adenoids stammering tonsils

PART III
DISEASES OF TH E RESPIRATORY TR ACT
GEN ERAL DI SCUSS ION
Certain st r u ct ura l p eculi ariti es d et ermin e th e cha rac te r o f the
di sea se s t o whi ch the r espiratory tra ct is s ubjec t. The a ir h ould,
normally , pa ss into th e lun g s by way o f th e nasal passages. T hese
ar e tortuou s and a r e lin ed w it h a m oi st cilia ted epi t he liu m. Thu s
tlie air is clea ne d. w arm ed a n d m oi st en ed b e fo re reaching th e
more d eli cate ti ssues o f th e lun g s.
I n the upp er r espirat ory t ract th e mu cou s m em bran e is
atta ch ed rath er loo sel y to th e und erl yin g b on es . It is h ighl y vascu lar and the bl ood ye s els a re co n trolle d fr om th e vaso mo to r
centers in the upp er th ora ci c s p ina l column , I,y w ay o f th e ce rv ica l
and cra n ia l sy mpat h ct ics. Th e lymph -flow d ep ends up on the circu lati on . The nutriti on o f a ll th ese ti ssu es is controll ed l.y th e
sa m e nerve m echanism .
Bact eri a and du st a rc u su all y ex pe lle d t hrough th e ac t io n o f
th e cilia and o f th e se cre t io ns. Infection s age n ts m a y . h o w e ver,
gain en t ra nce by w a y o f in juri es . o r as th e re sult o f im ped ed c ircul atory co n d it io ns. Bon y lesion s of th e cerv ica l and u p p er do r sal
regi on a re important fact ors in m odi fy in g th e ci rc u la t io n and lo w er ing th e reoist an ce to infecti on .
"The n er ve mech an ism s in the r espir atory field . from their co mp le x ity
and co mparatively close relations to grosser structures, are more usceptible to
lesion , an d will how g reater pathologica l effect. from lesion of slight degree.
th an pe rhaps any ot her part of the body, T he cranial and u pper spina l nerves,
cerv ica l a nd d or sal , are affected hy slight derangement of vcrtchrre or r il« or
th eir m u scul a r o r ligam en tou s a ttach me nts. The sympathetic chain lie in e10 c
r elati on to th e anterior as pec t of the later al spi nous pro c . cs, and th e h ead s
o f th e r ihs, an d in the dorsa l r eg ion is bound down hy the pleu ra to th e
spino us processes a nd to th e head s of the r ibs. Nearly all t hese n er ves con ta in
fiber s of vasomo tor fun ction. w hic h arc r ath e r widely d istr ibu ted in a so rt of
'cr o sv-rcfcr cn cc' m ann er. . . .
lesion at any poi nt may affect anyone
o f a number o f st r uc t u res , o r a g ive n pathol og ical con d itio n m ay be du e to
lesion a t anyone o f severa l po ints."-C . ~1. T . Hul ett.
"T he lun g s r ecei ve vasomo to r impul ses hy way o f t he foll owing str uc tu res:
Th e wh ite r ami co mm unica ntes lea vin g the cord wit h th e seco nd to th e Ii fth
dorsal nerves (prob ably chie fly th e th ird a nd fourth ) . then throu gh th e lntc r a l
r ha in o f syrn pa t he tics to th e ce rvical ga ng lia. in one of wh ich a rel ay is ma de :
then by g ra y fiber s to th e vagus, wi th w hich th ey a re ca r rie d to th e pulmo na ry
plexu s. V aso -co ns t ricto r impul ses ma y he in cr eased r eflexl y hy th e sti mu lation o f senso ry ner ves enrlinp in th e tissu es n car th e secon d to th e Ii fth do rs al
spines. Va so- con strict or imp ulses ma y he decr ea sed by lessenin g the senso ry
impulses by stea dy pressure upon the sa me ti ssue s.
181
182
THE RESPIRATOR}' TRACT
"Osteopathic inhibition imitates the conditio n pr odu ced by the bon y lesion
and the muscular contraction; hence the in fluence of these in p roducing ch ro nic
pu lmonary congestion.t'-c-Pearl A. Bliss,
The ne rvo u co ntro l o f the circ u la t ion through the u pper lobe
of the lu ng s is fr om th e second to the fourth spina l egment - and
for the lo wer lobes, from th e third to the fifth . Di sea e a ffect ing
th e upp er lobe o f th e lungs give reflex mu scular contracti on s o f the
u pper th oraci c segme n ts, while diseases o f the lower lobe gi ve
r e flex mu cu la r contracti on s inv olving th e fo u rt h to the seventh
th or acic eg me n ts. A ce rta in degree o f locali zation o f the injured
a rea may be m ade in thi s w ay ,
The 'circul ation through th e lungs is prof oundly m odified by
va r ia t io n in th e syste m ic bl ood pres ure. \\'h en any great area
of th e syste mic ar te r ia l syste m is dil at ed. a for example, the
sp lanc hnics, th e lung s are left co mpa ra t ively i che mic. Th e pl ace
of a bdo mi na l co nge ti on s in modifying the circulation a nd the
nutriti on o f th e lun g s is tim evid ent .
T he act ivities of th e r espirat ory cente r are m od ified by va r ia ti on in t he circ ula ti ng bl ood a nd by em oti on al sta tes. 130th th ese
fact ors ma y be important et iolog ica l fa ct ors und er cer ta in conditi on s. Th e turg idity of th e na sal m embran es durin g th e influ en ce
o f emo t ion s is we ll kn own , a nd , und er rep eated o r co ns ta nt ernoti on al exc ite me n t . m ay b ecom e eff ecti ve in p rom oting mou th b reat h ing, w it h r esulting irritation o f th e lo wer r esp ir a torv tract
and vario us d is t u rba nces of th e na sal m em br anes. \\'h en e\ 'er rc...pirat ory va r ia t ions a re noti ced , an investigati on o f th e habit s of
th e pa t ien t . es pec ially o f th ose h abit s usuall v a ssoc ia t ed with emo
ti onal stress, sho u ld be ca refu llv m ad e. a nd t rea t men t of u ch ca e.
sho u ld in clud e th e co rrect ion 'o f bad habits as well a of Iaultv
bodily st ruc t ure,
'
CII.\PTER
D L E. \
E~
xvnt
O F TIlE . ' 05E
ACUTE RHINITIS
( Ac ute nas a1 catarrh ; acute co ryza ; "cold in the head")
Acute rlunit is i~ an acme cat arrhal inrl amm at iun o f the nasal
111 UCOU' membran es cha rac t eri zed by head ach . sl izht Iever, sneezing-. and dryne s o f nasal membranes. foll owed by a b u n d a n t secreti on.
Etiolo g y . The m o st common etiol ogical fact or is mu scular contra ct iou-, along the spine. These may be caused by cold draughts
o n the back o f the ne ck. gastro-inte"tinal irritation. etc ., o r by subluxarions of the upper cervical, third to se ven t h dorsal, o r the
lurubo-sa cral vert ebrre. I nfection by the microc oc cus catarrha li s
i, rc-pousihle for epidemics. Staphyl ococcu s or treptoc oc cu s or
both. m ay be present. It mu st be remembered th at the symptom, of acute rhinitis occ ur in t he initial stages o f ce r ta in o t h er
acute infectious di senses.
Dia gnosis. The condition is p receded by la s itudc, wea riness,
m ore o r Ic" he ada che . and sneezing. these fo llowed by chilliness.
then ,light fev er. 100 0 t o 101 0 F., and dryness o f the nares, This
'tag-e i, foll owed In' abundant watery saline secretion fr om the
no-t ril- and a sen e 'of fullness in the nose, which mav be 1110mentaril, reliev ed by bl owing the no 'e.
'
The anteri or nares are red and the eye - are suff'u-cd . Later,
the di-charve bec omes purulent. The vo'ice is peculi ar. na sa l and
mu ffled. \\hen the atta ck is nearing rec overy. hard crusts form
o n the septum and turbinate, a nd are expelled with difficulty. The
compli .a t io n s vary in intensity , Labial. m ore rarely n asal. herpes
mav occ as io n considerable discomfort . Extension o f the inflamm ati on t o the a ccesso ry s in u ses and ad jacent tis sues is frequent.
I f to the front al. ethmoid al. o r sphenoidal s in u se s , th ere is seve re
hcad ache : if to the antrum o f II ighm ore. tendern ess oyer the
cheeks : if to the Eustachian tub e" and middle ear. temp orary
deafness results: if to the pharynx o r larynx . cough result s. Conjunct ivit is i s less frequent. Chronic rhinitis is apt to foll ow
repeated attack",
Treatment. Correct lesi ons o f the cervical spinal co lum n especially : correct mandibular lesi ons, Careful w ork o ver the supe rio r
cerv ical gland" promotes dra inage. St imu lat ine treat men t oye r
the branches o f the fifth nerve. 'p ring-ing the m a nd ibl e . and pre sure o v er the u p p er part of the nose. sudden ly rel ieved, are all
1
184
THE NOSE
u ef ul palliative measure. I n some cases of st rep tococc u infect ion the treatment may be tediou s.
If the accessory -inuse- become infec ted expert consultation
may be required, though many case clea r up by ca refu l o. teopathic
treatment.
"Secure tempo rary relief from the genera! cont ractions in the spinal musculature. For this, the familia r 'Dana bend' may answer or any forcib le
hyperflexion of the spine ca refully and gradually app lied. * * * Relax
general spinal contractions; treat regional contraction apparently iuvolved :
relieve the head congestion by securing relaxation of the supra- and in frahyoid muscles; treat upper cervical articulations; avoid sudden force; leave
no contractions; vary the order of procedure if anyone co ntraction g roup
fails to rela x. If a muscle is hurt or an importan t ir r itab le lesion is ove r looked, fai lure is usua1."-]. A. MacDona ld.
A few meal s om itted, a fruit or milk or ve rv rest rict ed diet,
plenty of hot d rinks to pro mo te dia ph oresis a nd' clea ns ing of th e
bo wel s, out-doo r life, mod erat e exe rc ise, plenty of un shiu e promot e spee dy recover y a nd pr event relap se.
Prognosis. If taken ea rly, o ne t reatm ent ofte n suffices to
relieve th e co nd it ion and co m ple te recovery follow w it hin a
sho rt t im e. In ve ry yo ung infant s, 10 s of flesh a nd st reng t h may
follow from inability to n ur se.
CHRONIC RHINITIS
( Ch ro nic co ryza; ch ron ic nasal catarrh)
Chro nic rh initi s is ch ronic inflammat ion of th e nasal mu cosa
pro d uc ing st r uc t ura l cha nges a nd cha rac te rize d by a feeling o f
full ness in th e nose, " haw ki ng," a nd th e di sch ar g e of a thick
mu co-purul ent sec re tio n.
Etiology . R ep eat ed a t tacks of th e ac ute form; co ntinue d inhala tio n of irritat ing vapo rs o r du t ; chronic s ubluxa tio ns of the
cerv ica l a nd u pper dorsal ve rte brre, th e r ibs, a nd th e m andible are
t he most frequ en t ca uses.
D ia gnosis. T hree form a re recogni zed , whic h a re often three
stage in th e progres - o f th e di ea e in one pe rso n.
Simple chronic catarrh is a n ea rly stage mark ed by liability to
" ta ke cold," whe n th e mu cou m em br an e spcc d ily beco mes co ngested a nd swolle n. Occasiona lly ste nosis follow , a nd a n overab unda nt thick sec re t ion . If it pe rs ists, it develop into the
secon d stage, hypertrophic rhinitis. I n th is fo r m th e lo wer turbin at es a re swolle n a nd enla rged. th er e is a co ns ta nt "h a wking"
to rem ove t he thi ck sec re t ion, a nd th e pati ent becom e more o r
less a mouth-b reath er. Th e phary ngeal a nd ade no id t issu es ma y
becom e coinc ide nta lly affected ( naso-pha ry ng eal catarrh) . The
voice becomes nasa l an d va ry ing degrees of deafn ess occ ur.
Atrophic rhinitis may follow th e hyp ert rop hi c, hut is not neee sa r il y a seq ue nce . T he m uco a is hrun ken a nd at rophic p ro -
CHR O.VIC RHINITIS
185
ducing an abn ormal roominess in the nasal cavity . Cru st s o f
di sgusting odo r (oz ena) a re fr equ ent ly present. In any o f th ese
form s , sudde n cha nge in th e w eath er is liabl e to ca use an ac ute
ex acerbation . Rhin osco pi c ex amination shows the c ha rac t er ist ic
structure of th e m embranes.
Treat ment. "Th er e a re two principles of treatm ent in ca ta r rha l
condition s: First, rem oval o f th e ca us e o f overgro wt h o f ti ssue
a nd o ve rst im u la t ion o f fun cti on. Second , th e in stitution of m ea sures to a bsor b so me pa rt , if possi bl e, of th e exce sive co nnec t ive
ti ssu e a lrea dy fo rme d , a nd to rest ore norm al fu nc t io n to suc h
cell s o f high er typ e as ha ve not s uffe red irrepa rab le inj ury. Th e
hygi en e o f th e indi vidual d em and s ca re fu l attenti on . Thi s in clud es
t he closest investigati on o f th e h abits o f relax ati on, bathin g , slee pin g a n d dre . S exu al per ver sion s a re to be cons ide re d, bea rin g
in mind th e reflex es fro m a n ad here nt clitoris or prep uce. El imin ati on mu st b e carefully wa tc he d a nd th e kidn ey , liver , pan cr eas,
and inte tin es m ay ha ve mu ch t o t ell.
"Th e first hint o f diab et es o r Bri ght's di sease m ay be g ive n by
th e dry . sc ra tc hy feel of th e mu cou s m embra ne o f th e throat. * * *
R elax at ion ca n be main tai ne d bv aid o f either hot or co ld co mpresses o r w arm bottl es, w hi le we t pack s o f va rio us tem per a tures
and full bath s a re o fte n u seful to p rom ot e elim ina t io n. Local
dou ches o f norm al sa lines a re indi cat ed at tim es. es pec ially in
oze nic a nd a t ro ph ic co nd it io ns w it h c rus t fo rma t io n. Th eir use
is rar ely ju st ified in ac ute. non-purulen t disc ha rges. * * * Co pious
drink s o f w at er, eit he r hot o r co ld . so me t imes d i ti lled a nd o fte n
acidul at ed. a re indi ca ted for elim ina t ive rea son s. Fruit jui ces a re
al so h elpful.
"To co n t ro l th e n eg ati ve pressure co nd it io n , co nse rva t ive s urg ery mu st b e e mp loyed w hen in di cat ed .
"1\ ft er th e co rrec t io n of a ll a b no r ma l ph y sical re la t io ns a nd th e
applicati on of uch rem ed ial m easures as arc indi cat ed in each
case . the next s te p is th e ed uca t io n o f th e pati ent in cor rec t habits
o f sit t ing. s ta nd ing, wa lking, a nd br eathin g'. wit h pr escripti on o f
specia l exe rc ise for th e co rrcct iou o f wea k st ruc t u ra l co nd it ions."
- Ma ry S. Cros well.
Progn osis. R ecovery is to be ex pec te d in th e s im ple ca tar rha l
form. Symptom ati c recover y m ay occ ur iu th e hypertrophi c and
atrophic form s, th ough very o fte n th e path ologi ca l ti ssu es remain
a so u rc e o f irritatiou throu gh life. Th e di sea se docs not . ce rn t o
hort en lif e, but it vc rv m at eri all v lessen s th e com for t a nd efficien cy o f th e pati ent , and it is a n important ca use o f deafn ess.
NASAL POLYPS.
na sal membranes. a nd re
or serous, accordin g to
mu cou s sec re tio n within
Th ese are pedun cul at ed tum or s whi ch g row fr om th e
tri ct the air passages. Th cy arc called fibrou s, mucou s
th e preponderan ce o f connec tive t issue , se ru m, or
th eir sacs.
186
THE NO S E
The mem br an es o f th e nasal pa ssage a re rath er loosely bound to the underlying bon es, a re highl y vasc ula r, and both th e membrane s and the vessels a re
fr eely suppl ied with se nso ry and sympa thetic ner ves. Di sturbed inn er vati on
or nutrition o f th e membran es o r vesse l wall s permits an ov er fillin g o f the
lymph spaces and th e blood vessels; th ese factor s ar e due to repe at ed a tt acks
o f rh initi s ; th e inh alati on o f irritat ing gases or du st ; and es pecially to bony
or othe r lesions o f the man dibul a r , hyoid or cer vical areas. \V hen th er e is a
loss of tone of eithe r vesse ls o r mem bran e. the weight a nd th e neg ati ve pr essure thu s estab lished pe rmit furt her dr opping , th e loosen ed mem br an e fills
cr nstantly, and thi s weight acts as fur th er ir r ita nt. \ Vhether the tum or mer ely
fills with lymph and blood seru m, or wh eth er mu cou s cells are plentifully
included in the a ffected t issu e, o r wheth er th e conn ect ive ti ssue cells, having
exce llent op portu nity, un duly mu ltiply, is due to st ructu ra l relat ion s of the
parti cul ar a reas affec te d.
Wh en the polyp ha s becom e recogni zabl e, its su rg ical rem oval is indi cat ed.
If thi s is all th at is done, lat er g ro wths ar e very apt to appear. But if the
factor s respon sibl e fo r th e gro wth a re rem o ved-bon y lesion s, especially-t he
g ro wth o f success ive crops of polyps shou ld be prevent ed. A fte r any polyp
ha s been rem ov ed , os teopathic tr eatm ent for th e rem oval o f lesion s as found
should follow imm edi at ely. and th e pati ent sho uld be exa mine d at int er val s for
a yea r or mor e, in order that furth er injury to th e membrane may be av oided,
RED NOSE. Th e nose is subjec t to cons ide rable vari ati on in cir cul at ion.
So met imes th e dilatation of th e bloo d vesse ls, especially near the end o f the
nose, causes g rea t an noya nce to t he pa tie nt. .'or rnally, th e nose is rath er paler
than th e rest o f th e (ace, ev en dur ing blu shin g. Th e most co mmon ca use of
red nose is th e use o f a lcoho l; and thi s fact , whi ch is g en er all y r ecogn ized, is
respon sible for mu ch o f the discomfort th at att end s th e pr esence o f red nose
in temp erat e ind ividu als.
