromic acid, and also with the galvano-cautery. Such a condition is of rare occurrence, though under the name of hypertrophies are generally described, in the current text-books, simple dilatations, which I have termed erectile tumefactions, in contradistinction to the true hypertrophies. An important point to be observed, also, in the use of chromic acid, is never apply enough to allow of its running. In my own practice I take a common copper wire, No. 14, about six inches in length, and flatten one end for about one inch. The acid is then smeared on one face of the flattened surface ; the application is introduced to about the middle portion of the lower turbinate
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body, and applied, as it is withdrawn, with a gentle brush motion. If, now, the erectile i tumefaction is well shrunken, and the surface is seen to be well “ burned,” we may 1 again anoint the applicator, and if we have observed, by rhinoscopic examination, I slight tumefactions on either side of the septum or posterior border of the turbinate j bodies, they may be likewise “burned.” Cocaine should be applied before we use the j acid and the application becomes painless. Unlike the action of the galvano-cautery, j there is severe pain often following the use of chromic acid, and ofttimes accompanied i by a slight depression, which has been wrongly described as chromic acid poisoning.
It must be remembered how frequently we witness such a depression following uvu- ] lotomy, more from an acute inflammation in the vicinity of ganglionic centres than from absorption of morbific products. After the chromic acid has remained in situ for some minutes, and before the patient has been allowed to blow the nose, it is desirable j to spray the nostrils with a Dobell solution, and to keep this up two or three times a day until the sloughs detach from the turbinate bodies. The absolute relief of nasal stenosis occurs when under no condition there can be contact of the turbinate bodies with the septum.
When the superior meatus is thoroughly free the middle meatus will in most cases follow suit, for it is principally by a deflection of the air current to the middle meatus which, a priori, has produced there the congested condition of the turbinate body and contact with the septum. There is no erectile tissue in the middle turbinate body, and enlargements of these are neoplasms or true hypertrophies.
The tissues of the middle turbinate bodies never shrink up upon pressure from a probe, as one frequently sees even in youug children upon making slight pressure on the anterior erectile structures of the inferior turbinate bodies.
Chromic acid alone has been spoken of in the treatment of turbinate stenosis, because it has advantages over all other means. The galvano-cautery is not as certain of accomplishing as much, as the effect is over on the withdrawal of the electrode, and to do sufficient work we must of necessity greatly alarm our patient. I have tried both methods, and the patient’s evidence is immensely in favor of chromic acid. NasaL surgeons have been accused of giving too little attention to therapeutics, and here I take occasion to give my evidence in favor of treating any stenosis of the third subdivi- sion, temporary or reflex, by doses of arseniate of strychnine, phosphide of zinc, aconi- tine, digitaline, etc.
This class of cases, however, seldom reach the specialist until they have, by an enervation of the vasomotor centres, entered the class of permanent dilatation and demaud local treatment.
For patients to whom I have made applications for simple dilatation I always pre- scribe a course of tonic treatment against recurrence; otherwise, there will be a return of the trouble within the following six months, which will necessitate another applica- tion of the acid. To sum up: the relief afforded to the various pharyngeal and laryn- geal troubles by the simple operative procedures necessary to overcome a nasal stenosis would take a volume. I will, however, close my paper by citing, in as few words as possible, some illustrative cases : —
Case i. — C. W. A.; November 6th; age eighteen; 121 pounds.
History. — Nasal catarrh; dry throat in morning; insomnia; constant cough; deafness on left side; tinnitus, not constant.
Examination. — Nasal stenosis, L. H. D.; glandular pharyngitis; bronchitis. Watch:
R. 32 ins. ; L. 4 ins.
Treatment. — Op. Saw. L. H. D. ; chromic acid R. I. T. and L. I. T. ; Politzer infla- tion and cleansing spray daily. (12 office visits.)
Result. — January 3d, Watch: R. 42 ins., L. 22 ins.; cough and insomnia cured; no
- - "
SECTION XIII — LARYNGOLOGY.
i trouble from catarrh ; glandular pharyngitis entirely disappeared; no longer a mouth breather; weight 124 lbs.
Case ix. — A. R. B. ; November 12th; clerk; age forty-five.
History. — Catarrh; headaches; nightmares; nervousness; cannot read, 011 account of t restlessness; vertigo during working hours.
Examination. —Stenosis R. I. T. and L. I. T. ; erectile tumefactions; subacute pha- I ryngitis.
Treatment. — Chromic acid to R. and L. I. T., at weekly intervals ; hygiene; brom- hydrate of quinine; cleansing spray.
Result. — January 12th, patient reported himself well and had gained eight pounds • in weight.
