Complete Text (Part 20)

the diagnosis may be made of a lesion of the laby- rinth. When the deafness exists in only one ear, the use of the tuning- fork aids in a diagnosis. Prognosis is bad in all these cases, especially so in Meniere's disease. The treatment recommended is iodide of potassium, iodide of sodium, strychnine, and the use of electricity. That the disease can be of syphilitic origin should not be ignored ; hence an antisyphilitic treat- ment should not be neglected. DISEASES OF THE THROAT. THE PHARYNX. ANATOMY OF THE PHARYNX, PALATE, AND TONSILS. Briefly give the anatomy of the pharynx. The pharynx is a space which extends from the base of the occipital bone above to the anterior surface of the fifth cervical vertebra below. It communicates anteriorly with the nasal and oral cavities, laterally with the middle ear, and inferiorly with the oesophagus and larynx. It has a fibrous investment, the pharyngeal aponeurosis, a mucous lining, as well as a muscular coat. The mucous membrane is covered with columnar ciliated epithelium as low down as the level of the floor of the nares; the rest of it is covered with squamous epithelium. The mucous membrane of the upper portion, or naso-pharyngeal space, is of importance, as on the upper posterior and lateral walls it is rich in cellular structures and abounds in follicles. This follicular mass bears the name of adenoid tissue, pharyngeal tonsil, or Luschka's tonsil. What is the chief function of the pharynx ? It consists in carrying the food after mastication into the oesophagus. The muscles which effect this are the stylo-pharyngei and the pharyngeal constrictors. Besides this chief function it has duties in relation to nasal respiration, tone-production, and hearing. Describe the palate. The palate forms the roof of the mouth, and consists of two por- tions— the hard palate in front and the soft palate behind. The hard palate is bounded in front and at the sides by the alveolar processes ; behind it is continuous with the soft palate. It is covered with mucous membrane, which is closely united with the periosteum. In the middle line is seen a ridge which terminates anteriorly in a small papilla. This papilla corresponds with the inferior opening of the anterior palatine fossa. The mucous membrane is corrugated, covered with squamous epithelium, and contains numerous glands which lie between it and the surface of the bone. 159 160 THE THROAT. Describe the soft palate. It is attached to the posterior border of the hard palate. It is made up of muscular fibres, aponeurosis, vessels, nerves, adenoid tissue, mucous glands, and is covered with mucous membrane. Hanging from its middle is a small process, the uvula, and running down from the uvula on each side are two folds of mucous membrane, called the pillars, anterior and posterior. What are the muscles of the palate ? They are the levator palati, tensor palati, palato-glossus, palato- pharyngeus, and azygos uvulae. Describe the tonsils. The tonsils are two almond-shaped organs situated between the ante- rior and posterior pillars on each side of the fauces. The surfaces of the tonsils present a number of orifices leading into small recesses, from which numerous follicles branch out into the substance of the gland. In the healthy subject they do not project beyond the pillars of the fauces, and hence are not seen. INFLAMMATIONS OF THE PHARYNX. Give the etiology of acute pharyngitis. Persons of a tuberculous or rheumatic diathesis and those of sedentary habits are predisposed to attacks of acute pharyngitis. It is said to be most frequent in children. Cold is, as a rule, the exciting cause of this condition. It often occurs as a complication of other affections, such as acute rhinitis, acute tonsillitis, etc. What is the pathology? There is engorgement of the blood-vessels, with an infiltration of round cells in the mucous membrane ; the glands become enlarged, and their action is interfered with by the dilated blood-vessels. As the dis- ease advances the secretion of the glands becomes increased. What are the symptoms ? In a large number of cases the constitutional symptoms are slight, consisting of some headache, lassitude, with perhaps a slight febrile dis- turbance. In other cases these symptoms are more marked. The attack is often preceded by a chill, followed by considerable fever. The local symptoms are first a feeling of dryness in the throat, followed by pain, which may be very severe, especially on swallowing. The patient has the sensation of a foreign body in the throat, causing repeated acts of swallowing. There is a desire to hawk and clear the throat. The voice is muffled, and the secretion, which at first was arrested, becomes in- creased. On inspection the posterior pharyngeal wall is seen congested. The congestion may be present on the posterior pillars and the posterior portion of the soft palate. In other cases congestion of the anterior PLATE I :m^ Fig. 1— Fauces and Pharyngeal Wall in Phthisi^ Fig. 2.