Oth er com mon ca uses o f r ed nose includ e : go ut ; nephr iti s ; sex ua l disturbance s; over ea ting of anyone article o f di et , as sweets. sta rches, meat s, past ries ;
th e use o f excessive amo unts o f spices, tea , co ffee, tob acco, and "so ft dr ink s,"
especially of the sweet vari eti es ; chro nic rhin iti s, and certa in loca l a ffect ions,
as ecze ma, etc. Occas iona lly no cause can be found , th ou gh th e no se is as red
and rou gh as in habitu al alcoho lics.
The place o f th e bony lesion in th ese cases has been found im por ta nt in a
few cases. Th e struc tu ra l cha nges assoc iated with red nose are so pro fo und,
how ever. th at th e co rrectio n o f th e lesion s is effectual in lead ing to relief of
the cond iti on on ly in mild cases.
The treatment co nsis ts in th e r emoval o f the caus ative factor s, for the
most pa rt. Local ap plicat ion s o f soo thing oint me nt and ve ry mild as t ri nge nts
may g ive so me reli e f. It is neces a ry to a void anything irritat ive, lest the
late r conditi on be wor se than the first.
HAY FEVER
(Rose or J une cold ; a utumnal ca ta r rh)
H ay feve r is an affec tion of t he upper air passagcs d ue to th e
effects, probably toxic or anaphylactic, of certai n pollens acting
up on a hypersen sitive mucou s membrane, characteri zed by sneezing, increased lachrymation, headache, and a watery nasal dis charge.
Etiology. I t seems to be a neuro tic id iosync ra sy ma nife te d
as a morbid sensit iveness of the na sal mucosa to the action of the
pollen of gras es and of certain plants, sometimes of du st. Sub luxati on s and contraction s are found from the atlas to the fifth
H A Y FE VE R
187
dorsal vertebrre and the upper three rib s, a nd clavicl e. Local
disease of the na sal membrane may be re sp on sible.
Diagnosis. Th e co ndit ion begin s a s an ordina ry co ld ; sneezi ng
is ver y frequent ; th er e is more or less he ad ach e and di str ess ; t he
pati ent becom es low - spiritc d : co ug h is co m mon; the eyes are
wat ery, with it ching a nd sma rt ing es pec ia lly at th e in ner cant h us;
a sthmatic attack s are co m mo n and may a lte rna te with th e hay
fev er. T aste, sme ll, and hearin g are im paired . A n a ttac k usu all y
la st s four to 'six w eek .
Treatment. Th e care o f eac h indi vidu al mu st be b ased upon
th e resul t s of per son al st u dy. P rob ably no 111"0 peop le are affec te d
in exact ly th e sa me way , nor is th e et iology th e sa me in any
great number o f case s. Th e et iolog ica l fact er mu st be rem oved
a s fou nd . if r ecover y is to be perm anent. Correct ion of th e cervical
and upper th or acic bon y lesions result s in recover y in certa in ind iv idua ls ; rem oval o f na al deform it ies is necessar v whe n th ese
exi st; so me cases are esse nt ia lly neuroti c, and th e treatm ent mu st
be dep endent up on th e con stitutional find ing s ; in eve ry case it is
n ecessary to find the e sc nt ial ca use o f th e neu ro sis, if possibl e.
'Th er e a re m an y peopl e w ho ca n only be sen t to a po llen-free
locality every yea r. Relief of th e a ttac k m ay be sec ure d ve ry
ofte n. by special manipul ation s.
"T rea tme nt cons iste d in tr acti on to left for fr eeing r ight nasal arte ry and
tr action to right to fr ee left ar te ry. Thi s gave local relief . th ou gh 1 ha ve regarded freeing ten sion around axis and atlas as the curative t reatmen t."E lla \{, Gilmou r.
" I firmly believe the typical ca e will never fai l in respond ing to the vasomotor reflex existing between the tenth dorsal and the Schneiderian membr an e. Thi s reflex 1 excite by having th e pat ient lie on sto mac h on ta ble. and
ex erting deep stea dy pr essu re ove r tenth dor sal spinous process (s t rad d ling
process with end of th umb. and firs t finge r flexed at first distal joi nt)."-A. 1\1.
Sm ith .
" Whi le tr eat ing hay fever this season. I found that fifty per cen t o f the
att acks cou ld be ar rested by sof t pa late manipul at ion alone; and in those cases
whi ch d id not respond . the cond ition wa immediately relieved by a dilata tio n
of th e epi-na ris, with th e intra-nasa l techn ique. . . . H o wever . both o f the
local tr eatm ent s we re supported hy a dail y norm al sa line ir riga tion o f th e naso ph ar yn x . and the adjus tment of t he osteopat hic lesio ns."-]. D. E d war ds.
J. Deason reports excel lent resu lts from na. al ir rigation with hot 1';'
so lutio n of sa lt, borax and soda. 3-2- 1. beg inning at 1080 F. and rai sing to 1170
o r eve n highe r. One to five qua rts of wate r shou ld be used at each irrigation.
and II non -ir r itant lubr icant. as cho nd rus je lly. appl ied af te r t he ir riga tion.
" Digital tr eatment o f post -n asal region throu gh pha ryn x is goo d. Pre ssur e
o ver termin al s o f fifth and othe r senso ry ner ves-c-on e finger in nares, thumb on
outsid e-con tr ol s attac ks."-] . Deason .
Prognosis. " 'h en th e treatm ent can be b egun befor e th e
sy m pto ms have a ppea red, th e progn osis is good for pr evention .
After th e cha rac te r ist ic sy mpto ms ha ve appear ed. relief may be
secu red. In very ob stin at e ca ses, chang-e o f climate for on e or t\VO
summe r ma v be ne ce ssar y. P er sistent treatm ent in th e interv ening month s sho uld result in ob viat ing thi s need .
CHAPTE R X IX
ADEl TOIDS AND 'TONSI LS
ACUTE TONSILLITIS
(Acute arnygdalitis ; follicular tonsillitis; parenchymatous tonsillitis; he rpet ic
tonsillitis)
Th is is an ac ute in fla m ma t ion of one o r bo t h ton sil s, affecting
va rio us ly t he ton s illar lay ers, and res ulti ng in more o r less p ermanen t inj ur y to the to nsi l affected . The inflam ma t ion is of a
si mp le pa renchym atou s ty pe wi t h mar ked co nges tion of the
g la nds , hy per plasia of t he lymphoid eleme nts, ex uda tio n and desqu am ati on of th e epit he lium.
Etiology. P redisp osin g cau ses a re lesi on s of the cervica l ve rtebr re, eithe r as a co ns ta nt condition o r th e result of trauma.
Mouth brea t hing a nd malnutrition of any kind lower resist an ce
to in fecti o n. Excit ing fa ct ors a re pyog eni c bacteria, exp osure to
cold , a nd trauma.
Diagnosis. The onset is usually sudden, wit h chi lliness o r
chi ll, fever (102 to 103 F.). full freq ue nt pulse, headach e, ofte n
fro nt al , tongue coated, breath fetid; t hroat, hot a nd d ry . The
g lands at the angle of t he jaw are enla rged an d the re is pain on
moving the jaw or swal lowing. R eflex con t ractions affec t esp ecia lly the hyoid group of muscle, t he ante rio r cervical g ro up, a nd
the uppe r thoracic spinal muscles. The skin of the neck a nd over
t he angles of t he jaw, as we ll as t he t issu es associa ted wit h the
muscles named, are hypersensitive to pressure and to co ld.
In pection revea l the ton ils greatly swolle n and red, covere d
wit h a creamy mu copu s, o r, in the follicular form , t he surface is
covered with yellowish rounded masses of secretio n prot rudi ng
from the mouth of t he follicles.
I n some cases the tonsi l may be covered wit h a d irt y-y ellow
membrane which strips off readily. The fever u ually s ubsides by
crisis on the third or fourt h day and reso lut ion takes place . Occasiona lly seq ue lm follow as pneu mo nic o r rh eum ati c fever, a cute
neph ritis. endocarditis, perica rditis, an d otit is media.
Cultures should he made to disti ng uis h th is disea e from dipht heria. In herpetic tonsillitis, vesicles appea r o n t he surface of th e
to nsil. T he pa in is very severe , a nd t he co ns tit utiona l sy mpto ms
are intense, ap pa re ntly out of propo rt ion t o th e local lesions.
L eu cocy tosis is usu all y present in a ll fo rms of ton si lliti s.
"T reat ment, "Adj ust th e inf eri or ma xill ary bone. See that
t he st ructures between it a nd the upper ce rv ica l vcrtebrm ar c
188
0
0
AC UTE T ON SILLITIS
189
set fr ee on bot h side s o f the neck. * * * Adjus t w ha teve r slig ht
irreg ulari ti es you find in the cer vical and upper dor al regi on s.
B ri ng you r cla vicles w ell up and forwa r d. Look ca ref ully to your
u pper fou r rib s, a nd see th at th ey are pe rfectly adj us te d t o your
st ern um and spi ne. Free the hyoid hon e fro m any co nt rac te d
mu scles w hich could bind it. * * * Th en go to th e lumbar regi on and treat th er e t o ope n up th e exc reto ries. See th at th e lumbar verteb rre are in lin e, and th at th e float ing ri bs a re well up
a nd in th eir proper pl ace. Do all yo ur work in th e neck regi on
fr om the outs ide. "- A. T . Still.
"The first effort at tr ea tm ent was direc te d to th e rel axation of cer vical
and dor sal musculature; th en ge ntle, ca reful effo rt was made to secu re movement at fifth cer vical.
" N ext, light local tr eatm ent was give n to eac h tonsil. Besides re mov ing
ob struct ion to the lym phat ics and other vesse ls, the local tr eatm ent forced fro m
t he cry pts con sider able of th e muco-puru len t ma te ria l. pa tient clearing th roat
a ft er eac h atte mp t. E ach ton sil was tr eated in th is way three tim es. A cold
compress was placed a rou nd th e throa t and pa tien t was advise d to ga rg le with
hot no rmal sa lt so lution seve ra l tim es during the night, if aw ak e ; he was
directed to tak e all th e wa te r he wanted, bu t no food . . . . I nst ructions
wer e g iven for colon irri gati on , patient af te r wa rd sayi ng that con sider ahl e black.
o ffensive smelling feces was passed . Urin e was normal. . . . Lat er , mor e
norm al mot ion was secured at poin ts o f bon y lesions ; pa t ient felt ve ry well.
.
Th e local t reatment to th e ton sils wit h th e removal of infect ious mat erial lodged in the cryp ts. is im portant. Tr eatment to the lesion s present was
very light and non- irr itatin g."
" In all acut e in fec tions such as ton sillit is. I pay ve ry close attent ion to th e
lower dor sal region. with a view to no rma lizing the vaso -moto r control to the
adren al bodies, believing as I do t hat th e liberat ion of thei r sec retion g reatly
aug me nts th e auto-protect ive for ces of the body. I a m thorough ly convi nced
th at ton sillit is both acut e and ch ro nic is often seco nda ry to diseased teeth and
gum s. T he lym ph atics fr om the teeth and peri-denta l struc tures d ra in by way
of th e ton sils."-E. C. Bond.
" It is a mistak e to thi nk tha t strenuous man ipulative measures a re necessary in relieving tons illa ry conditions . \ \' e have to do with a t issue condi tio n
sen sit ive and inflam ed, contra-indicati ng rough manipulative mea urcs. and it
is remarkable how nicely th e soft cervi cal ti sues can be handled if no strong
ir ritat ion is pro d uce d while tr eat ing. It is no t uncom mon to reduce the congestion within a few mom ent s' ti me su fficient ly for th e patient to be ab le to
sw allow with some degr ee o f com fo rt.
"It is well to rememb er tha t th e ton sil is a lym phati c structu re and sho uld
not be di rec tly tr eated as a rul e. If so. with t he greates t care, It is no t always
th e to ns il th at we feel on palpation. bu t the lymphatic glands and t issues ove r
the ton sil. A car efu l co rrect ion o f max illar v, ce rvical and do rsa l les ions is
sufficient , as a rule, to redu ce th e congestion. alt ho ug h ge ntle tr eatm ent is so metim es beneficia l ove r the ton sil."-F. P . Millard,
Prognosis. R ecover y is th e rul e, unl ess co mp licati on s ari e.
T o pr event recurren ce, th e pati ent mu st be instruct ed in ge nera l
hygi en e, and if he feels th e slig h te st indi cati on of t roubl e to immedi at ely see hi s os teopat hic ph ysician . Eac h at ta ck incr ea ses th e
danger o f permanent injury to th e ton sil.
190
ADENOIDS AND TONSIL S
PERITONSILLAR ABSCESS
(Quinsy )
So me tim es an att ack beginning a s acute ton silliti s takes a
seve re r for m. The uvula , so ft palate, and parts ar ound th e ton si l
appear ede ma to us , swallo wing is exce ssively painful, artic ulation
is d iffi cult , a nd the voic e is na sal. The con stituti onal yrnptom s
a re more sev ere th an in the simple form. In from two to six day ,
fluctuati on can be felt, usually in the so ft pal at e. Quin sy is pr oba bly due to th e presen ce of a more malignant inf ecti ou age nt th an
simpl e ton silliti s.
Treatment. I n add itio n to t he treat me nt g iven under ac ute
ton silliti s, incision may be made with a cur ve d bistoury guarded
nearly to the point, making the in cision from ab ove downward
par all el with the anteri or pill ar. If thi s is not done th e pati ent
suffe rs longer a nd th e ab scess ruptures ant eri orl y or tow ard th e
ton iI, with imm edi at e reli ef of th e sy m ptoms and g ra dua l recoverv.
In' rare ca ses, if the swelling pr oduces symptoms of suffocati on , excision o r tracheot omy may have to be done.
CHRONIC TONSILLITIS AND ADENOIDS
(Hypertrophy of th e ton sils; apros ex ia; n aso-pharyngeal obst ruction ; mouthbreathing)
Thi s is a chronic infla mmation of the tonsils and re lat ed lym ph o id ti ssu es, characteri zed by hypert rophy of th e ti ssu es aff ected,
and sy mpto m referable both to me ch ani cal ob tructi on of the
respiratory pa ssages and to the toxic effects of infection.
Etiology. The condition is mo t frequent before and during
pube rty; in boys more often than in gi rl s; in childre n with tubercu lar or syp hilit ic ancest ry; in t hose w ho live under in sanitary
condition s, esp eciall y th ose kept within doors; and in th ose ub ject to recurrent acut e ton silliti s. Upper th oracic lesion s a re practi cally in vari ably present; lesion s of atl as and axi s are usually
present . O t her lesion s oft en found include the first a nd seco nd
ribs, the clavicle , the hvoid and mandible , and vertebra: from
occiput to mid -t horacic. Th is wi de spread area of probab le eti olog ical relati on hip s is due to the pecu liar va som ot or inn ervation of
the ton sil s.
Pat holo gy. Both ton sils a re u su all y invo lved. Th ere may be incr ease
in th e lymphoid elements with or with out incr ea se in th e st ro ma; disten sion
o f the cry pts with plu gs o f chees y yellowi sh mat er ial o f pec uliar o ffens ive odo r
-Dittrich's plugs. Th e latt er may becom e infiltrated with lime salts , thus
formi ng conc retions .
Associated with hyper tr oph ied ton . ils is usu ally an ove rg ro wth o f the
ph aryng eal lym phoid t i sue. Thi s may be papillomatou s with a lymphoid
1
CHRON IC TONSILLITIS
191
par en chym a, may appea r as masses fro m a small pea to an almond in size, or
m ay be sess ile or ped unculate d. Th e ti ssu e is reddi sh in colo r, o f moder at e
firmn ess, co ntains numerou s bloo d vesse ls, and is most abundant ove r the vau lt
of th e pha ry nx in line with the fossa of th e E ustachian tube, or th e masses
may lie poste rio rly in the fossa o f Rosen rniiller, o r upon parts pa ra llel to the
posterior wall o f th e ph ar yn x .
Diagnosis. Chro nic ton silliti s w it h a de noids is resp on sibl e for
"mouth-breathing." Thi s a ppea rs at first at ni ght ; th e child is
r estl ess, a wa kes w ith "ni ght t error ," a nd sno res of te n. A sho r t
dr y co ugh may be present , due par tly to th e ner vou s irr it ati on a nd
partl y t o th e effects of th e mouth- br eath ed a ir u pon th e r espi rat or y
passag es. R ecurrent bron chitis, ph ar yn giti s, laryn giti s, st utte ring,
as t hma , diges t ive di ffi culti es and va r ious func tio na l n ervou s dis- ,
turb an ces may be th e mor e o r less d irect result s of chro n ic t onsillit is a nd ade no id g ro wt hs . S uc h child ren have lower ed res istance to in fecti ou s disea ses.
The face of th e mou th breath er is cha rac te r ist ic. Th e ope n
mouth and th e loose han gin g jaw g ive an expression of st up id ity
which m ay or m ay not be deser ved. T he lips are u su all y thick
and dr y ; th e nose is broad , th e nost ril s have dimini sh ed openi ng,
a nd the edges look pal er and so mew ha t waxy . Th e " pigeo nbr east" or "c hic ken- b reas t" m ay be present. A thi ck vo ice, o fte n
hoar se, sligh t co ns ta nt h ead ach e, slig ht or pr onoun ced dea fn ess,
and so me mental torp or are co ns ta nt in th ose w ho have been
mouth-breath er s for any len g th of tim e.
Th ese sy mpto ms sho uld lea d to a n exam ina t ion of th e pati ent.
Th e diagn osis is made up on palp ati on a nd in sp ecti on, by m ean s
of w hic h th e enla rged t on sils and th e ade noi d m as es in th e nasoph arynx a re ev ide nt .