Case hi. — C. ; actor; age forty-one years; 182 pounds ; robust.
History. — Had “been off” for a year; voice never lasted more than ten days; had been treated with strong astringents daily for several months; severe catarrh and ten- dency to clear throat after a few words.
Examination. — Vocal resonance muffled; pitch lowered; could use low middle regis- ter, but broke on higher speaking tones; stenosis R. complete, L. slight; R. V. D. L. I. T. tumefaction; glandular pharyngitis; chronic laryngitis; rosy, fibrillated cords.
Treatment. — Saw, R. V. D. ; chromic acid L. I. T. and R. I. T.
Result. — One year has passed, and since restitution of nasal breathing has not been ' “off ” a night, though playing constantly,
Case iv. — A. P. ; actress; aged thirty; robust.
History. — Singing voice becoming uncertain; constant sore throat; takes cold easily; throat a source of constant worry; cannot rest, as engagements made for season; oppres- sion on chest; travels continually.
Examination. — L. P. D. almost complete stenosis; R. I. T. tumefaction; inflamed pharynx and larynx.
Treatment. — Saw, L. P. D. ; chromic acid; R. and L. I. T.
Result. — Seven months after operation: Voice has been in excellent condition; has not caught a cold nor had an attack of tonsillitis since the operation.
Case v. — C. B. C. ; bank cashier; age forty-six.
History. — Spasmodic asthma for eight years; never can go up stairs; obliged to use horse cars instead of elevated roads; always sleeps in an easy chair; has not been in i bed and slept lying down in five years; exhaustion on slight exertion; constant cough, with clear, gelatinous, starchy expectoration; frequently casts of smaller bronchi are i expectorated; very emaciated.
Examination. — Antemia; total R. and L. stenosis; R. and L. H. D. polypi; R. and L. I. T. hypertrophied; pulse 120; respiration 42; temperature 98; weight 129 pounds.
Treatment. — R. L. H. D. trephined; chromic acid R. and L. I. T. ; posterior fibroid tumor R. I. T. snared ; polypi snared ; deep inhalations of iodoform in ether spray daily ; milk, three quarts daily, in addition to unrestricted diet; digitaline, quinine and strychnine; treatment persisted in for two months.
Result. — -Sleeps all night, with mouth closed; asthma, except slight symptoms on catching cold, cured ; pulse and respiration normal; after six mouths, weight 154 pounds.
The above patient presented himself in my office, supported by two attendants, under the impression that his lungs were the seat of his troubles, and had long been treated under that assumption. Notwithstanding some apprehensions of collapse, I immediately trephined both H. D. of the inferior meatus, and relieved him of some polypi, leaving two hard nasal catheters, 9 English, in situ for the day. Then followed a series of operations with the saw, trephine and snare, requiring several weeks of attendance once in every three days.
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This case must be regarded as typical, in exhibiting a complete stenosis and the systemic derangement therefrom. There can be no artificial oxygenation from medi- cation that will so rapidly overcome an anaemia as the reestablishment of the nasal respiratory tracts.
THE USE OF RESORCIN (C6H4(H20)2) IN THE TREATMENT OF NASAL CATARRH.
L’USAGE DE LA RESORCINE DANS LE TRAITEMENT DU CATARRHE NASAL. UBER DIE ANYVENDUNG DES RESORCINS IN DER BEHANDLUNG I)ES NASENKATARRHS.
BY A. B. THRASHER, M.A., M.D.,
Cincinnati, Ohio.
The marked natural action of resorcin as a reducing agent has been pretty well demonstrated in diseases of the skin where there is infiltration of the corium.
It causes a shrinking or contraction of the epithelium so as to produce a true corni- fication of this layer. The deeper tissues are affected by the contraction of the blood vessels and a consequent stoppage of the nutritive supply of these parts. The experi- ence of Professor Unna, of Hamburg, seems to indicate that this contractile effect lasts for a long time, and may be due to the absorption of oxygen from the histological ele- ments of the tissues and vessels. This active affinity for oxygen may also explain the very powerful anti-mycotic action of the drug. The brilliant results attained in the treatment of parasitic diseases of the skin, notably herpes tonsurans, by Ihle, of Leipsic, indicate that resorcin acts not only by reducing inflammatory conditions, but also that it is a powerful specific antiseptic. From Ihle’s report* it appears that resorcin penetrates the skin deeply and destroyes the spores which have extended into the hair follicles.
Having the physiological action of the drug thus pretty well demonstrated, it occurred to me to try its action in certain forms of nasal catarrh.