— Acute Pharyngitis and Tonsillitis with (Edema of the Uvula. Fig. 3— Chronic Pharyngitis with Bifid Uvula. (Face page 16 1 ) INFLAMMATIONS OF THE PHARYNX. 161 pillars of the fauces and the uvula is noticed. The tonsils may also be involved. (See Fig. 2, Plate I. ) What is the prognosis ? The prognosis is favorable, provided the inflammation does not spread to the larynx. The disease may become chronic. What is the treatment of acute pharyngitis ? Opium and quinine may be given at the onset of the attack. A preparation of mercury, followed by a saline, is recommended by Lennox- Browne as a first step in the treatment. Where constitutional diatheses are present these should be treated by appropriate internal remedies. Locally, the use of gargles is recommended by some and discounte- nanced by others. When given, one containing chlorate of potassium should be prescribed. Lozenges of guaiacum are often grateful, and should be given internally as well as locally, especially when a rheumatic diathesis is present. The sucking of ice often gives relief to some, while the taking of warm drinks gives relief to others. A 4 per cent, solution of cocaine gives temporary relief where there is much pain and congestion. Lennox-Browne especially advocates the use of menthol, employed in the form of a paint or spray. Seiler recommends the use of nitrate of silver in a strong solution, 60 grs. to ^j. What is the etiology of chronic pharyngitis ? It may be the result of repeated attacks of acute pharyngitis or the result of extension of an inflammation from one of the neighboring cav- ities, chiefly the nose. It is a common affection in those addicted to the use of alcohol and tobacco, and is frequently seen where disturbances of the digestive apparatus exist. Give the pathology. There is dilatation of the blood-vessels, with serous infiltration of the tissues and thickening. The glands are found dilated, and after an acute exacerbation there is an increased secretion, due to over-stimulation of the glands. What are the symptoms? There is a feeling of dryness in the throat, which is generally relieved by a drink of some kind. The patient often experiences the sensation of a foreign body in the throat, and endeavors to relieve it by hawking and coughing. On examination the fauces appear swollen and relaxed. The uvula is, as a rule, seen to be more or less elongated. This elonga- tion of the uvula produces a tickling sensation and cough, which may become very troublesome. The mucous membrane may or may not ap- pear congested. A varicose condition of the smaller veins is noticeable in some cases. The examination not infrequently gives negative results. (See Fig. 3, Plate I.) 11— Eye 162 THE THROAT. What is the prognosis ? As regards life it is favorable. Persistent treatment often effects a cure. What is the treatment of chronic pharyngitis ? An avoidance of the causes that give rise to it must be enjoined. Where disturbances of digestion are present they should be remedied. Where irregularity of the bowels exists, calomel, Hmryadi water, etc. should be given. Where the symptoms are slight, the use of a gargle of chlorate of potassium often gives relief. Local applications should be made use of; nitrate of silver is one of the best. This should be ap- plied daily by means of a cotton-applicator or brush. Sajous recom- mends it in the strength of 40 grains to the ounce. Chloride of zinc, 30 grains to the ounce, is also useful similarly applied. Where tonics are indicated they should be administered. Where extreme elongation of the uvula exists amputation often becomes necessary to remove some of the distressing symptoms. Give the etiology of granular pharyngitis. Mackenzie states that the chief cause of this condition is over-exer- tion of the voice, and that therefore it is found to exist chiefly among those who are compelled to make frequent use of the voice, such as lawyers, clergymen, etc. There is said to exist in some persons a predis- position to this disease, especially in those of a tuberculous diathesis. As an exciting cause l ' cold ' ' is said to be the most common. Others attribute this condition of the throat to an excessive use of tobacco. It occurs most frequently in the young and middle-aged, and the male sex are more affected than the female. Those obliged to work in an atmosphere where