Treatment. A deno ids a re ab nor mal, and sho uld be rem oved
wh enever th ey are larg e en ou gh t o in t erf er e w it h respirat ion . To nsils a re u seful orga ns, a nd sho uld be saved if possibl e. Of te n badl y
hyp ertrophi ed t on sil s r eturn to practi call y normal size a fte r t he
r em oval o f ade noi ds, and ot he r indi cat ed treatm ent g ive n. \ Vh en
th e t on sil s a re filled with pu s, bein g prac t ica lly destroy ed alrea dy,
or whe n th ey do not y ield to ca ref u l treatm ent, interf erin g with
r esp ir ati on and be ing th e seat o f co ns tan t in fect iou s p rocesses,
th ey sho uld be r em oved by clean and co mp lete surge ry.
"The r estor ati on o f th e norm al blood supp ly and perlect drainage to and
f ro m the organs lessens the liability to cont ract colds or to the recurrence of
th e ac ute form o f disease know n as tonsitlit is.t'<- A. T. Sti ll.
T o secu re thi s end, th e neck an d upp er th or acic areas mu st be
k ept perfectl y adju st ed, th e rib s norm al in arti cul ati on at both ends
and k ept rai sed as mu ch a s ca n be sec u red . E very effort mu st be
m ad e to sec u re th e coo pe ra t ion of th e child in t akin g pr escribed
ex er cise s. Liftin g th e lar g e t on sil s a nd g iving a ve ry ge ntle circul ar motion at th e sa me time a ssist s in draining th em . Car e mu st
192
ADENOIDS AND TONSILS
be t ak en not to tou ch th e pharynx , as gagging will result. The
han d and fingers a re to be s urgica lly clean ; a fing er co t is most
ea sil y sterilize d, but it lessens tou ch se nse .
Afte r the a de no ids have bee n rem oved , an d a fte r resp ir at ory
in terferences due to enla rged ton sils have di appea re d, th er e ma y
sti ll be diffic ulty in ove rco ming th e mouth-brcathing habit. Syst em a ti c breathi ng exe rcises a re good to faci lita te th e return to
t he norm al nose br eathing . E xer cises th at retra ct and elev a te the
so ft pal at e a re bcn eficial ; a lso fo rccd ex pira to ry exe rc ises th at
affect t he e nt ire respira tory tract. V a rious mec hanica l applia nce
are no w o n th e mar ket fo r holdi ng th e mo ut h close d at night.
Th ese a re a nnoy ing and sho uld be used only as a last resort. 1\1 uch
living in th e o pe n, both durin g day a nd night, is of g reat value in
sec u ring th e norm al respirat ory habit s. It sho uld be rem ember ed
th at di seased ton sils are pr oba bly a frequ cnt so urce of in fecti on s
elsewhere in th e body.
" T he conclusio ns wer e th at th e ade noids prese nt in the epipha ry nx o f th e
ch ild was th e prim e fa ctor in th e pr odu cti on o f deviated se pta, hypertrophi ed
and othe r ways diseased tu r binat es a nd a ll fo rms of nasal blocking. also for
acute and chronic ca tarrha l cha nges in th e ear with a ll their sequelae, fo r
enla rged tonsils and ce rvical glands ; and, seco ndarily. by reason o f the ch ro nic
inflammation induced throughout the entire area of mucous me mbra nes of th e
h ead and throat, with the resultant lower ed tissue resistance tha t the adenoid
was respon sible for the g reater propo rt ion o f th e exant hema ta of child hoo d.
"Second ly, th at the ad enoid, in man y, if not all inst an ces, wa s th e result
o f vaso mo tor perver ion due to osteopathic lesion s in uppe r dorsal and cervical
r eg ions occurring either in utero or during the first few years of li fe, and not
due, as generally stated, to syphi lis or lymphoid overgrow th fo llow ing toxemia
of va r ious in fe ctio us diseases."- l1ary S. Croswell.
"Briefly, enla rge d ton sils a re ope ra tive wh en they really co nt ain an ab scess,
th e ope ra tion simp ly co nsist ing in lan cin g. Th ey a rc also operat ive if chron icall y or at fr equent in ter val s enlarged. and whe n osteopathic treatm en t has
failed to redu ce them. In thi s case clipping or guillotining is us ually sufficient.
"In th e ve ry wor st case s I enucl eat e, bu t in most cases I a m perfectl y
sa t isfied wi th t he lesser operation as it us ua lly leaves them two goo d ton sils
tha t do ge t sma lle r and st ill ha ve good fu nction s, while th e dissecti on opera tion
robs th em entirely of t he lon sils. The ton sil is a normal orga n whil e ade no ids,
whi ch I r em ove entirely, ar e abnormal.
"In those few cases where cu tt ing off the top is a failure. th ey ca n still be
dissected ou t and t her e has bee n no damage done and nothi ng lost."-Geo.
Still.
"Undoubtedly su rge ry mu st be resorted to in spec ific cases.
Repeat ed
infecti on se rves to t ran sf orm the lym phati c tissue to a mer e fibro us shell eliminatin g those factor s esse ntial to act ive phagocy tic an d an ti-toxic power. Gapin g
r emnant s of follicles welcome invading bacteria t ha t must penetrate to th e
cervical nodes before meeting resi ta nce. Surge ry is ou r one remedy, temper ed
with conse rvatism and ju dgm ent ."-F. C. F armer.
"Irregul ariti es in the positi on o f th e cer vical and upp er th oracic vertebrre,
th e mand ible, th e hyoid. or th e up per rib s. a re prob ably efficient facto rs in the
d istu rbed circu lation and thus the incr eased tend ency to abno r ma l ton sillar conditi ons and the growth of a deno ids.
ADEN OIDS
193
" T he co rrect ion o f th ese st r uctura l ab no rma lities is a necessar y pa rt of the
t rea tme nt o f th e condition s, wh eth er surg ica l interference is indicated o r not .
"Every e ffort sho uld be made to save no rmal to ns illar tissue. T here is no
reason for sav ing ma sses of d iseased tissu e whi ch may ha ve replaced the
ton sils .
" A de no ids lar ge eno ugh to compel mon th- breath ing sho uld be removed.
The g ro wths ar c not apt to recur if th e sp ina l conditions and the hyg ien ic condit ions a re co rrectetl."- P. C. O . Clin ic Repo rt.
"A de noi ds and ot he r ab no rma l nasal conditions a re importa nt causes of
ment al deficiency. A n imp ortan t d rai nage- wa y for the lymp h fro m the anterio r
fossa o f th e sk ull, and thu s f rom th e front al lobes of the hrai n, is by the
peri vascul ar and per ine ural lymph spaces of th e crib rifo rm plate. A ny d isease which inte rferes with thi s drain age-w ay mu st exe rt a malevolen t influence
u pon th e dev elopm ent o f th e fr ontal lohes o f t he hrair. ; in the case of adenoids.
thi s evil influ en ce is most effectiv e at th e t ime of life wh en the fro nta l lobes a re
beginning the ir most rapid developm ent.
" Mo ut h- brea th ing is an oth er fact or in pro mot ing inefficiency. Not only
does mouth-breath ing cau se mal -nu trition o f th e br a in. as of the rest of the
bod y. but th e lax sta te o f th e j aw mu scles see ms to be associated with fau lty
development o f the co r res ponding ner ve cells in th e co rtex. Th e enti re cereb ra l
and so ma t ic mechani sm concerne d in wh at is usu ally ca lled "s t rong-w illed per so na lity" is weak en ed by th e open mouth an d th e dr oopin g man d ible o f th e
mouth-breath er. F or thi s reason surgical interference o ught not to be too lon g
delayed.t'<-L. Burns.
CHAPTER XX
DISEASES OF THE PHARYNX AN D LARYNX
GENERAL DISCUSSION
Th e pha rynx in cludes seve ra l va ryi ng st ruc t ures, which are
variously ubject to disea se, but which are anatomically a nd
physiologica lly re lated . The to n ils lie between th e pha ry ngeal
p illa rs; t he respir ato ry pa th as we ll as th e diges t ive path traver ses
t he cavity of th e phary nx . T he m em bra ne lini ng th e ph ary nx ,
la ry nx , and the lower digestive and respirat o ry t ract s is co ntinuou s, throu gh th is com mo n cavity, wit h th e membran e of th e
b uccal a nd th e nasal pas ages. Thi s m em br an e is w ell supplied
w it h blood vessels, lym ph atic path s, lymph nod es, mu cou s and
se ro us g la nds, a nd t he se nso ry nerves which a re con cerned in severa l varieties of se nsatio ns, as we ll as th e effe re nt ner ves whi ch
gove rn th e sec retio n of th e g la nds, th e ca libe r of th e blood vessels,
and th e t ension of t he muscle fibe rs w hich lie be neat h th e membrane th rou gh a vary ing extent of it s area.
Th e vaso moto r ne rves a re deri ved , for th e m o t pa rt, from
t he superior cerv ica l ganglion, and also fro m others of th e sy mpathetic ganglia of the cranial and ce rvical regi on . These, in turn,
de rive stimulation from the pinal egments of t he upper th or acic
cord, a nd from certain visceral cente rs of th e med ulla, pon s and
mid-b ra in . All of t hese centers a re active acco rding to the im pu lses reaching them . which are ultimately sen ory in or ig in. V ertebra: of the u pper thoracic and t he cervical segme nt , upper rib s
and clavicles, the 'hyoid and the mandible, are all inclu ded in the
bones whose disturbed relationship may be respon ib le for dist ur bed circulation throug h this phary ngeal area, as we ll as for
distu rbed sec retions.
Without discussing w he the r or not infec t ion of the normal
m ucous membrane occu rs, it m ay be g ra nted t ha t th e dan g er of
infect ion is in cr eased by th ose age nc ies whi ch interfer e w it h the
norm al circulat ion of th e bloo d, an d t he norm al co urse of nerve
imp ulses t h rough the governing cen te rs. T o th ese fact or s mu st
be adde d th ose w h ich low er th e syste mic immunity , suc h as the
rigid lower th or acic spinal colum n, various di sturban ces of nutrit ion , a nd th e effects of a utoge no us or ex tra neo us poi sons.
The treatment of th e di sea ses of th e ph ar yn g eal regi on consists chiefly in th e rem oval of the fact or s which ca us e or perpetuate
th e diseased co ndition.
194
ACUTE PHARJ 'NGITIS
195
ACUTE PHARYNGITIS
( Angina catarrhalis ; sore throat; angina simplex ; hyp er emia; edema o f the
uvula)
An acute inflammation of th e ph arynx is usu ally associated with
varying degrees of laryngiti s and ton silliti s. The trouble begin s a s
an ac ute hy per em ia, which may terminate in recovery, with no
fu rth er symptoms, may go on to seriou s forms of ph aryngitis, or
may persist a s a chro nic hy peremia. This disturban ce is an important cau se o f the more se r ious inflamm ati on s, and permits th e
infect ion of the throat by ba ct eria whi ch might have been un able
t o attack a t hroat otherwise normal.
Hyperemia of the pharynx is due t o irritatio n by tobacco sm oke,
constant use of the voice, is a part o f naso-pharyngeal catarrh;
may be due to lesions o f the man di bl e, upper cervi cal or upp er
tho racic reg ion, eit he r a lone o r associate d with a ny of the firstm ent ioned cau se s.
T he m ucosa is re dd ened, and t he ven ules may show di stension .
Distended veins may be due t o val vular heart lesions or to pr essure up on the supe rior vena cava. Hemorrhage is due to local
cause s, usually traumatic .
Edema of the u vula is not unc ommon in debilitated condit ion s; in milder deg ree it may be a ssociated with lesions especially
of the mandible, less frequently the upper cer vical vertebrrc. The
enlarged uvula ma y irritate the throat to suc h a n extent a s to cau se
chronic hyp eremi a or even t end t o a pharyn giti s; the voice may
bec ome hu sk y a s the re ult o f the laryn g eal in volv em ent. \ Vhen
th e ede ma persi st s an ove rg ro wt h of ti ssue may occur ; it ma y thus
bec ome nec essary to r em ove the supe rfluo us ti sue su rg ically.
Wh en acute hyp er emi a per sist s, o r as a r esult of ex pos ure to
cold, digesti ve di sturban ces, rh eum ati sm and g out, o r ot he r so ur ces
of di sturban ce of mucou s sec re t ion, a mor e ac ut e inflammation
of the pharynx occurs. Cervi cal ami mandibular, upper rib and
clav icular lesions predi sp ose to th e di sea se.
Diagnosis. The trouble begins as un ea sin ess and so reness on
swallowing, a feeling o f tickling and dr yn ess in the throat, a desire
to hawk and spit, a nd st iffness of the neck. The cervical ly m ph
glands are enlarged and painfu l. The pr oce ss may extend to t he
E ustac hia n tu be, pr oducin g sligh t deafness, an d to the lary nx wit h
hoarseness. The con stitution al sy mp to ms are chillin ess, fever o f
mod er ate degree, increa sed pul se r at e, cou gh, a nd more or less
na al voice.
I nspect ion shows a g en eral dry, red, congested condition of
th e w hole th roat w it h edema of th e uv ula. T he t on sils may or
may not bec ome invol ved. The ce rv ica l m uscles a re irregularly
contracted and painful when touched. The skin over the neck is
196
THE PHARLVX AND LARYNX
often hypersensitive. The sec re t ion is thick, te nac ious and opaque.
The vo ice is u su all y affec ted , a s a result o f th e associated laryngitis.
Treatment. " In trea t ing pharyngeal d iseases, I first adjust t he
clavicle at both ends. 1 also adj ust a ll of the ribs of eac h side
from the first to th e fift h. Adj us t t he atlas and axis. * * * Then
I see t hat t he lo wer ri bs fro m t he eighth to t he twelft h a re a ll le ft
in a normal conditio n. I a m very careful to ha ve a norma l adj us tme nt of the whole lum bar vertebrre.t'<-A. T . Still.
M uscu la r co nt ractio n anywhe re in th e neck o r u pper dorsal
region need s rela xa tion to prevent Ie ions and blood stasis. Especially is it necessa ry to relax a ro und the hyo id bone. Ca ref ul
t reatm ent of t he upper ce rv ica l lym ph ati cs is effec tive . Th e d iet
sho uld be liqu id if th er e is mu ch fever, o r if so lid foo d ca uses mu ch
ir ritati on . As a gargle or a p ha ry ngeal do uc he, a norm al sa line is
bett er th an an yth ing else. Th e m ain purpose of a ga rgle is clean sing of th e membran e fr om th e a bno r ma l and irri tati ng sec re tions ,
which ofte n co nta in p athog eni c organis ms.
Prognosis. R ecover y is th e rul e, in a few day s to a w eek or
more. Each attack pred isposes to lat er a ttacks, a nd to chro n ic
ph aryn giti s.
PHLEGMONOUS PHARYNGITIS
(Ac ute inflam matory phlegmon o f the pharynx; retr opharyngeal absces s)
These d isease are p ract ica lly th e same in et iology, d iagnosis
and treatment , whethe r t he loca t ion is in the walls of the pha ry nx
o r in th e poste rio r sub -m uco us ti ssue.
Etiology. Primari ly, th e d isease is due to pyog eni c mi croorganisms. It m ay complicate sca rlet feve r, dip ht he ria, erysipelas,
or syphi lis .
Diagnosis. Th e d isease begi ns w it h so re throat , dy sph agia
and hoarsen ess. Fever, dy spnea, and swelling of th e cer vical
ly mpha t ics are assoc iated wi th consi de rab le prostra tion. The
pharyngeal m ucosa is a t first deep red, purple, swolle n, t en se,
shi ny a nd dry . Vesicles appea r an d th e sec re t ion becom es p ro fuse ;
suppuratio n occ urs speedi ly. T he p us may be locali zed o r ma y
be d iffuse ly scattered th rou gh t he m em bran e.
Th e mu scles of th e n eck, mid-thoracic regi on, a nd so me t ime s
of th e lum bar regi on are co nt rac te d and hy persen siti ve.
Th e blood shows leu cocytosis in vari abl e degree, a ccording to
th e sever ity of the inf ecti on and th e st reng t h o f the rea cti on to the
in vading o rg anis ms .
Treatment. A n im portant fact or in prom otin g th e resistance to
thi s, as to a ny infection , is to increase the m obility of the lower
ME .1IBRANO US PHA R}'JYGITIS
197
th oracic regi on-from the six th to the twelfth th or acic, with the
corresp onding rib s. Manipul ati on o f th e ne ck is difficult, yet, w ith
care, mu scl es can be relaxed, bon y and ot her lesion s correct ed,
ven ou s and lymph dr ain age facilitat ed . The ri bs sho uld be rai sed,
the clavicles loosened , if they are found d epressed or a ssociat ed
with t en se mu scl es; th e mand ibl e a nd hyo id free d fr om t en sion.
All treatment mu st be ca ref ully ba sed u pon a recog n iti on of th e
pathological changes occu rr ing in ea ch patient, as found o n fr eque nt examination.
\Vh en th e pu s accumulates it sho uld be surgica lly evacua te d at
once. I nci ion mu st be made a s indi cat ed by the locati on o f th e
pu s. and by ot he r loca l conditi on s. \ Vhil e th er e is little doubt th at
quite larg e coll ecti on s o f pu s can be abso rbed and carri ed away,
sometim es without apparent injury , th ere is always th e ri sk o f
rupture, with inf ecti on o f the lung s or the dig esti ve tract; se pt icemia may result fr om the in va sion o f the ly mphat ics or the vein s
by the inf ecti ous ag ent. Sp ontaneou s ev ac ua t ion during sleep ma y
re sult in suffoc at ion. The clean in ci sion u nder ord ina ry su rg ical
precaution s with evacuation o f the pu s is mu ch less dangerou s.
Progno sis. \Vith co rrect su rge ry and suc h ot her treatm ent as
is indi cated, practi call y a ll pati ents s ho uld recov er. Th e pr ognosis
of th e underlying di eas e is t o be con sid ered ; the out loo k is always
so mew ha t doubtful, in thi s a s in all ca ses wi th pu s formation, with
th e po sibility of sept ice mia.
MEMBRANOUS PHARYNGITIS
( Cr ou pou s ph aryngiti s)
Mem br an ou s pha ryngi tis is due to infection by d ipht her ia ( q. v.) o r
by any o f the pyogenic o rgani sms, rar ely the pneumococcus or the baci llus co li
comm uni s; usuall y such invasion s arc upon pharyngea l memhranes injured by
dir ect tr aum a, o r by th e e ffects o f circ ulato ry di stu rba nces , Th e conditio n m ay
be associa ted with sca rla tina . measles, typh oid, va r iola, etc. (q . v.) . The tr eatment is th at of the pr im ar y d isease, plus the tr eatm ent o f cat arrh al o r phl egmon ous phar yngit is.