There is a very obstinate rhinitis where the hypertrophy is uot great and the oedema is considerable, where the acute stage has passed and the hypertrophy is not yet suffi- cient to occlude the lumeu of the naris. The patient comes to the physician wit)* the story that he “takes cold ” very easily, and his nose is stopped up at night. Sometimes but one side is occluded, and then both, or more frequently the stoppage alternates from one side to the other. Questioning will generally elicit the information that at night when the patient lies on the right side of the body the right side of the nose is stopped, and “vice versa.” Examination of the nose usually reveals both nares more or less well open. If there is a closure of either or both sides a spray of two per ceut. solution of hydrochlorate of cocaine will cause it to open in a few minutes. It is in this condi- tion that I have found resorcin of signal benefit.
The use of acids or the gal vano -cautery or the snare will quickly remove the hypertrophy and cause the most urgent symptoms to subside. But it leaves over a greater or less surface scar tissue instead of the normal nasal mucous membrane. Resorcin accomplishes the same result as far as the subsidence of troublesome symptoms is concerned, and the nasal mucosa remains intact and is still capable of fulfilling its normal functions.
Given a case as described above, aud the daily application of a solution of resorcin
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will cause a whitening and shrinking of the swollen membrane, and a marked decrease in the action of the over-active mucous glands. The effect is somewhat similar to ; cocaine, with this difference, viz., whereas cocaine acts rapidly, and its action is over in a short time, resorcin acts more slowly, and its action extends over a very much i greater length of time.
The vehicle employed by me in its application has been either vaseline or olive oil, and the strength of the solution varying from two per cent, to ten per cent., in accord- ance with the amount of hypertrophy and the irritability of the membrane.
I first cleanse the mucous membrane thoroughly by throwing a coarse spray of the i following solution : li . acidi borici, sodii, biboratis, a a drs. ij ; 01. gaultheriae, gtt. ij ;
Aqute, Oj. Misce. Then the mixture of resorcin is put in an atomizing tube having a j large aperture, warmed, and the nasal mucous membrane drenched with the spray. The remedy is applied for the first week daily, to the cleansed mucous membrane.
After the first week the nasal atomizer every second or third day, and on other days the patient uses an ointment (two to four per cent, of resorcin in vaseline), apply- ing it to the nasal mucous membrane by means of a small camel’s-hair brush.
My notes on forty cases treated in this way show that ten were dismissed cured in three weeks, fifteen in four weeks, seven in five weeks, four in six weeks, and three in two months. One obstinate case, where exacerbations were frequent, and which would tolerate only the weakest solution of the drug, seemed not to be entirely well at the end of twelve weeks’ treatment.
These cases were all essentially chronic, having had symptoms of stenosis and an excessive muco-purulent discharge from one to ten years. Some of these patients, since their discharge, have returned, with attacks of acute coryza, which, however, have I readily yielded to the usual treatment given such cases. In summing up my experience with resorcin in the treatment of nasal catarrh, I would say : —
1. It is most useful in chronic nasal catarrh accompanied by oedema of the mucous i membrane without much hypertrophy.
2. These cases are, as a rule, cured in from three to six weeks.
3. Resorcin should be used daily in from two per cent, to five per cent, solution in ; vaseline or olive oil as a spray or in the form of an ointment.
4. Resorcin allays the oedema of the turbinated bodies, checks the over -secretion of the mucous glands, and leaves the membrane in a normal condition.
5. In acute coryza resorcin is not necessary ; in atrophic and in hypertrophic rhinitis : it is not useful.
6. Its good effects are due to its power of lessening the caliber of the hypersemic •< vessels, of reducing the oedematous and semi-hypertrophic mucous membrane, and of j hardening (tanning) the epithelial cells, and to its remarkable anti-mycotic properties.
DISCUSSION.
Dr. J. A. Stucky, of Lexington, Ky. , said — I desire to make only a few I remarks on the very valuable and practical paper of Dr. Thrasher. Two years i ago, I mentioned at the Kentucky State Medical Society my views as to the use of I resorcin in atrophic rhinitis. Since then I have used the remedy in the manner men- i tioncd by the speaker, but in much stronger solution. A five to twenty per cent, of ' resorcin, in equal parts of glycerine and water, applied ten or fifteen times, two or * three times a week, not only relieves the turgescence and tumefaction of the mucous membrane quickly, but in the large majority of cases permanently.
In hypertrophy or hyperplasia, a saturated solution of resorcin in glycerine and water, with five grains of cocaine to the drachm, applied by means of the cotton- ri covered probe, affords a quick and satisfactory cure, if the hypertrophy is not too
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NINTH INTERNATIONAL MEDICAL CONGRESS.
large. The rapid oxygenation of the tissues caused by the remedy produces some pain, but lasts only a moment. After the application of resorcin, I think the parts should be covered with spray of an oleaginous, soothing substance, either vaseline or olive oil.