ANGINA LUDOVICI
( Ludw ig's ang ina; cellulitis of the neck )
Thi s di sease is not ve ry f rcqu cnt in th is count ry . It is cause d by st re pto coccic in Iecti on. and is usu all y seco nda ry to diphth eria o r sca rlet fever. The
pro cess is atte nde d by swelling- o f th e su b-max illa ry gla nds o f one side , sprea ds
to the Roar o f th e mouth . and to th e f ro nt o f th e neck. The pa rts a re du skyred and pr esent brawny indurati on .
Diagnosis. The sympto ms ar c int en se with mu ch pai n. D yspha gia, difficult ma sti cati on a nd a rtic ula tion. and g rave dyspn ea may su pe r vene fr om
compression o r edema of the glott is.
Treatment. When the pu s doe s not accumu late, the treatment sho uld he
carefully devoted to secu ring bett er cir culatio n th rou gh th e infect ed ar ea . So
long as no ne crosis occurs, th ere is little dan ger of se pt icemia fr om the circu-
198
TIlE [,lIAR} 'NX A.YD L A R l 'N X
lation o f the blood through the infected a rea; wh en the pus accumulates and
necrotic t issues are present, loca l man ipulation sho uld be lim ited to th e su rgica l
evac ua tio n o f the pus, Throu gh out th e disease, th e ri bs sho uld be fr eely rai sed,
reflex muscular con t racti ons co rrected, and the mobility of th e th or acic region
secured by t reat ment as frequent ly give n as may be necessar y to secure th ese
result s.
VINCENT'S ANGINA
Thi s form is du e to the bacillus fu sif ormi s and th e spiroc heta de ntinum
and is feeb ly conta g ious . Ther e is superfi cia l ulcer ati on and the form ati on
o f a mem bran e. usu ally begi nning on one o r both ton sils and spreadi ng to othe r
parts o f th e ph arynx ,
Treatment. Tn addition to th e co r rec tive work adv ised for oth er forms
of pharyngiti s, th e fr equ ent use o f a mild gargl e is helpful and comfortable,
ULCERS OF THE PHARYNX
Follicular ulc ers a rc usu ally small, super ficial. and ge ne ra lly a ssociated
with ch ro nic cata r rh. Sy philit ic ul cers a re sma ll, sha llow , painless, round ed ,
yello w and sloug hy, su r ro unded by a redd en ed zone, and appear upon the
post eri or wall . Typhoid ul cers a re small, round o r ova l, and ap pear toward
th e close o f an a ttac k o f typh oid fever. Tubercul ous ul cer s ha ve irregul ar
bound ar ies and a yell owish- gray floor , a re int en sely pain fu l, and also appear
upon th e poster ior wall. Can ce r ou s ulcers ha ve th e usual cha rac te ristic s o f
malign ant disease.
Th e tr eatm ent o f th ese is co ns t itut iona l o r su rg ical. Local appli cati on of
1 to 1070 silve r nitrat e may clear up non- cancer ou s ulc er s.
CHRONIC PHARYNGITIS
(Clergym an' s so re th roat; chron ic foll icul ar pha ryng itis )
Thi s is a di sease cha rac te rize d by a hu sky o r muffl ed vo ice,
and a tend en cy to clea r the throat . Sp eaking be comes difficult,
and the throat bec om es tired wh en pcech is ne cessary.
Etiology. Th e di sea se follow s rep eated ac ute attack s; improper
or ex ce sive u se of th e voice, espe cially with loud ton es; excessive
use of alc oh ol or tob acco o r naso-ph aryng eal catarrh . P erhap s
the most important etiological fact or is the pre ence of lesions of
the third cervi cal or it s neighbors, o r of the occiput. The hyoid
is frequently inv olv ed throu gh mu scular co nt rac t ions. These
lesion s them selves t end to change the ea se of vocali zation; t hu s
they act in at lea st tw o way s in the et iolog y o f the disea se ,
Diagnosis. The sy mpto m s and hi st ory a re fairly pathognomonic. The examination of the throat sho ws the ch aracterist ic
granular me mbrane,
The m uc ou s m embra ne is more or less congested, num er ou s
distended ven ules are seen , and th e secretion is mu coid , mu copuru len t, o r purul en t. Often d ry sca les of offensive odo r a re
found. Hyperpla sia of the ly mph-f oll icles fo rms elongated rows
in th e la teral or poste rior wa lls.
ACUTE LARYNGITIS
199
Treatment. The correcti on o f faulty habits of spe ak ing is
im port ant. Correction of the bony Ie ion s found in each ca se is
usually necessary to permanent re cov ery. A gargle of normal salt
so lut ion o r of boracic acid or of hot water gives comfort and
clean s t he roughened membranes. Condiments, alc oh ol, t oba cco,
sh ould be discontinued. Cauteri zation and astringents are dange rous and rare ly give any reli ef. The scars left by th ese m eth .
ods are often very annoying, and may lead to serious troubles later.
Prognosis. Tn early cases rec overy ma y be exp ected within
a few weeks. The time necessar y for recov er y depend s up on the
time during which the di sease has been pr esent , the obe d ience t o
the instructi ons concerning the use o f the voice, to a correct dietetic
a nd hyg ien ic regime, and t o the po ssib ility o f sec u ring permanent
co r rection of t he lesion s as found . There is a tend enc v to recurr ence if the lesions r ecur, or if the voice is used improperly, or
if th e tob acco, alco ho l, or ot he r ir ritat ing fact ors are r esu med.
ATROPHIC PHARYNGITIS
(Ph ar yngiti s sicca )
In this typ e the secretion is scanty, th e mucou s membrane is reddi sh-brows
in color, thin, smoo th and shiny.
Diagnosis. There is a cons tant desir e to hawk and spit, with a dr opping
of mucus fr om th e upper pharyn x . slig ht redn ess increased fr om var ious causes
at time s. On inspecti on, the mu cou s membran e o f the posteri or pharyngeal
wall is seen a du sky-red and studde d with th e elon gat ed lymph-follicles or is
dry and gl ist ening.
Treatment. The patient mu st he tau ght co rrec t meth od s o f phonati on
and articulati on; th e lesions as found mu st be cor rec ted ; th e ge nera l health
mu st be kept at high level. Complete rest o f th e voice may be found necessar y
in some cases .
Prognosis. Recover y is slow. It is not dan gerou s to lif e and may be
greatly help ed, if not entirely relieved, by lon g- continu ed, per sistent tr eatm ent.
ACUTE CATARRHAL LARYNGITIS
(Acute laryngitis; sore th roa t ; acut e endo laryngi tis)
Etiology . Acute lary ng it is may be cause d by the inhalation of
irrita t ing vapors or d u t; by drinking irritating liqu id ; by overuse, o r im proper use of t he voice; or by exten sion of inflammation
from ot he r a reas. I t is usuall y a ssociate d with pharyngiti s, and
often wit h tonsi llitis and r hiniti s. It o ft en occurs during the co ur se
of th e ac ute in fecti ou s fever s. Con tractio n of mu scles a nd s ubluxati on s of bon es in th e cervica l and upper th or acic a reas are im port ant ca uses ; com pa ra tive ly slig ht ir rit an t s ca use severe inflammati on s wh en th ese st ruc t u ra l pe rve rs ions a re already p rese nt . T he
hy oid a nd th e ax is a re most ofte n co nce rned in th ese ca ses. T he
200
THE PHARYNX AND L AR YNX
r eflex mu scul ar contracti on s cau sed by th e irritant perpetuate the
infl amm ati on in many ca ses.
Diagnosis. The di sease u uall y begin s rath er sudde nly with
sensations of dryn ess, pain and ti ckling in the laryngeal regi on,
hoa rseness increasin g to apho nia, slig ht fever, painful deglutition ,
and a d ry, noi y, hoar se co ug h. The laryngoscopic examin ati on s
r eveal swe lli ng of the mu cosa, usually most marked in th e aryepi gl ottid ean fold s, with redn e s and swe lling of the true vocal
co rds . Th e surface m ay be covere d with a va ry ing am ount o f
mucu s. So me times pat ch es of ero ion a re found .
Treatment. Rest in bed, a nd a b olute rest of th e vo ice, is indicat ed . If it is ne cessary , th e patient may whi sper very faintly , but
it is better for him to write hi s communication s. Inhalation s of
stea m, th e ice bag to th e neck , a cold pack , a nd a hot wat er bottl e
bet ween th e sho ulde rs , are so me of th e thing s whi ch gi ve reli ef.
U su all y a n ac cumul ati on of fecal material is found o n palpating
th e colo n; thi s sho uld be remov ed by a mod er at ely w arm enema.
The important factor s in treatment are th e relaxation of the
reflex mu scul ar cont rac t ions, and th e correcti on of whatever ot her
lesion s may be found. Car efully elevat ing th e lar ynx and relaxing
contig uo us ti ssu es a re ben eficial.
Tote th e co nd it ion of th e first
rib s. It may not be adv isa ble to do th e co r rec t ive work until th e
local inflamm ati on has begun to subs ide, but if further attacks are
to be prevented , and if th e pati ent is to recov er and ke ep hi vo ice,
t he correcti on s mu st be mad e. O rie or tw o treatm ents eac h day
shou ld he g ive n, until th e ac ute tage has passed; if one th orough
treatm ent is g ive n a t th e beginning of th e attack it may be all that
is need ed . But the complete co rrection of st ruc t ural perver sion s
mu st not be negl ected , even th ough the acut e sy mpto ms di sappear
complet ely, with or without palli ative treatment.
Prognosis. 1\10st case recover in o ne o r two da y s, if th e treatm ent is g ive n on th e first appea ra nce of th e sy mpto ms. Each day
o f delay in treatm ent mean s severa l day s of delay in rec overy.
Re current attacks are to be expected , if the lesions remain or recur,
o r if th e irritat ing age nts per si st o r reappear. The repeated attack s
lead to ch ronic lar yngiti s. ( q. v.)
EDEMATOU S LARYNGITIS
(Edema o f th e glotti s)
Th e infiltrati on of th e ti sue of th e larynx and gl otti s may be
a tru e inflammat ory edema, o r may be the re sult of di seases in
o t he r orga ns .
Etiology. It is rather more frequent in chronic laryngiti s than
in ac ute, a nd is es pec ially frequent in acute exacerbation s of th e
CHRO NIC L A R Y N GI TI S
201
ch ro nic for m. S ubacut e or ch ro nic inflamm ati on s arc o ftc n associated w it h cdc ma-t he hu sky voic e in t ub ercu lar o r sy philit ic
laryn giti s is almos t pat hogno moni c.
Non in fla mma tor y cdc ma occ u rs in ang io-nc urot ic ede ma, w hich
may affc ct t hc g lot t is ; thi s may resul t in se rio us or eve n fat al
as phyx ia. N ephr it is, and ot he r disease as oc ia te d wi t h cde ma,
may aff ect t hc la ry nx ; ede ma o f th c g lottis thus produced may be
se rious .
Diagnosis. Th c o nse t va ries accor ding to the etiological fac tor s. Th e dy spn ea i ur g cnt ; dy phagia, aphonia, vio len t, ineffcctu al cou gh , stridulous breathing , a nd wcak nc s a rc so me of th c
mor e co m mo n sy mpto ms. D eath fr om asp hyx ia may occ u r a t
any time ; sudde n death wit ho ut prem onitory sy mp to ms may occur.
The la ry ngoscopic exam ina tio n shows very lar g c, se m itra ns par ent, g ray ish ye llow s we llings, w h ich in vol ve th e ep ig lo tt is a nd
th e t rue and fal se vocal co rds.
Treatment. Vi g or ous treatm ent mu st be g ive n to sec u re rapid
drain ag e from th e a ffec te d ti ssu es. Th e cerv ica l a rea a nd t iss ues
a ro und epiglott is mu st be r elaxed and carefu l atten tion give n to
th e up per dor sal ve rte bras a nd ribs. A n ice hag appl ied over t he
laryn x and ice in th e mouth are good. If re lief is not speed ily
ohta ine d, trach eot om y mu st be per form ed. Ad rena lin spray m ay
g ive t em por ar y reli ef.
Prognosis. About half t he cases t erm inate fata lly. Patients are
liahle t o di e fr om ex ha us t ion, sepsis, or pulmona ry complications
af tc r th e ede ma is r em oved . T he durati on is from a fcw hou rs to
several day s. R ecover y dep end s up on ea rly vigo ro us treatm ent.
CHRONIC LARYNGITIS
( Chron ic ca ta rr ha l la ryngitis ; ch ro nic cndo la ry ngitis )
Ch roni c la ry ng it is m ay follo w rep ea ted at tacks of th c ac ute
form , or it m ay beg in in sidi ou sly , and be chronic from th e firs t.
It is of te n associate d w it h g ra nula r pha ry ngit is.
Etiology . I t is ca used by t hc usu al factor s concer ne d in ac ute
laryn giti s ; th ese m ay be mi ldl y irritat ing throu gh a lon g t im e,
thu s ca u ing th e chro nic ty pc ; ot he r causes inc lude na sal o hs tructi on a nd mouth-breathi ng ; execs: ive a nd im proper u sc of th e
vo ice (dy ph oni a c1 eri corum ), espec ially in th c open a ir; excessive
inh ala tion o f tob acco smo ke, a nd chro nic alco ho lis m.
Diagnosis. T he co mm on sy m pto ms arc constant h a wk ing and
a de sire to sw allo w; exp ector ati on o f a sca nty mu coid or mu copu ru len t materia l or o f sma ll g la iry ba lls o r cru st s; attack s of
hoa rsen ess or apho nia; a nd a hu sky , hoa rse, rou g h voice. Ve ry
littl e pai n is pre se nt. T he g en era l health is 110t aff ected. L ar y n-
202
THE PHAR YN X AND L ARYNX
goscopic examination sho ws the mucous memb rane slig ht ly r eddened , pe r haps g ra nular; the true cords g rayish o r slightly injected .
T rea tmen t . R em ove mu cula r co nt rac t ures, and correct any
bon y Ie ion s found , particularly th ose of the atlas, axi s and third
ce rv ica l verteb rre, the hyoid and th e clavicle and th e fir t rib.
Rem oval of th e cau se i neces a ry . If the condition is due to
ove r use of the vo ice, re st ab solutely; if to sm oking o r alc oh oli sm,
in titut e treatm ent to rem ov e th e habit; and if environmental o r
per sonal habits a re faulty, sec ure their remova l as far a possible .
Pl enty of fre sh a ir , spo ng ing the neck night and morning wit h
cold water, avoida nce of wrapping the neck too much, sys tema tic
throat ex erci se , and education in th e use of the voic e are so m e
of the factor s of general hygiene necessary in these ca ses.
Prognosis. Compl ete re covery is not common o wing to the
persist en ce of cau ses and the lack of cooperation on th e pa rt of
th e pati ent . If more fa vorable circum stance s permit , t he cha nces
for re covery are g ood within a few wee ks .
CROUPOUS LARYNGITIS
(M em br an ou s cro up; cr oup )
Thi disease is usu all y diphth eri a. (g. v.) O cca ion ally other
pathogenic o rga nis ms ca u e the formati on of a fal se m embrane,
whi ch usually peel s off ea ily, without injury to th e underlying
mu cou m em bran e. It may be du e to an y of th e o rd ina ry infecti on of child hoo d , and ma y accompan y mea les, sca rla t ina, or any
of th e exant he ma ta.
D ia gnosis. Cultures sho uld alwa ys be made ; diphth eria is
a lway to be sus pec te d. The diphtheritic m embrane is thi ck, y ello w, ten aciou s, with necrotic a rea ; it s removal leaves a n injured,
b lee ding surf ace . Th e membran e due to ot he r o rga nis m is usually
thin , blui sh-white , sem it rans pa re nt, and it rem oval leave a hyperemic but intact mu cou membran e. The membran e may be purulent an d ye llo wi h, t en aciou s a nd thi ck, wh en th e inf ecti on is by
th e more virulent py og eni c orga nisms . Th e rem ov al of such a
m embran e injures th e underl ying muc ou s membran e, as i the ca se
in th e true diphth eritic form ati on . The only di tin cti on is found
in th e re sult s of the culture t ak en fr om the throat, which is not
a bsolute ly reliable.
Th e sy mpto ms a re sta r tling, and th e di sea se i su fficiently
s erio us. The on et is either sudden with an attack of spasmodic
cro t.p or gradual with ac ute catarrha l laryngitis. The voice
becom e hu sk y, smo t he re d , whi pering o r suppre sed; a pr odroma l
" cr oupy" cou gh for a day o r so becomes hi ssing, explosive and
m et alli c durin g the a ttac k; di fficult y in breathing follow ' . The
n t
r
I1fC eR O P
203
child is u nable to lie down. Ii quiet for a time . he st art s up
in fright. breathing hcavily with a shrill in spiration. Expiration
he come" ditticult and noi-v; suffocation seem" imminent fr om
sp asm of the gl"tti". Cvano-is. profuse per-pi ration . and sympto m" of asphyxia seem ab out to terminate in death, when the
pa-m cease- . and the child i- fairly comfortable. th ough stupid
for a time. P ortions of the membrane may be expelled by coughin<T. dur ing the int er m is- ion s. In cas es tending t oward r ecovery.
the appearance o f improvemen t is maintain ed between attacks. the
parox ' - m - be come lc-.s frequent and sevcre : expect or ation of
membrane is marked. The fever les sen s and di sappears,
In th ose cases tending toward fatal terminati on. the attacks
become more frequent and scv er e : ex pector ati on is abse nt : respirat ion is m ore frequent and shall ow without whistling and stridor;
stupor and in-cnsihility deepen . and the child die s o f asphyxia.
Treat m ent. The first thing is the rel ief of the dy spnea . Thorough relaxation o f the t issues of the throat and neck u sually give
relief. The treatment for simple cr oup . especially t he inh ala t ion of
-t earn from hailing wate r o r sl aking lime , are efficacious in promoting relaxation of t he spasmodic muscles. H ot pack to the
throat . if they can be used , are g ood . The ro om must he th oroughly well ventilated ; the perspiring body of the child sho u ld be
protected from drafts . •\ hot bath m ay he employed: this to be followed bv vigorous rubbinrr of the sk in .
During the intervals. if the child is not asleep. washes o r ga rgle
very soft and aseptic are good : care sh ould be taken t o av oid
injury to the mucous membrane. .'0 attempt at antisepsis is of
any avail. hut the washes should be a sept ic-e-sh ould carry no new
germs into t he inju red throa t. Restricted die t or none is permitted.
Frui t juices. especially pineapple j u ice, are r efresh ing.
A child w ith any sickness shou ld be k ept from other chi ld ren.
especially is this true with fevers . and in case - which bear clinical
resemblance to the acute infections. even th ough the actual in fecti ousness cannot be demon-trated. it is much ~be tte r to secure a complete isolation as possi ble.
The prognosis is doubtful in all cas es; most patient- recover in
six to ten days. but th ere i always the danger o f asphyxia. and
o f more extended inva ion of the tissue - by the organism con cerned.
SPASMO DIC CROUP
(Including spa sm odi c lary ngit i : simp le croup; fal se or pseud o croup; catarrhal
cr ou p ; l ar~ n iti, \\ ith spa srn : spa sm l f the lotri s : • Iill er' s, o r
K opp's, o r thymic as thm a ; ch ild-c ro w in g ; tetanic croup;
laryn ris rnu str id ulus )
This IS ssentially a nervous distu rbance with symptom due
t o the spasmodic ten . ion f the vocal muscles . with closure of t he
204
THE PHARYNX AND L A R J"NX
laryn x . The ten si on is of te n pre ent in m em br an ou s lar yn giti a nd
in many forms of ac ute an d chro nic la rvngi tis . pha ryng itis, and
so metimes to ns illitis, rhinitis, bro nc hi tis, and pne umo nia.
Etiology. Th e pa tients a re almost a lways child re n of neuroti c
make- up, not ofte n mor e th an seven o r eig ht yea rs o ld, rar ely
less t ha n one year. Cases have bee n reported of ve ry sma ll in fant s,
and of ad ults an d se nile pa t ients. Reflex cau ses in clu de wo r m ,
overeat ing, irrita tin g a nd im pro per foods; chro nic ton silli tis. a nd
ade noid ; ba d t eeth; rach it is, m ar asmu s, o r ot he r m alnu trition ;
exposure to sudde n cold, or to dampness ; emo t iona l sto r ms, fr ights,
un wi se a t te mpts at di cipline , and ot he r shoc ks to th e ner vou s
ce nte rs.
Diagnosis. Th e sy mpto ms vary a cco rd ing to th e etiolog ical
fa ct or s. U su all y it is of sudde n nocturn al onse t; th e child is well
or suffering fr om th e ca us a l co ndit ion, slee ps a few ho urs and
wakes s udde nly with a met alli c, reson ant respirat ion a nd g rea t
dy spn ea, with st rid ulo us inspirati on s from narrowing of th e g lo tt is
by spas m , and wh eezy st ridulous ex pira tions ending with a highpit ch ed, in spiratory cro wing so und o n relaxati on of th e spas m.
In seve re cases all th e accesso ry respirat ory mu scl es a re ca lle d
into ac t ion durin g th e at tack. Th e lips and nails are blu e, th e
surface cold, th e co unte na nce a nx ious, th e inferi or port ion o f th e
che t dra wn in in st ead of expan ded d uring in spira t ion . a nd t he re
may be ca rpopeda l spasms . Ge ne ra l co nv ul ion s. st rab is m us . a nd
in voluntar y di sch ar g e of feces an d urin e o me t imes occ ur.
T he attack last s from a few minut es to an hour o r more, a nd
may return a fte r a few hours' slee p or o n th e follo wi ng- night.
D uring th e day th ere m ay be a light co ugh. Th er e is littl e or
no fever or hoar sen e . It ofte n recurs a t th e same hour on sueces ive nights.
Treatment. T o relieve th e spasm, treat th e upper part of th e
ch e t a nd d iap h rag m, es pec ially throu gh th e phre nic ner ve a nd it s
sp ina l relati on s, third to fifth ce rv ica l, a nd treat th e eig ht h to tenth
r ibs an te riorly. Correct a ny subluxa t ions fou nd .
A hot ba t h, w it h co ld spo ng ing to th e ches t a nd back, i a good
emergency mea ure. Thi s may be rep eat ed if t he pasms are pe rsistent. Th e a ir of th e room is hes t kept moist by stea m fro m
boiling wa te r. Em esi m ay be pr odu ced by ti ckl ing th e fau ces with
th e finge r. Thi s ofte n reli eves th e spasm very qui ckl y . A fte r an
a ttack , th e ge ne ra l health a nd di et mu st be regul at ed . A ny irri t ating env iro nme nta l co nd it ion, or personal habit s. mu st be
a tten de d to pr om ptl y .
Th e prognosis i fa vorabl e for reco ver y . D eath rar ely occ urs
dur ing th e pa roxys m in ve ry yo ung o r deb ilitated child re n.
CH .\PTER
DI E.\SE
x xr
O F TIlE BRO. ' CHI
ACUTE BRONCHITIS
( Acu te bronc hial cata r rh; tr acheo-bronc hitis}
Acute bron chiti s is an ac u te ca ta r rha l inflammation of the
larger and middl e-si zed bron chi, occ u rr ing at all ages, but -pa rti cularlv at the extremes o f life, cha rac te rize d by slig ht febrile
reacti on, substernal pain, cough and expectoration.
Etiolo gy . Among the predisposin g cau ses are in ufticient food
and improp er clothing; ex cessive co nfinem en t in warm rooms;
sublu xati on s of verteb rre fr om occ iput to seventh dor sa l, o f the
ribs from first to sixth, and the cl avicl e ; and interscapular and
anterior th oracic mu scu la r contraction s.
Among the excit in g cau ses are exposure to cold or wet, r ecurring rhiuit is, certain infect iou s di sea ses, inhal ati on o f irritant vap ors
and du st s, and many mi cr o-organi sm s am ong whi ch are py ogenic
cocci, pneumoc occus, and micrococ cu s catarrhalis .
D ia gnosis. The condition is usually u hered in with na sal o r
laryngeal catarrh o r both, chilliness with aching pain in the limbs,
joint s, and trunk , a sen se o f con tri cti on ab out the chest, pain o f a
raw, burning, tearing character behind th e ster num aggravated by
d eep inspiration or coughing, a se nse of lan gu or and weariness ou t
o f prop ortion to the fever.
•\t fir -to the cou gh is hard and dry with little expect oration; in
a day or so it becomes looser and the sput um more a bunda nt. Th e
breathing is em barra sed . noi sy o r whistling. The temperature
is not hi gh, !Oct t o !O3° F., but th e sk in i moist ; the pul se ac celer at ed acco rding t o th e fever. The more acute symptom s ub sid e
in a w eek or so according t o severity and conva lesc ence be com e
sl owly e stab lished,
Br on chi al fr emitu may b e felt in thin ches ts. Percu s ion give
a clear re son ance ex cept when bron ch o-pneumonia and atelect a is
compli cate; hence the che st sho u ld be examined daily. During the
fir st stage, there is harsh breathing with bil ateral diffu se, piping,
sibilant, or son orous rales whi ch are sh ift ing and affected by co ughing . After a few day, the breathing i puerile with pro longed
expiration, profuse m oi st bubbling rales. Breat h sounds are suppressed ov er collapsed areas if a po rtion of the t ube becomes
p lugged with secretion.
205
206
THE BRO.\"CH I
I ncr eased respirat o ry rat e, cyanosis an d dys pnea in d icat e inv olv m ent of ma ll t u bes, o r bronchiolitis.
U rin e is febri le, o f th e ordina ry ty pe.
The sputum duri ng th e firs t t wo day s is a lmos t pure mu cin, IS
t enaciou s, visci d, Ir oth v, a nd t ran sp ar ent. It co nta in - a few leucocvt es and red blood 'cell s, few cil iat ed ce lls, a few mon onuclear
leucocytcs. a nd a fe w myel in dr op - of th e simpler type . After
thi s, th e co ug h loosen s, th e sp ut um i in cr eased in am ount, i - less
vi scid and ten aciou s, Irothv, with wh iti sh and so me t ime ' bloodv
st. ea ks . Thi s is foll ow ed' by mu co-purulent secretion o f nearly
uniform yellow color, cont aining m any pu s cell s. Later, it bec ome
almo t purely purul ent, 100 to 200 cc. dail y; co nta ins much myelin ;
cell s mainly polyrnorphonucle ar s and fat in large masses.
Treatment. Most ca ses yi eld with out treatment if patient will
t ak e a hot foot o r full tub bath and go to bed aft er fre eing the
bowel s, th ough time can usu ally be sa ved th e pati ent by foll owing
with a th or ough g en eral treatm ent with spec ia l attenti on to the
upper re spirat ory are as until a definite rea cti on is sec ur ed. If the
di sea se persist s, relax the mu scle s of the spine and chest, ra ise
the ribs, correct an y s u blux a t ion found, sec ure fre e eliminati on
by bo wel and kidney s. The room -air is best kept moist , the
pati ent in bed , plenty of wat er admini stered. acidulat ed with lem on
jui ce if preferred, and a liquid di et pr escri bed for a few days .
Treat on ce or twi ce ea ch day until acute stage passes.
The prognosis is fa vorable for re coy er y within a few day s o r
w eek s. In young children a nd the aged . th e co ur e is more protracted, the symptom s more se ve re, and co mplica t ions are more
apt to occur, but recov ery is the rul e. Th e very aged a nd the
feeble may rar ely succumb, o r chronic bron chitis su pervene.
CHRONIC BRONCHITIS
(C h ro nic b ro nchia l ca tarrh ; seco ndary bro nchi ti ; "winter co ug h")
Chroni c br on chiti s is a n inflammation of long durati on, affecting th e larger a nd middle- si zed bronch i, very common in th e
elderl y and a __ oc ia te d with chro nic cardiac, pulm onary . and ren al
di seases, cha rac te rize d by cou gh with no ch ange in the g en er al
health .
Etiolo gy. Th e chro nic foll ow repeated a tt ac ks of acute bronchiti s ; occ urs a an occ upa tio na l di sea se am ong th ose working in
mu ch du st a nd s mo ke a nd in irritating vapors, in gout and rheumati sm a nd in th e ch roni c cardia c, pulmonary and renal ca se.
Di a gnosis. Th ere is cough of a paroxy mal nature, often more
t roubl esom e at night and in the morning. with either scanty or
copi ou s ex pec to ra t ion depending up on the variety. Som etimes
CH R ONI C BRONCHI TI S
207
sh ortness o f breath is noticed u pon exe r t ion. The conditi on do es
not u su all y impair th e ge ne ra l health excep t during ac u te exacc rbation s. Th er e a re u su all y so me a sso ciated st ruc t u ra l cha nges as
emph y sem a. o r bronc hiec tas is.
M an y cases a re assoc ia te d wi t h chro n ic ca ta rr ha l g a strit is. Th e
cou gh is ofte n a bse n t in th e sum me r.
Th ere a re four g en eral varieties.
Mucous Catar rh is the most common during the winter. and marked
by more or less violent paroxysms of coughing and the expectoration of yellowish mucus.
Dr y Catarr h has a harsh, distressing cough with a feeling of soreness or rawness under the sternum. and the expectoration of small globular
masses. This occurs particularly when associated with emphysema, gout, rheumatism, or asthma.
Bronchorrhea is associated with bronchial dilatation, occurring
most commonly in the elderly and marked by severe coughing, followed by
copious expectoration of greenish-yellow, often fetid mucus (fo ur to six pints
in twenty-four hours) .
Fe tid Bronchitis is often associated with bronchiectasis and marked by
excessively fetid odor of breath and sputum. The decomposition of the secretion within the bronchi may cause gangrene of the mucosa, or even of the
lung itself.
P er cu ssi on is norm al in s im ple, un com pli cat ed ca ses , If bron chi ect a si s is pre e n t, th cn th er e a re di ffu sed s po ts o f a m pho ric o r
tympaniti c so u nd. If em p hyse ma is assoc ia te d, th cre is h yp er -r esonan ce.
Th e r e pira to ry murmur is rou gh cn cd , ha rsh , le ss inten se th an
norm al. w ith expiration p ro lo nge d a nd fo rc ible o r w heezy. Th er e
are d iff use, b ila te ra l, so no ro us, si bi la n t o r mo is t ral e s of a ll size,
o fte n c rep ita nt a t th e ba cs , d ep end in g u po n t he a mo unt of ec re ti on. If dil atat ion i a s oc ia te d , th er e is bro nch o-ca vernou s breathin g . with larg e a nd s ma ll g urgling ra lcs, If emp hyse ma i pre c n t,
the so u nds a re modi fied accor d ing to th e ex te n t.
Sublu xations are present fr om th e occipu t to th e sac ru m.
A mo ng th e co m mone r ones fo u nd are a t las. axis, thi rd ce rvica l,
s econd t o fifth dorsal vcr teb r.e. firs t rib and clavicular lu xat io ns ,
curves ant eri or o r post eri or o f th e upp er dorsal a rea a nd co n t racti on s o f the deep spina l muscl es.
Urine may he hi ghl y acid a nd slig h t ly alb u m ino us in tho se
ca ses with a d ecid ed ac ide m ia. In ch ro nic bro nc h it is a lways exa min e th e urin e on acco u n t o f the liabil it y o f a p rima ry kidn ey co nd it io n.
Sputum. I n some ca se s is a very sm a ll am ount of tenacious
y ello w i h v i c id mu cu s; in ot he rs a white ti ck y mu cu s. In th e
chronic ca se s, t he am o unt is m ore abundant, yell owi sh , mu copurul ent, separates into three la yers , a mu cou s lay er, browni shgray s eru m, and a mu co-puru lent se d im en t.
208
THE BRONCHI
I n fetid bronchitis, the sp ut um i usu all y thin, g rayis h-white,
separating into lay ers ; th e u pper is cover ed by a frothy mu cu s,
and the lower is a t hick ed ime nt w her e m ay be foun d pea-sized
gray or yellow ma ses-D itt ric h's plu g s, bact eria , pus , leptothrix,
and fatty ac id crysta ls.
Treatment. A ca refu l exam ina t ion is necessar v to de term ine
whether the re is an underly ing organic disea e. R~l ax at i on of a ll
contracted mu scles and correctio n of th e les io ns found is of firs t
impor ta nce ; a nd th e elimina t ive o rga ns sho uld be kept ac t ive. T he
genera l hygi ene is impo rt ant a nd mu st be ca ref u lly s upe rvised.
The clothi ng sho uld be sufficient but not too warm. Room tempe ratures should be kept eve n.
The diet s ho uld be liber al , nutritiou s, a nd mi xed , inclu din g
plenty of wat er , fr esh vege ta bles , a nd fru it s.
In structi on in breathing and exer cises to s t re ng the n th e ches t
mu scl es a re important in th e y ounger pati ents. A cha nge to a
wa rm clima te for the winter is ofte n ben eficial.
Th e prog nosis is nev er dan g ero us to life unl ess associa te d with
o the r diseases.
FIBRINOUS BRONCHITIS
(Chronic idiopathic bronch itis; memb ranous, croupous, dip ht heritic or plast ic
bronch itis)
F ibrinou s bron chitis is a n inflammati on. usu all v chro nic, m ark ed
by paroxysma l co ug h, diffic ult breat hing, a nd t he expec tora tion of
fibrinou cas ts of th e larger a nd middle-si zed br onchi.
Etiology. Th e di rec t ca use is unknown . It is assoc iate d with
ast hma, emphyse ma . ty ph o id feve r a nd tu ber cul osis, a nd is usu all y
a disease of a dults.
Diagnosis. Th e sy mpto ma to logy is not diff er ent from th e
catarrhal forms, unti l th e expectora tio n of the fal se me mbrane. A
vio lent paroxysm of co ughing preced es or accom pa nies th e ex pec toration whic h reli eves th e dysp nea. Afte r more or Ie s of th e
memb ra ne has bee n rai sed , a mu co-purul ent, blood- tain ed sput um
is prese nt for severa l day s. Th er e may be a slig ht feb ri le react ion .
There are acute, subacute a nd chronic: fo rms , th e a ttac ks
recurrin g at int er val s of days, week s o r y ear s, the sa me br on chu s
being invol ved eac h tim e.
The re is d im inis he d fr emitu s and Ie ene d respi rat ory murmur
ove r th e po rt ions of lun g sup plied by th e obs t ruc te d tub e. \ Vh en
t he casts a re di slod g ed , th e murmur becom es slig htly rou gh en ed .
I n th e un a ffect ed porti on s of lung the so unds ar e norm al. If co llapse of th e lun g foll ow s, th ere is dullness. The upper portions
of th e lu ng s a re th e ofte ne r aff ected.
Sp ine. See chro nic br on chitis.
BRONCHIECTASIS
209
The sputum is muc us , the casts being rolled up and mi xed with
it, but the true nature i show n when the sputum is sha ke n in
water, appearing as littl e tubes, from th e size of a bodkin to almost
a s la rg e as the finger. The larg er on es are holl ow a nd the sma ller,
so lid, with a t ree-lik e appearance. They a re nea rly st ru ct u relcss,
of fibri lla te d ba se wit h pu s a nd mu cou s co rpus cles , a few gland
cells, occasionally a blood cell in th e oute r lay ers, man y eosin ophili c
ce lls; Charcot -Leyd en crys ta ls and Curschm ann's sp irals arc so met ime s pr esent. I nst ead o f the definite cas ts, th ere may be shre ds,
lumps, or patche s o f membrane.
The treatment i th at o f chro n ic br on chitis. Th e vapor from
alkaline olut ions seem to help di slodge th e ca st s.
The prognosis is fav orabl e if not a ssociat ed with tub er cul osis,
pneum onia , or emphy sema. I n young children it not infrequ ently
proves fatal.