In the absence of Dr. F. Semeleder, of Mexico, Dr. S. N. Benham, of Pitts- burgh, was appointed to read his paper, entitled —
TWENTY YEARS OF LARYNGOSCOPICAL WORK IN MEXICO.
VINGT ANS DE TRAVAUX LARYNGOSCOPIQUES AU MEXIQUE.
ZWANZIG JAHRE LARYNGOSKOPISCHER THATIGKEIT IN MEXICO.
BY DR. F. SEMELEDER,
Of Mexico.
When, in 1864, I came with the Emperor Maximilian to this country, laryngoscopy was still unknown here, so it took that then new branch of medicine six years to cross the Atlantic. The physicians of the country had then no scientific intercourse with any other country but France. Whatever was done outside of France no notice was taken of until it became known through the mediation of French books or papers. The United States was then, practically, far more distant than France or England; railways did not exist here, nor direct steamship communication. It was a great deal easier to get anything from France than from New Orleans ; the English language was hardly appreciated or cultivated among the profession, and German was altogether neglected.
I had then already published a monograph on rhinoscopy and the first manual of laryngoscopy,* both considered in one volume, and translated into the English language by the now deceased Dr. Edw. T. Caswell, of Providence, E. I. ; published by W. Wood & Co., New York, 1866.
Since then I have occasionally practiced laryngology and rhinology, and propose, in the following, to give a brief account of my work.
The only Mexican publications on the subject I am aware of, are: “La Laringo- scopia,” etc., por Angel Iglesias, printed in Paris by Rosa & Bouret, 1868; and a translation into the Spanish language of my first two cases of “ Extirpation of Laryn- geal Polypi through the Mouth ;” f besides a verbal communication to the Academy of Medicine of “A Successful Extirpation of a Papilloma of the Vocal Cords per Vias- Naturales.”
Taken as a specialty, laryngoscopy in this country was certainly a most ungrateful business, and would hardly pay one’s house rent.
Laryngeal affections are comparatively rare here, owing to the mildness and equa- bility of the climate.
Acute and subacute laryngitis are common ; the chronic form is rare. (Edema of the larynx I only observed in one case, where laryngotomy was performed by a friend of mine, and with good results.
* “Dio Rhinoskopie,” etc., Leipzig, W. Engelmann, 1862; and “Die Laryngoskopie,” Wien, Wilh. Braumiillor, 1863. f Gaceta medica de Mexico, V ol. IV, No. 6, 1869.
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Tuberculous laryngitis I saw iu five cases ; three of them were laryngotomized by me, with immediate good result ; two of them died later on ; one left the city for his home and, probably, must have died. In none of these cases the pulmonary affection was much advanced at the time wheu surgical interference was required, to prevent choking.
Of syphilitic laryngitis, I have seen a number of cases iu different stages. Laryn- gotomy performed in eleven cases, with good results.
Diphtheria is happily rare here. The Mexicans pretend that it was altogether unknown here until about 1860 or 1862. We had two epidemics, pretty severe ; now for several years past we had only single cases. I have performed laryngo-tracheotomy for croup iu two cases, both unfortunate as to the liual result.
Motor affections I observed in three cases of paralysis without appreciable causes, if not oedematous infiltration of the bands and the mucous membrane ; in a fourth case the paralysis was due to aneurism of the arteria auonyma.
Benignant tumors ; only three cases belonging to Mexicans. I saw several more, but the patieuts were foreigners, and all but one only transient in the city of Mexico. On a young German I performed extirpation, per vias naturales, of a papilloma of the left vocal cord. Result good ; singing voice reestablished.
Of people of the country, I only know of two cases of papillomata of the vocal bands. The first I saw in 1868 ; woman, thirty-eight years old ; papilloma, the size of a mul- i berry, left vocal band ; extirpated per os. The second case, a man, presented himself in 1885 ; twenty-eight years old ; two papillomata, the size of a pea each, one in the anterior angle and the other on the lower surface of the left vocal band, about its middle ; both extirpated per os, the latter with some difficulty. The patient had repeatedly, before he came to me, when he had spells of coughing, expectorated small, fleshy particles of the tumors and a few drops of blood.
I In one case, a lady of about forty years, whom I saw only once, I observed on the left vocal band a flattish tumor, size of a cherry stone, bluish, which I took for a varix. The lady did not like to have anything done to her tumor, and left town at once.
In two cases, one a young man,