BRONCHIECTASIS
(Dilatati on o f th e Lronchl )
Br on chiecta sis occu rs primari ly from traumati sm or, seco ndari ly, from chr oni c pu lmonary conditi on s wh ereby th e wall s of
th e br on chi dil ate so that sacs are produ ced, a nd clinicall y mark ed
by co ug h a nd abundant expectoration.
.
Etiology and pathology. In th e seconda ry form, co nt rac t ion o f
th e support ing lung ti sue cau ses th e wall s to y ield fro m lack o f
support. Th e cy lindrica l form is o ft en p rodu ced by v iolent co ug hing. Until the cavity is in fected, th e m embran e lin ing th e cav ity
i smoo t h with ver y thin wall s. It i mu ch more fr equ ent in th e
lower lobe s th an in the upper. The co ndi t ion ver y fr equ entl y
foll ow s an attack of "grippe." It may be wide spread o r a sing le
cavity.
Dia gnosis. The cough is usuall y ab sent during the da y, oc currin g mai n ly in th e morning. T he mode o f expect oration is ch ar ac teri tic, the patient usually rai sing an en ormou s quantity of
greeni sh-yellow sput um in the morning up on ari sing, o r up on a rising from th e recumbent position . If a sing le larg e dilatation occ urs,
th ere are th e phy sica l sig ns o f cavity.
\Vhen diffu se , the phy sical ig ns are th ose o f th e ca usa t ive d isea se, usually tuberculosi . F at al hem orrh ag e m ay occ ur from ru ptur e o f an aneury m in the wall of the ca vity.
The phy ical sig ns di sappear as th e ca vit y fills with scc rc t i n,
to re appear up on coughing a nd exp ect oration . These a re tympan y,
cracked-pot so und , bron chi al br eathing, with ral es, bron ch oph on y ,
and increased vocal fre mi t us. The s put um is a gra yi sh-brown . or
greeni sh-yellow co lor, epa rating into a brown ish frothy top, a thin
mu coid zone, and a sed im ent of almo st pure p us, sho w ing, mi cr ocopi ca lly , pu cells, epit helial debri s, la rg e fatty acid cry stal s;
•
1
210
THE BRONCHI
some t imes cho les te rin occ urs ; valerianic and butyric acids and 1-128
pr odu ce t he horri ble odo r. Cerebr al a bsc ess is a very fr equent
complicat ion.
Treatment. I s th at of the primary condition, o r if it self prim ar y, th at of chronic bronchitis.
Prognosis. It is incurable but has a pr otract ed course. The
ac ute form is unfavorable.
BRONCHIAL ASTHMA
( Sp asmodi c as thma)
Bronchial asthma is a neurosis marked by parox ysms of ex piratory dy spnea during which all the accessory respiratory muscles a re used; the diaphragm is fixed and th ere is a peculi ar loud
noisy wheezing.
Etiolo gy . It oft en occurs in neurotic familie s; may be a re su lt
of bron chial irritati on, direct o r indirect, through the blood or
nervou s syste m ; in ch ild re n it occurs from imperfect recovery
from naso-ph ar yn gea l condition s, mea sles, wh oop ing-cough, or
capilla ry br on chiti s.
Th er e a re three m ain th eori es o f its form ati on : That it is a
ne urogeni c spas m of th e in voluntary bron chial mu scle s ; a hyperemia with swe lling of th e mu cou s membran e ; an inflammati on of
the smalle r br onchioles. Acidosis is al so to be co ns ide re d.
"The etiolog ical factor s found vary cons idera bly, and include:
" Cont ract ion of the cerv ical mu scles. pro bably du e to lesions o f cervica l
ver tehrse and exe rt ing irr ita tion to the t runk of th e vagu s;
"Pleuriti c adh esion s ;
" Les ions o f th e firs t, seco nd a nd third th ora cic vert ebrre, w ith slightly approxi ma ted ribs ;
" Reflex effec ts from d ist ant orga ns include : eye-s tra in ; con tr acted sphincte r
ani . itself app ar entl y du e to a nte rior coccyx ; sca r ti ssu e in cervi x ut eri ; na sal
polyps ; ca rdiac disturban ces. especially functio na l; gast rec tasis and ot he r condition s with accumul ati on s o f gas ."- P . C. O. Clinic Report s.
Diagnosis. The re ma y be prem onitory symptom s as cory za,
br on chi al irritati on , th or acic co n triction, gast ric di sturbance, depr essin g emo tio ns o r worry , o r the passage of a qu antity of pale
limpid urine.
The Atta ck. During th e night . the pati ent a wa ke ns in great
di stress, feels as if th er e wer e no air in th e room; a sumes a cha ract eri sti c attitud e g ras ping so me s uppo rt ; fixes the sho ulde r girdle
a nd uses a ll th e acces o ry respirat ory mu scl es. E xpirati on is prolonged and acco mpa nied by a peculi ar loud noi y piping o r wh eezing . Th e face is flush ed o r cy an osed, covere d with swea t , and the
neck mu scles are pro m ine nt ; inspirati on is hort ; respirati on is not
acceler at ed, a nd lit tl e a ir ente rs th e lungs. A parox y sm of coughing
A STHMA
211
and expect orat ion g ives r elief , a nd may even t erminat e the dy spnea ;
slee p int er ven es, or a light lull occ urs b efore an other paroxy sm .
The dy spneic attack m ay la t for a n hour or b e prolo nged , w ith
more o r less sever ity , for seve ra l day s. The patient is left m or e or
less exh au st ed a nd with a cou gh for seve ra l day s. During the
att ack the th or ax is expand ed a nd fixed ; the di aphragm only
lightly moves ; th e. sp ina l mu scl es a re ri gid ; in spirati on is sho rt
an d ex piration is p ro lo nged; th e face pa le, a nxio us in exp re sio n;
spe ech is im po ibl e, and lat er, t h e face j s covered wit h perspi ra ti on. Dry, loud , wh ee zing, whi stling, sibila nt a nd so no ro us ral es
are heard on ex pira t ion; lat er , bu bbling ral es a n d vesicu la r br eathing, wh en the air enter s mor e fr eely. During th e h eight o f the
att ack , ves icu la r breathing is hidd en und er th e louder so u nds .
Percu ssion sho ws a m arked hy per -r eson an ce ove r both lungs,
du e t o an ac ut e ernp hy erna, or a vesiculo-tympanitic not e (bandbo x tone o f Bam ber g er ). Ca rd iac a nd hepat ic d ullne s a re dimi nish ed but return to normal at end of a t tac k. Afte r m an y recurrenc es. the condition t end s to m erge into a perman ent and ch ro n ic
em physema .
During the int er val s th er e ar e th e usu al sig ns o f bron chiti s, or
very lit tl e cha nge from normal.
Su blu xat ion s are apt to be fou nd fr om t he occ iput to th e coccyx
b ut th ose of th e third to fift h ce rv ica l, second to fifth dor a I, and
o f ninth and t enth dor sal a re parti cul arl y co m mo n. During th e
attack the wh ole sp inal mu scul ature is firml y co nt rac t ed. Th ere
are changes in the natural curves of th e sp ine , as t hma t ic humpback , a poste rior co ndi tio n of th e low er neck a nd th e u pper do rsa l
is fre qu ent, o r th er e are irregul ar short curves, th e wh ol e spi ne
being sti ff a nd the chest ne arly immovable.
The b lood sho ws a g rea t in crease in the eos ino ph ilic leu cocytes,
o fte n to 20% of the actual leu cocyte count. V ery high eosinophile
counts are rep orted. T he b lood pressure is g ener ally reduced.
The sputum is ex pe lle d with di ffi culty and is di stincti ve, co ns ist ing
o f ba ll-like ge la t ino us m asses (pearl of L rermac) . w hich ca n be
unfold ed and fou nd to be casts o f the sma ll bro nc h ioles; co nta ins
Curschrn ann's piral s o f two so r ts, one o f spira l thread s with
eos ino ph ilic leu cocytes enta ng le d in th e m esh es, and th e second
with a clear ce nt ra l filam ent su rrou nde d by a spiral n et work o f
st rands of mucu s. Later in the condition , th e filament s are rep lac ed
by octahe d ra l ph osphati c cr y stal s (Cha rcot- Le y den crysta ls ) in the
now mu co-purulent sput um.
T re at me nt . Tn a few ca ses, adj us t ment o f t he tipp er th oracic
vertebra: a nd r elated ri bs g ives perm an ent r elief, e peciall y wh en
th is is done during the interval s o f the attack. Occasiona lly the
sa me work done during an attack gives immediate and permanent
relief.
212
T// E BRONC/ II
"During th e attac k, r aisin g th e first, seco nd and third ri bs may g ive reli ef."
- Meacham.
"H eavy movements, sp ringi ng th e sp inal column ge ne ra lly, and ra ising the
ribs, freeing th e neck st ructures, with th e pati ent firs t upon the side, then
up on a st ool , gives imm edi ate relief."-S. C. Edmiston .
I n the in t er val s, thc genera l health mu st be b uilt up by n ut ri ti ou s, ea sil y digc stcd fuod s , th c per sonal habit s rcgulatcd if nccessa n'. I t is o ft cn necessary to t cach t h c patient a m ore rationa l
view o f life and it s ac cidents so a s t o prevent emotional storms.
Prognosis. The di sea se may be intractable. Recove ry is more
fr equ ent under os teo pa t h ic care; thc parox y sm s arc relieved more
qui ckl y a n d th e patient docs not ha ve to rec over from the effect
of drugs. Deat h seldo m occu rs from p ure ast hma.
Sequelee, T hc condition resu lt s in emphyse ma of g rea te r or less
de gree, dilatati on o f th e right heart with s u bs eq ue nt dropsy,
chronic bron chiti s, or cerebra l emboli sm . Sequelre are best p revent ed by early att ention to the a sth ma and, if possib le, it s pennan ent re lief.
BRONCHO-PNEUMONIA
(C ata rrh al pn eum oni a; lobula r pneumoni a;
cat arrh)
capilla ry br on chitis; suffocat ive
Bror cho -p nc u mo n ia is a n acute catarrhal inflammation, affecting th e ext rern c s o f life, lim it ed to the mucosa o f the mal ler and
t erminal bronchi al tub es o r bronchiole s, and the a lve oli, caused bv
th e pn eumococcu , ba cillus tuberculo sis, o r a mixed infection';
charact eri zed by fevcr, impeded and increased re pi ration, impeded
circul ation, sh ort cough, sc an ty expect oration, sy mptoms of nonaeration o f the bl ood, and great depression . Doth lu ng s a rc
affected.
Etiology. It o fte n occurs a an exten sion o f bronchitis and
infecti on by a mi x ed ba ct cri al flora; foll ow s the infectious fevers,
particularly m ea sles, pert us sis , and influen za; attack s th ose suffering from tubercul osi s, ri ck et s, a nd ot h er debilitating di seases; a nd
may be an in fect ion by the ba cillu s of tubercu losis .
An acut e primary form attack s children under t wo yea rs in
g ood he alth, and is probably a pneumoc occus infection. T here are
a spirati on and d eglutition form s, and it al so occu rs after ethe r
anest hes ia .
Diagnosis. It is u ually preceded by a m ild bronch itis, t he onse t
b ein g gradual with chi llinc ss or chill s, ri se of te mpera t u re 102 ° t o
104 ° F. of a ty p ical re mit te nt charac tc r ; th e pul se rat e in cr eased ,
100 to 120 pe r m inut e, somew hat compressi b le; th c sk in is hot,
th e fa ce flushe d, t hc h ead , n eck , a nd upp er part of th e bod y m ay
be covered wit h pcrsp iration. T hc brcathi ng becomes rapid, 40 to
80 per minute, sh a llo w, and diffic ult with an expi ra to ry m oan,
BRO XCHO -PXE~·.lIOXIA
213
d ilating alre n asi. and use o f the accessory mu c1e . I n pi ration
m ay b e ea y or di ffi cult bu t is always imper fect. Th er e i a progressive dy spn ea w it h o rthop nea. followed by th e onset o f cyanosi s, with in s pirat or y r etracti on of t h e base of t he sternu m a nd lower
co. tal ca r t ilages. The cou gh is dry . short . hacking, pai nf ul, and
soon followed by more o r less copiou m uco-pu ru lent expectorat ion. Occasionally in chi ldre n , th e ympto rns a re predorninent ly
g ast ro-i nt est in al or ce reb ra l.
A th e cyano is develops , th e pulse becomes feebl e and flick er in g ; th e co ug h is slig ht a nd supp ressed: general venous congestion
is in dicat ed by th e livid co un te na nce ; lips and na ils, blue; su rface.
cold a nd o fte n covered wi t h a clamm y pers pira tion ; th e m ind, du ll.
I n ch ild re n, st upor a nd co nv ulsion rapidly supe rve ne . The expe ct or at ion is scanty , vi scid , and di fficul t t o ra ise; th e littl e pati ent
usu all y swallo wing w hat spu t um it does ra ise ; or it alrno t cea es.
Death foll ow s fr om apnea a nd depr ession .
Th e unfav orabl e sy m pto ms are pal e and livid count en ance,
b lui sh lips. dull eyes, r estl essn ess g iving pl ace to apath y and a
progressively in cr ea sing so m no lence . D efer vescen ce is by ly sis
and is rapid. alt ho ug h se ve ral week s m ay e lapse b efor e co m plet e
r ecovery. The durati on is fr om one t o three wee ks; rarely t o three
m ont hs.
Su ppuration and g angren e ofte n foll ow th e as p ira t ion a nd deglutition form. A fibroid cha nge is th e co m mo n t ermin ati on whe n th e
cau al age n t is the bacillus tubercul o is.
Increased v ocal fr emitus is presen t if larg e a reas -are in volv ed .
The in ter vening hea lt hy lu ng g ive a more or less holl o w o r tympanic not e; th er e is incr ea ed r e ist a nce; w he n po rt ion of lun g
ar e collap ed. t h er e are circumscribed area of du llness, these bei ng
som eti m e sh ift ing. T he change are mo t marked in th e low er
lob e poster iorly, an d t her e may be co mpensa to ry ernphy ema in
the up per lobes. During th e fir t pa rt of t he di sease, th er e i a
fee bl e, h igh- pitch ed resp iratory murmur which becomes dis tan t an d
harsh as t he d isea e p rogre ses, or there may be a diff use, or basic
vesic ulo-b ro nc hia l b rea thing. E xpirat io n is leng t hened , je rky .
h ar h a nd g run ti ng. Pers i t en t u bcrepit ant do ub le ra les are hear d
ov er limited a reas, pa r t icula rly on either side of th e spine, foll ow ed
in seve re ca e by larg e mu cou ral es. Th ere m ay be u ndefined
mucou s cli ck on forc ed in spirati on. So met imes th er e are pat ch es
of tu bu lar breathing . V ocal reso na nce is incr ea sed . Th e urine is
febr ile.
The sputum is mu coid or mu co-purul ent , gl airy and vi cid, and
mav be so me wha t rtl t v o r b loo d- treak ed . It is d iffi cult to r ai se
and alm ost never ty pi call y ru sty, cea ing with failing st re ngth.
214
THE BRO .YCH I A.Y D U ; .YGS
Subacute and chronic forms are known, presenting the ame
general and ph y ical symptoms but marked by lo ng er duration and
greater exhau ti on.
Treatment. The patient is confined to bed in a well-ventilated
r oom o f even temperature, 65 ° to 68 ° F., the air being moistened
by ste a m. The position s ho uld be changed frequently in the aged
and in the very weak.
"Feed milk, eggs, broth, ice c ream and gruel fr eely; also
give plenty o f water to drink, and keep th e org a ns o f elimination
wide open. L ook carefully for upper dorsal le sion " a bo ve the
eighth, al 0 the corresp onding rib lesion s, which are 0 o fte n found
in conjun cti on . Protect the ch est by a cotton battin g jacket, but
I prefer t o om it the antiphlogi stine. I ce hags o ve r th e ch est gi\'e
comfort. I n ca se wit h high fever, sp onge the patient or apply the
we t pack. Keep close wa tc h on th e heart for sign s o f failure. and
g ive ge ne ra l relax ati on to a ssist t he ci rc u lation a nd raise the left
ri bs to re lieve th e heart ."- \V. H . Be dwe ll.
R educti on of t he t em per ature is best sec ure d by dee p, steady
pre ssu re in t he su bo ccipita l fossa , or in th e m id-th or acic reg ion .
D ur ing co nva lesce nce, t he chi ld must be ca refu lly g uarded to preve nt re lap se, a nd be bui lt u p by to nic treat m en t.
Prognosis. I n the primary cases, it is g ood, rec overy foll owing
prompt and th orough treatment.
In feeble and debi litated chi ldren and in the aged, it is unfavorab le, altho ugh recover y m ay occur in apparently very eri ou cases.
In weakly ubjects, it may terminate fatall y after a protracted
course o r d evel op into tuberculosis. The a spiration and deglutition
form are usually fata l.
CHAPTER XX II
DISEASES OF THE L UNGS
CONGESTION O F THE LUNGS
Active congestion is an ea rly sta ge in m an y pulmo na ry affecti on s, a ltho ug h this may include so m e of th e abo rt ive for ms see n
during epide m ics of the in fecti ve lung di sea ses. It is m arked by
initial ch ill , pain in the ch est , dy spn ea , moder at e cou gh , t em perature 101 0 t o 103° F . ; th e ph y sical sig ns being defecti ve reson an ce,
feebl e so m et im es bron chi al breathin g, a nd fine r al es. Simple cong esti on clears w hile the mor e se rious di seases in cr ease in seve rity.
Passive con gest ion occ u rs from thr ee cla sses of ca uses: Mechanical co nges t ion is found wh en ever th ere is an y obs ta cle t o th e
r et urn o f the b lood fr om the lungs t o the heart or, more rarely,
from t h e pressure o f tu mor s ; and is marked by dy spn ea, co ugh ,
fr othy , ofte n bl ood- st ain ed , sp ut um containing "heart di sease cells ."
Pa ssi ve co ng es t ion occasiona lly results fr om inju ry or o rga nic brain
di sea se. H yp ost atic co ngest ion is found in lon g- con t inu ed fever s
and ady na m ic sta tes, th e bases of th e lung s bein g deepl y co nges te d
part ly as a r esult o f gra vity, but ch iefly by th e weak heart ac t ion,
th e ge ne ra l sy mpto ms bein g ab sent. Th e ph y sical signs of passive
co ngest ion are slig h t bil at er al d ullness , feeble, so meti mes bl ow ing,
breath so unds, th e ba ses post eri orl y be ing pa rt icu la rly affec ted ,
m oist r al es, a nd so me t imes increa sed vocal fre m it us.
Treatment. Thi s is th e sa me as th e treatment of th e firs t stage
o f pn eumoni a ( q. v.).
PULMONARY HEMORRHAGE
( He moptysis; bron cho-pulmonar y hemorrh age ; bronchorrhagia)
H em opt y si s is th e expecto rat ion of b lood, pure or mi xed w ith
air, usu all y bri ght r ed in colo r, foll owin g th e ac t of co ugh ing.
Etiolo gy . Pulmon ar y hem orrhag e m ay be ca used by t uberculosis a nd ot he r pulmon ary di sease s ; excessive cardiac ac t ion, pa rti cu larl y in the presence o f mitral lesions, wh en it ma y be profu se
and r ecur at intervals for years ; an eury sm rupturing into th e b ronchia l ar ea; canc er or ulcer at ion of th e la ry nx , trach ea, or br on chi ;
gangre ne or infarc ti on o f the lungs; traumati sm or excessive bodi ly
exertion; in hemophi lia, pu rpura, and scur vy ; rarely as an atte m pt
at vica ri ous m en st ru ati on ; recu rri ng hem opty si s in arth r it is subj ects; endemic hemopt y sis (s ee un el er ani mal parasites) .
215
216
THE L UNGS
Diagnosis. The hemorrhage occurs suddenly, i rarely preceded
by ep istaxis, cardiac palpitation, or so m e difficulty in breathing;
b egin s with a warm sen at ion under the st ern u m , tickling in throat,
s wee t ish t aste in the mouth and coughing to remove these sens ati on s. It is foll owed by a w arm , sa lt is h, bri ght red . fro t hy, alkaline
liqu id , g u hing fr om the mouth and nose, composed o f blood mixed
with a ir a nd mucu s.
The appearance of the bl ood depresse s th e pati ent; h e becomes
p al e, and o fte n faint s. Th e at tack may su bs ide within a half hou r
or several hours. r eturning for severa l day s. th e s put u m bein g eit her
bl ood y or bl ood-streak ed . Th er e ma y be a slig h t febril e reacti on
and ch est pain s afterward a s a re su lt o f inflammation at t he s it e
o f bl eeding .
A usc u ltat io n r eveal s coarse, bubbling ra le in circ u msc r ibed
areas. It is usually bett er not t o examine the chest until th e hem orrh ag e is sto ppe d .
Diagnosis must b e m ad e from ep ist ax is by -ab en ce of air bubbl es and by in sp ecti on o f fau ce s and na sa l ca vities ; fr om hernatemesis . by the bl ood b eing vomited in st ead o f expect orated , and
bein g dark-colored , clotted , mi xed with acid sto mac h co nt en ts , and
foll ow ed by black tarry stoo ls . with absenc e of ral cs in the ches t.
Th e exceptio ns are wh en th e bl ood from th e lung is swa llo we d and
th en vo m ite d ; and wh en a large g a tric arter y is erod ed by ulc er,
but th e rai sing of suc h bl ood is preced ed by ep igast r ic pain and the
bl ood is rarely fr othy.
Treatment. Th e patient sho uld be p ut t o bed in t he do rsa l
se m i-rec u m be n t pos it ion, o r lying flat up on th e - a ffec t ed side ( denot ed by th e bub bl ing r al es ) . The bl ood ca n be div ert ed fr om the
lung s by g iv ing st ea dy pre ss ure at t he sid es o f the eigh t h to t he
twelfth th ora cic s p ino us processe s; by appl ying ice bags t o the
affec te d si de; by appl ying h eat to the extremiti es and the abdomen;
or , less effec t ively , usually, by band aging the arm s and leg s to
del ay ve no us return. Certain drugs. as m orphine, may qui et t he
pati ent and dimini sh ble eding. but the dan g er of these is great ;
th e throat refl exe s arc lost. t he patient may drown in hi s o w n
bl ood, o r he m ay succ um b to at electasis or pn eumonia. N o food
or liquid sho u ld be g iven for ab out six hours after th e hem orrhage
sto ps. an d sho u ld then be o nly sma ll am ount s o f very cold liqu id s.
or icc crea m. Prev ention o f later attack s dep end up on findin g and
rem ovin g th e cau se of the hemorrhag e.
PULMONARY APOPLEXY
(H emorrh agic infar ct; diffu se hem orrhagic infiltration)
Thi s is an unco mmon form wh er e th e bloo d is effuse d int o th e alve oli and
int er st iti al tissues. It occ u rs in chro nic heart disease, particularly mitral lesi ons,
EDEJ/A
217
in th ro mbu s o r embo lus o f th e pulmo na ry artery in septicemia. pyemia. malig nant fever s. and in certa in brai n di seases. Th e sympto ms are indefinite. usually
th ose o f pulmon ary embo lism and throm bosis. I f th e injury is very lar ge a nd
in the lower lobe . th er e a re signs o f co nso lidatio n with blowing. br eathing and
pleuriti c fri ct ion.
Treatment. P erfect rest in bed with th e head and sho ulde rs eleva te d.
with a bso lute qui et insist ed up on . th e pati ent bei ng turn ed u pon th e a ffected
sid e. if it is kn own. is esse ntial. The first thin g to do is to reassure th e patient.
Then deep steady pr essure fr om th e seco nd to th e fifth do rsa l verteb rae decreases th e ca rd iac ac tion. Pressu re ncar t he nin th and ten th lo wer s blood
pr essur e. th e blood is d raw n into th e abdomina l veins. 1\0 corrective wo rk
sho uld be attempted unt il the bleedi ng is controlled. As soon as pos ible after
th e hem o rrh age, correc tio n of th e subluxations found. usually at the third dorsal . so me ti mes f rom secon d to the seven th dor al vertebras. clavicles. upper
ribs. o r in t he ce rv ical region . will ass i t in preventing a recur rence. T he diet
must be bla nd and non -ir rit at ing. with coo l d ri nks. and ice to d isso lve in the
mouth. T he success of tr eatment depends u pon the prima ry disease, and
mea sures mu st be u sed to comba t it.
PULMONARY ED EMA
(Drop sy of the lun gs)
Pulmon ary ede m a is a n acc um ula t io n o f se ro u fluid in th e a ir
vesicl es , bron chi ol es, a nd inter ·t it ia l ti ssu es of th e lun g s. associ at ed with co nd it io ns fa voring hyp ost ati c co ngestio n . a nd clin ically mark ed by dy pn ea, cou gh, and ex pec to ra t io n o f [r ot hy , bl ood st reake d s put um.
E t iolo gy. It i assoc ia te d w it h morbid bl ood ta te as Brigh t's
di sea se, a ne mias. a lco ho lic excesses, a nd wi th co nditio ns favori ng
hypost ati c co ngest io n, as ca rd iac va lve lesion s, m al ign a nt fever ,
paraly si s, and lon g -continu ed lyin g o n th e back. It m ay occ u r
after the use o f pil ocarpin . Th e co nd it io n m ay a lso follo w asp iration of th e th orax . Upper th oraci c a nd rib lesion s pr edi sp ose.
Dia gnosis. The o ns et is usu all y s ud de n with dy spnea o r
or t hopnca : the breat hing is h ur r ied , la bu ring and ratt lin g ; all th e
a cce ssory mu scl es arc used . P a in in th e c hes t . se nse o f o p pressio n
and an xi et y a rc ex t re me. Th e co ug h is s ho rt. co ns ta nt. a nd hara ssing. foll o wed by ex pec to ra t ion o f co pio us, foa my . sero us. blood st reake d spu tu m . Th e ca rd iac ac t io n is tremulou s o r feeble. Th e
face is flush ed a t fir t , hut a s the left ve nt r icle fail s, o r if th e efi us io n
into the a lveoli prevent s th e e nt ra nce o f s u fficie nt a ir, sy m pto ms o f
cyan osi s rapidl y foll ow , a s show n by th e feebl e pul ...e. cu ld s urface ,
s ha llo w hurri ed breathin g, su p pr e se d co ug h, restlcs ness repl aced
by stupor, which soo n deep en s into co ma .
Percussion is not resonant at first , oo n he coming dull at th e
ba se s post eri o rly. Th e breath so u nds arc deficient, weakened , with
SUbcrepitant and bubhling rales o f an unu sua lly liq uid cha rac te r.
The se cond pu lmonic cardiac so und is accentuated. Hyperten sion
u su all y precedes the edema.
218
THE L UNGS
T he treatment is t hat of th e cau se, by rem oving the obs t ruc t ion
to th e circ ula t io n a nd sec ur ing fr ee elim ina t ion. R elaxati on is indicat ed ; raise t he ri bs and clav icles to reli ev e th e dy spnea. Inhalati on s of oxyge n m ay be necessary in sev ere ca es.
P rogno sis. Piilmon ar y ede ma m ay prove fat al within a sho rt
tim e, o r be reli eved to recur lat er. It is es pec ially g rave when co mpli cating pn eumoni a, a nd in ca rd iac or ren al di sea ses. In the
majority of ca ses it is a terminal affec t ion.
COLLAPSE OF THE LUNG
Collapse o f th e lung is a part of ot he r di sea ses, but is associated
with definite ph y sical sig ns , a nd is of severa l typ es.
Con genital coll ap se, o r a te lectasi , occ urs in weakl y new -b orn
in wh om th e in spirat ory pow er is not sufficient to pr op erl y inflate
the lungs.
Ca ses due to pressure from without , as in pl eural o r peri cardial
effu sion or pn eumoth orax, m ay present collapse of th e wh ole lung .
Ca se s a re so met imes du e to wound s of th e ch est wall and perforati on of th e pl eura.
O rdi na ry or lobul ar co llap e o fte n occu rs in th ose case 0 1
bron ch opneumoni a w hich co mplica te o r foll ow measles, wh ooping
cou gh, or oth er condition s.
Collapse ma y be du e to par al ysis of th e respirat ory mu scl es,
th e elas t ic recoil of th e lung ti ues be ing a ide d by abso rption of
air by th e blood ve els.
Diagnosis . If a n exten sive ar ea is inv olv ed , a ny exi stmg
dy spn ea becom es incr eased , th e pul se more rapid, a nd cya nos i may
foll ow . In slig ht cases, th e sy mpto ms of th e prim ar y di sea e o nly
ar e present-th e "grip py chest " of m ild er cases of bron ch opneuand po sibly tubul ar
moni a. If th e a rea is ex te ns ive, d ullne
breathin g a re pr e ent.
A usc ultat ion di scl oses s ubc re pita nt ralcs and weakened re spiratory murmur.
T reat me nt . Th e pr im ar y disease mu st recei ve fir t attention .
Th e pa tie nt mu st be tau ght full br eathing, holding the lung full
of a ir for pro gressively len gth ening peri od s. If th e heart is good ,
cold showe r bath s, o r ha vin g cold wat er poured up on the ba ck of
th e neck , st im ula tes th e re pirat ory o rga n. Car e mu st be u ed ,
lest th e shoc k to th e heart be serious.
Prognosis. When th e condition i due to pre sure, as in emph y sema, th e o utloo k is ver y g rave. \ \ 'hen th e a rea inv olv ed is
not g rea t, a nd no ac tive inf ecti ou s ag ent is pr esent, sy mpto matic
r ecovery may be expect ed.
E.lIPHYSEMA
219
EMPHYSEMA
( Al veola r ectas is)
Th is te rm is applied t o severa l rath er widely di ffer ent co nditio ns, a ll o f w h ich are cha rac ter ize d by th e pr esen ce of abno r ma lly
larg e a ir spaces in th e lu ng s. T wo c1 as es a re recognized-inte rlobu lar a nd vesic ula r.
Interlobular or Interstitial Emphysema is th e p rese nce of a ir
spaces ou ts ide th e lung cav ity, in th e in te rs t itia l ti ssu es, o r rarely
en t ire ly outs ide th e o rga n. It is du e to ru pture o f th e a lveo la r wa lls '
durin g vio lent ex pira to ry effo rt. Th e ca uses inclu de: violen t co ug hin g, as in wh oop ing -cou gh or br on ch iti s ; ur g ent st ra ining, as in
part u riti on , defecati on , mu scula r effo rt, o r hyst eri cal fits ; a nd
inj uri es t o t he lung, a s sta b or g uns ho t wounds, etc. Th e a ir
usu all y esca pes u pon t he anter ior aspec t of an upper lobe ; if it
esca pes fro m ot he r a reas , it is a pt to wo rk u p wa rd throu gh th e
med iast inu m , u ntil it r eaches th e neck regi on, wh en it s furt her
pr ogress is imp ed ed. O ne o f my cases ( Burns) had a sac as la rg e
as a walnut , u pon t he upper as pec t of th e left su pe rior lob e. U nless bact eria a rc ca r r ied in wit h th e a ir, no harm result s. No t reatment is required.
Vesicular Emphysema is du e to dil at ati on of th e a lveo li. Se veral typ es o f thi s a rc recogni zed , eac h wit h ce rta in pecu liariti es.
Compensatory or Inspiratory Emphys ema is a co ndit ion in
whi ch a portion o f th e lung ex pa nds to t ak e the place of a co llapsed
po rt ion, as in b ron ch opn eum oni a , pleu rit ic ad he ion s, or in a n area
of old tuber cul ar cicat rice.
Atrophic or sma ll-lu nged cmp hy erna is d ue t o p rima ry seni le
at rop hy of th e lung , th e ches t a rid lun g s bein g sma ll.
H yp ertrophic, subs ta n tive, o r ex pira to ry emp hyse ma, wh ich is
th e usu al form, is d ue to th ose ca uses w hic h keep up a mor e o r Ie s
per si st en t high in tr a-al veol ar t en sion , suc h as playin g on wind
instrum ent s a nd g lass- bluwing; occ upa tio ns involv ing seve re s t ra in
or hea vy lift ing ; chro nic br on chit is ; her edity , p roba bly depending
up on co nge nita l weak ness of th e elas t ic ti ssu es of th e lung . A ny
o f th ese ca uses produces ovcrdi ten sion o f th e ves icles ; at ro phy
o f th eir walls; oblite ra t ion o f th e blood vessels and a co nse que nt
d imin uti on o f t he oxygena t ing a rea; cha nge in t he ches t co nto ur ;
cha nges in t he right heart ; ge ne ra l changes due to imp erf ect
oxyge na t ion; and o fte n a n a ssociat ed b ron chi ect a sis. Th e condi t io n is clin ica lly m arked by the phy sica l sig ns , dy sp nea, a nd a
ch ro nic br on ch iti s.
Diagnosis. Th e g ene ra l sy m pto ms a rc not man y until th e co nditi on is we ll ad va nce d a nd consist o f dyspn ea a nd cya nosis from
th e deficien t ae ra t ion. T he se are g rea tly in cr eased on ex erti on, and
220
THE Luxes
th e pati ent is a ble to go ab out with cyanosis of an extreme grade;
mor e or less co ugh from associated bronchiti ; retention of waste
pro du ct s wit hin th e blood causing variou di sagreeable symptoms;
th e tem per ature is subno r ma l; the surfa ce of the body, coo l ; and
th e pul se is weak. Hypertrophy and dil atation of the right heart
with it s sy mpto ms of ge ne ra l ve no us stas is foll ow .
Th e chest is lar ge, barrel- shaped, with round sho ulders ; the
dorsal cur ve of the spine is increa sed and rounded ; th e scapulre
a re a lmost hori zont al , th er e ar e promin ent ste r n um , clavicles, and
ste rno- mas to id mu scles, a deep ste rna l fo sa ; th e int erc ostal spac es
a re wid ened, th e vertical diam et er i elo nga ted. The neck vein s are
di st end ed . Th e aux ilia ry mu scles are used. Prolonged expiration
with a s ho rt in spiration is not ed . A zo ne of dil ated venules may
be found a lo ng th e line of attachm ent of th e di aphragm.
Vocal fremitu s is dimini shed, the cardiac impul se is depressed
and nearer the ste rn um , the ap ex being o nly rarely palpable. Epiga stric pul sati on may be present.
There is a drum-lik e note to the hyper-resonance which extends
to the sevent h and eig ht h rib a nteriorly and to th e twelfth post eri orl y, if th e wh ole lun g is in vol ved . Th e ar ea s of cardi ac and
hep ati c fulln ess a re encroac he d u pon; th e mar gin o f th e lung are
fixed in th e position of full in spirati on from the di sappearance of
elas tic ti ssu e. Th e ves icula r murmur is so ft a nd we ak, eve n ab ent ,
dep endin g up on th e am ount o f br onchiti s present. The breath
so unds a re wheezy a nd harsh on ex pira tion. Th e fir t cardi ac ound
is Ie enc d in inten ity and duration; the se co nd sharply ac centu ated.
Treatment. The br on chiti s ofte n associat ed with emphy sema
mu st recei ve a tte ntio n. \ Vhatever ot he r cau sative fact ors are found
mu st be rem o ved , if thi s is possible. During expirati on. an att endant sho uld exe r t pr essure up on th e th orax, relaxing as in spiration
occ urs . I nspiration aga in t pr es ure up on the ribs gives exer cise
to th e inspirat ory mu scl es, th ou gh thi s is of less importance. A
nurse ca n he taught to g ive thi s manipulati on , and the exerci ses
sho uld he se lec te d after du e st udy of th e pati ent's conditi on, and
espec ially th e positi on s of th e ribs. I t is best to see that rib lesion s
ha ve been well corrected bef ore any s t re n uo us me asures are advised. Cardi ac lesion s a re to be sus pec te d. a nd no violent ex ertion
permitted until th e sus picion ha s been allayed.
Breath ing in co mpressed air, and br eathing out into negative
pr es sure, tend s to rem ove the su pe rfluo us air, and to give exercise
to th e mu scl es of re spiration. Rai sing the ribs and clavicles often
g ives reli ef.
Th e ge ne ra l h ealth mu st be maintained in everv wav. The
hygi ene, exe rcise . die t, are th ose o f th e und erl ying cau se, plu the
measures indicat ed in chronic br onchitis. Sudden attacks of
ABSCESS
221
dy spnea may occur, and these , th ou gh rarely fatal , are se r ious . In
such ca ses oxygen may be required for reli ef.
The prognosis is clouded . P ati ents se ldo m di e from th e co nd iti on. \Vh en the emphy sema is a oc ia t ed wit h a sthm ati c attack s,
the pr ognosis is more se rious. Cardiac chang es are fr equ ent, a nd
d eath may be du e to injury t o the right he art. Gen er al ede ma may
terminate th e condition.
PULMONARY GANGR E NE
Infecti on o f th e d iseased ti ssu e by any of th e pro teo ly t ic orga nism s may re sult in g an gren e o f th e lun g s. It may foll ow ab scess
or pneumoni a, esp eciall y in ve ry old peopl e, o r th ose in w ho m th e
bodily resist an ce is greatly lo wer ed for a ny rea son . Th e most
important di stin cti ve diagn ostic sy m pto ms are th e odo r of th e
br eath and the g en er al sy m pto ms o f toxemi a. Treatm ent o f thi s
di sea se is o f very little usc. D eath usu all y supe rve nes w it h in a
very few da y s.
ABSCESS OF T HE LUNGS
Pu lm on ar y ab scess result s from th e in fecti on o f th e lun g s by
an y o f th e py og eni c o rga n ism. Sta phy lococc us or st re ptococc us
are the most fr equ ently found . Th ese may inf ect ti s uc alrea dy disea sed by pn eum oni a o r tu bcrcul o is.
" Cold Abscess" may be du e to inf ecti on by th e tu ber cle bacilli,
or by ac t ino myces. Abscess o f th e liver may pe netra te th e diaphrag-m a nd drain th rou gh th e lun g-s. In this case. th e prese nce
of bil e in the sp ut u m gives th e di agn osis.
Treat ment. Drain ag e throu gh th e br on chi may be sufficient ,
and recover y oc cur pontan cou sly. If dr ain ag e is not co m plete,
the treatm ent i th e su rg ica l evac ua t ion of th e pu s, Re ec t ion of
on e or more rib s may be necessary .
In an v case th e tr eatm ent sho uld inclu de a careful examina ti on o f th e condition o f the liver and th e kidn ey s. Th e circ ula t ion
throu gh th ese org a ns and th e splee n sho uld be kept ve ry fr ee, in
order that the norm al bact eri cid al co nd itio ns o f th e bod y ma y not
be interfered with.
The progno si s is grave in any ca se.
PNEUMOKONIOSIS
Thi s t erm is app lied to th e co nd it ion o f the lun g s alm o s t uni versa lly pre sent in t he cit ie , or eve n in country plac es. wh ere so ft
coa l is bu rn ed. T he inha lati on of particl es of soo t is in evit ab le.
Th ese are taken up by t he w hite blood corpu sc les, o r are pa ssed
J
_
222
THE L UN GS
t h ro ugh th e alveola r epithelium into th e ly m ph cha nne ls. Th e
connective t i s ues a re co lo re d dark g ray or b lac k, a nd th e bronc h ia l
lym ph n od es are ve ry deeply colored. T he a lveola r cell s th emse lves m ay b e perm eat ed with t he b lack particles.
\ Vh en t hi s di scolorati on is du e t o part icles o f coa l, a s in miner s,
th e t erm " a nt h ra cosis" is used .
T hose w ho wo rk in sto ne a n d breath e th e fine pa rt icles o f t h is
du st s uffe r fr om " ch alicosis."
Those w ho w ork in ir on a nd breath e t h e fine part icl es o f thi s
du st suffe r fro m " sider osis."
I n all of th ese ca ses, th e r esistin g ca pac ity of t h e lu ng s is di minishe d appreciab ly . Th e in jury t o th e ep it heliu m lo wer s t he resist a nce t o in fect ion s, and thu s, pn eum ok oni o sis rnu t be con id er ed
o ne of th e ca uses of p ne u mo n ia, tu ber cul o is an d ot he r les co mm on d iso r de rs.
RARE PULMONARY CONDITIONS
Hydatid Cysts m ay be found in th e lu ng s.
It is possib le t o di agn ose thi s co nd it ion o nly w h en t h e hook let s
are found in th e sp u t u m w h ich , in s uc h cases, is u su all y thin an d
wa te ry . Lung stones are ra rely found.
Bronchial Calculus. C. C. \ V right repor t s a ca e of b ro nc h ial
calc ulu s wi th r ecovery. Th e calc ulus w as "a hard . jagged sto ne
o f a dirty w h it e co lo r, nodul a r co ra l-like s u rface . and und er st ro ng
g lass look ed lik e bon e. Its dim en si on s we re 12 by 9 by 6 m .m ..
and w eight 10 grain s. No b lood foll owed it -a nd no so re ness preceded o r follo we d it s exp u ls ion."
Primary Carcinoma is ve ry r ar e in th e lung . It is u su all y found
in th e u pp er lob e o f th e ri ght lun g , a nd it may at ta in g rea t s ize.
_Second ary ca rc ino m a is usua lly fr o m mamm ary ca rc ino ma . th ou g h
it m ay follow sim ila r g ro w t hs a ny w he re else in th e bod y . These
seconda ry tum or s a re u uall y s ma ll a nd ve ry num er ou s.
Sa rcoma is u su all y secon da ry , and it s most fr equ ent or ig in is
in th e p u lmo nary lym ph at ic g la nds .
Diagnosis. P u lmo na ry n eop la m are r arely suspec ted a n te
m ort em . T he X -ray may g ive th e di ag nosis. Th e o nly treatm ent
is sy m pto ma t ic, a n d th e p ro g nosis is ex t re me ly g rave . D eath
usu all y occ u rs within a few m onth s a fte r th e first v rnp to m a re
n oti ced.
PLEURISY
( P leuritis)
Etiology. Inflam m ation o f th e pleura is u su all y th e r es ult o f
infl ammat ion of th e lung s. It is a lmost in vari abl y pre en t in pn eu m onia , tu bercul o is, b ronc hi ti , or in almo t any o t he r p ul mo na ry
PLE URISY
223
inflammation. The few prim ary cases are due either t o trauma
or t o seve re ex posu re to co ld and we t. R ep eat ed a t tac ks in dicat e
pulmon ary tu ber cul osis.
Syste m ic disease, suc h as rhe u matis m, nephri ti s, alco ho lis m,
ma y cause pl euri sy with littl e o r no lun g in vol vem ent. Th e right
pl eura ma y be infl am ed in cases o f hepat iti s. Three form s o f
pl euri sy are described: th e ac ute, subac ute, a nd ch ro nic.
Acute fibrinous pleurisy , dr y pl euri y, o r ac ute pl asti c pl euri sy
is th e most co m mo n co ndit ion. The di ease begins wit h a se nse
of di scom fort, foll ow ed by dy s pnea a nd pain in o ne side of the
trunk, "st itc h in th e side." Th er e is a littl e co ugh, w h ich is s uppressed on account o f the pain whi ch it pr odu ces. A slig ht fever
may be present. Th e sy m pto ms may be ve ry mild a nd th e attack
last on ly a few da y s . A t ot he r tim es, th e sy mp to ms are mu ch mor e
seve re and a cute, a nd ma y last for severa l w eek s, or m ay t erminat e
fata lly.
Treatment. Th e m ost imp ortant part o f the treatm ent is th e
relief of th e pain . P ainful are as ma y be st ra ppe d w it h band s of
ad hesive tape. Rib lesion s sho uld be co rrec te d at the be ginning
o f the di sease, if thi s is po sible. It is freq ue nt ly im possibl e to
correct the rib Ie ion s after th e inflammati on has becom e pronounced. H ot and cold applica t ions m ay reli eve th e pain. Co u nt er-irritation may be indi cat ed . R est in bed is always necessary
during th e acute sy mpto ms .
Progn osis. M ost ca es r ecover in a few day s unl ess th er e is
so me mark ed pulmon ar y di sease. E ver y at tac k p red isposes to further attacks . \ Vhe n th e inflamm at or y process does not disa ppea r,
th e co nd it ion m ay pa s in to th e subac u te or th e chro nic form .
Suba cute pl eu ri sy, pl euri sy w ith eff usio n, sera-fib ri no us pl euri sy , m ay foll o w th e ac u te a t tac k, but it usu all y beg ins w it h a
mu ch low er seq ue nce of ym pt orn s. A fte r a day o r two of pai n ,
slig ht co ugh, dy spn ea. th e norm al sec retions begi n to be co nside ra bly in cr eased . Th e fluid may acc u m ula te to suc h a n ex te nt
a s to exe rt co mpress ion up on th e lun g s or t he heart. Dy spn ea is
progressively mor e marked . Th e ca rd iac di sturban ces may be
ver y severe.
The dia gnosis rest s up on th e area o f dulln ess whi ch ma y change
with the cha ng ing position of th e pa t ient. Th e normal heart an d
breath so unds a re muffled by th e fluid ove r th em.
Diaphra gmatic pleurisy is a ssociated with nau sea, VOl111tll1g,
pain in t he pit of the sto mac h , and other sy mp to ms of ga strointestin al di sturban ces. Th e X -ray m ay be helpful in diagn osis.
En cy sted effu sion is du e to the adhesion of the inflam ed pleural
m embra nes ar ou nd an accu mu lation of flu id w hic h may inc rease
in qua ntity through a con siderable extent.
224
THE L UN GS
I nt erloba r pleuri sy occ up ies the reg ion between th e lobes o f the
lungs and ma y drain into a bronchu s. Hemorrhagic pleurisy is
du e to the ex t rava a tio n of blood into the pl eural exudate.
Abo ut three-fourths of the ca es of su bac ute pl euri sy a re tubercul ar in o rig in, th ou gh th e tubercl e ba cilli are rarely found in the
fluid. Th e co nd itio n ma y be a part of the sy mpto ms of acute articul ar rh eum ati sm .
A fever of usu all y not more than 103 F. may be pr esent. The
whole co urse o f th e di sease is slo w a nd co nv a lescenc e is usually
great ly ret arded . Tuber cul ar cases ofte n re co ver from th e.pleu risy,
thou gh the pulmon ar y eli ease may foll ow it s usu al co urse.
On e of th e most important fact ors in th e ca us e of pleu risy is
the ex is te nce o f rib lesi on s. Th e inflam ed ar ea ma y be cove red by
t he ribs o r ma y be o n a s ide of the th orax o ppos ite t he ribs, wh ose
adjustment is imperfect. It mu st not be forgotten, how ever, that
the refle x mu scular contracti on s due to th e inflam ed pleura ca use
th e a ppro x imat ion of t he rib s and the di sturbance of their s t ru ct ura l
re lations.
0
Chronic adhesive pleurisy m ay follow an y of the ot her ty pes of
pleuri sy mentioned . I t may or ma y not be assoc ia te d with con siderabl e effu sion . So met imes both form s ar c found pr esent at the
sa me tim e ; th at is, th e two la y er s o f th e pl eura may be a d here nt
with co nnec tive ti ssue band s o f varying st re ng t hs , whil e the areas
not adh er ent a rc engaged in pouring o ut an a bunda nt fluid . Thi s
form is es pec ia lly fr equ ent in chro nic rh eum ati sm a nd in nephriti s.
Th e pain is w ell locali zed a nd is in cr eased by mo vem ents of the
th orax , or the a r ms , by deep respirati on, o r by co ug h ing. The
eff usio n may emba r rass th e re spiration and the heart 's acti on to a
con sid er abl e ex te nt.
Paracentesis is ne cessary when the accumu lation of fluid be com es g rea t eno ugh to interfere with the respiration a nd the ci rcula t ion to an y great ext ent. It may have to be repeated many
tim es. Occasio na lly a s ing le draining is foll ow ed by adh e ion of
th e ple ura l membran e.
T his form does not usually sho rten life, but it predi sposes to
o t he r di sea ses, and ma y make life a very unco m forta ble matter.
EMPYEMA
(Purul ent pleuritis or pleuri sy; pleuritic abscess)
Th e infect ion o f a pleurit ic ex udate may re su lt in empyema.
Th e infect ious agent m ay gain entrance in to th e b ronchia l cavi ty
by careless par acentesis, or it may be ca rr ied fro m a n inf ecti ou s
area elsew here in t he body by m ean s of th e blood st rea m . Direct
exten sion from pu lm onary ab sce sses o r from th e liver o r a ny ot he r
abdomina l ab scess t hrough t he d iap h ragm is rare. A n exa m inat ion
THE MED IAS TINUM
225
of the pus ma y sh ow an y of th e pyog eni c orga nis ms si ng ly or in
combination .
Diagnosis. Th e dull area is usu ally rath er less in extent th an
is the ca se in pleuri sy w it h effus ion. Th e pa in may or may not
be very severe. The con stitution al sy mpto ms a re mu ch mor e
marked th an in ot he r form s o f pleuri sy. Th e fever may reach lOr
F . Th e blood how s marked leu cocy tosi s. Pepton uria and ind ican ur ia a re usu all y present. Castro-in test ina l sy mpto ms are t hose
ordinaril y associa te d wit h th e feve r.
Pul sat ing empye ma (pu lsa t ing pleuri y, empyema nccessitas).
is due to th e prese nce of co nsi de rab le amounts of pus, wa lled off
and circum scr ibed by adhesions of th e t wo ple ura l layers a round it.
Treatment. Th e pu s shou ld be evacuated and t he wa ll of t he
ca vity th or ou ghl y clean ed as soo n as a diagnos is is made. Resecti on of one or mor e r ibs is ofte n necessa ry in orde r to provi de sufficient dra inage.
\ Vith ea rly dr ainag e, rest in bed a nd th e t reat me nt o f suc h
sy mpto ms as may co mp lica te th e case, recover y sho uld be expec te d.
In old p ~opl e , o r in th ose in w ho m th e vita lity is grea t ly lo wer ed
for an y reason , th e pr ogn osis is ve ry se r ious .
Sequelae. Th e dan g er of metastatic ab ces es m u t be kept in
mind. T he pus or bact er ia may be carried in t he bloo d to th e liver ,
th e br ain , k idn eys, o r a ny ot he r organ in th e body . Wi th sep t icemi a , th e pr ogn osis is mo st erious.
PNEUMOTHORAX
Pun cture of t he th or acic wa ll, or as "t he result of a n in jury to
con sider abl e of th e a lveo li, may perm it a ir to ente r t he intrath or acic
cavity a fte r pulmo nary abscess. Th is co nd itio n is ca lle d pn eum oth orax. Rarely , ae roge n ic org an isms may inf ect th e pleural cavit y.
The treatm ent is surg ica l.
HYDROTHORAX
(Dropsy of the plcura; thoracic dropsy)
The acc um ulat ion of no n-in flam mato ry fluid in t he pleu ra l cav ity
is du e to th e ame cond itio n w hich ca uses d ropsy el cw he re in th e
body ; th at is, neph rit is, cirrho is of the liver, valvular les ions of
th e hea rt. etc. T he tr ea tm cnt is th at of t he u ndcrly ing disease.
P ar acent esis may be nece sa ry.
DISEASES OF THE MEDIASTINUM
Th e di sea ses of th e medi astinum are not ve ry fr equ ently found.
Lymph ad eniti s may be pr esent. Ab scess in th e medi astinum is due
226
THE L UNGS
to abou t the same ca uses as before men ti on ed for empy em a. Either
abscess o r tumor s may ex te nd into th e m edi astinum fr om the
esophagus, b ro nc hi or lun g s. H em orrhage of the m edi astinum is
du e to r up t ure of a th or acic ane urysm.
The symptoms pr od uced by t hese tumor s a re mostl y du e to
pressure. In m et a tat ic growths th e diag nosis re ts upon find ing
t he original tu mor . In certai n lym phom a tou s tumor s, excising a
sma ll g lan d from the neck for micr oscopi cal ex a mi na tion may gi ve
useful inf orm ati on .
Com pr ession of t he aorta ma y g ive murmurs like those of
ao rt ic ste no is. U neq ua l pulse in th e t wo ra dia ls is ap t to follow
compression of th e left sub clavian o r the innomi nate ar te ry.
Wh en the esophagu s is affe ct ed , dy sphagia and pain result. The
bougie or X-ray examination, esp eciall y with thi ck barium pa ste,
sho uld show the cau se of th e sy m pto ms . Pressure up on the
phre nic may g ive ob tin at e attacks of hi ccou gh. Pre ur e u pon
ot he r ne rves gives va ry ing pa in, w eakn ess. pup illa ry dist urba nces,
g astric sy mpto ms, hy per idrosis a nd ot he r sy m pto ms refer a ble to
the fun cti on of the affecte d ner ves.
Th e positi on and sha pe of th e m edia sti num va ries norm all y
d ur ing respirati on . a nd ab no rma lly as th e re ult of pa t ho logic al
cha nges in it s neigh borin g o rgans. Pl eural or pe rica rd ial effus ions,
pne umotho rax, an d ot he r variat ions in th e size or th e sha pe o f t he
lungs or the heart, m ay cause m ark ed variation s in the size and
form of the m ediast inum . Infl amm at or y chang es m ay r esult in
cica t ricial thi ck enin g a nd thi s ma y Ie se n th e normal ela ti city of
th e medi a tin al wa lls; t he co ntraction of thi s new t issue m ay pull
th e media tinum into a distinctl y lat er al position.
Neo plas ms of the med iastinum include th ose from Iyrnph nod es,
as in H od gkin's di sea se o r lymphad en osis ; sa rco ma , whi ch may be
prima ry or seco nda ry ; carcin oma, whi ch is probably alway econda ry. o r th e pec uliar th ymus-sarcom a or th ymu s-carcin oma.
D errn oid s may be found in th e m edi astinum. Supernum er ar y
th y roid masses may be found ; th ese cau se no sy mpto ms unl ess
th ey under go hypertroph y o r hyperplasia , as in goit er. Echinococcus cysts , tu bercl es. g ummy masses. a re not ofte n found.
In all th ese cases, diagn osis is di ffi cult o r imp ossibl e and treatment ext re me ly dou btful. The X-ray may be of value in diagno is.
The prognosi s is always very se riou s.