the vapors of certain chemicals exist are liable to attacks of this disease. What is the pathology of this disease ? The chief pathological change in this condition, besides the changes present in chronic pharyngitis, is a blocking up of the follicles, and as a result swellings, so that small elevations appear on the wall of the pharynx. What are the symptoms? Usually at the beginning of the disease the patient experiences a sen- sation of dryness in the throat, which may disappear only to return again. In those compelled to use their voice frequently hoarseness and loss of power are noticed upon the least exercise of the voice. A sensation as if a foreign body were in the throat is often experi- enced, and as a result there is a constant desire to clear the throat. The discharge is usually muco-purulent. Cough is present in a large number of cases, and the larynx often becomes implicated. On inspec- tion the mucous membrane is seen to be covered with small elevations. INFLAMMATIONS OF THE PHARYNX. 163 varying in size and number. As the disease advances these elevations increase and coalesce with each other. In color they are reddish. When the patient gets an acute attack, they become greatly congested and inflamed. What is the prognosis ? This affection presents no danger to life. Under appropriate treat- ment, conducted over a long period of time, a cure is often effected. What is the treatment of granular pharyngitis ? The treatment should be both constitutional and local. Where any disorder of the general system exists, internal treatment should be con- bined with the local. Where constipation or disturbances of the diges- tion exist, appropriate remedies should be given. The local treatment consists in the destruction of the granulations. For this purpose the galvano-cautery, carefully used, is one of the best methods. Cocaine may be applied before using the cautery to alleviate the pain. Nitrate of silver in solution, beginning with a weak solution and gradually increasing the strength, persistently applied for a long- period of time, is said to often effect their removal. It may be also used in the form of the solid stick. Morell Mackenzie recommends the use of the London paste for their removal. Give the etiology of atrophic pharyngitis. It is a form of chronic pharyngitis, and may be a sequel of the hyper- trophic condition. It may be also due to irritation from post-nasal dis- charges : it is frequently observed in atrophic rhinitis" and in those ex- posed to the vapors of smoke, dust, etc. Breathing and sleeping with the mouth open may cause this condition. What are the symptoms? Dryness, a tendency to swallow in order to moisten the parts. On ex- amination the pharynx is seen to be glazed, dry, and shining, and is sometimes covered with masses of discharge of a muco-purulent nature. What is the treatment of atrophic pharyngitis ? Any constitutional disorder must be remedied by proper treatment. If nasal trouble, this should also receive attention. Locally, the parts must be kept cleansed, and applications of nitrate of silver, chloride of zinc, or a solution of iodine and glycerin applied. Gargles of chlorate of potassium are also serviceable. In children the administration of tonics, such as cod-liver oil, syrup of iodide, iron, etc., should not be neglected. Give the etiology of retropharyngeal abscess. Retropharyngeal abscess occurs most frequently in children. The majority^ of cases are idiopathic in their origin. Tuberculous and syph- ilitic patients seem especially predisposed to it. It occasionally occurs as 164 THE THROAT. the result of scarlet fever. It is sometimes caused by traumatism. Necrosis of the vertebrae is present in a few cases, though this condition is rare. What are the symptoms? In most cases the symptoms are inappreciable until swelling takes place. In some cases slight systemic disturbances may be present, such as chill, headache, etc. When the disease has advanced and there is considerable swelling, dysphagia is present, and possibly dyspnoea. The voice is thick and nasal resonance is absent. When the abscess is situated laterally, the patient holds his head toward the healthy side. There is often present an effort to clear the throat, as if endeavoring to get rid of a foreign body. On inspection, when the swelling becomes sufficiently advanced redness with bulging of the mucous membrane is recognized. By means of the index finger fluctuation can be detected if pus is present, What is the prognosis? The prognosis in cases occurring idiopathically is favorable. In those occurring as the result of caries of the vertebrae the prognosis is less hopeful. Where there is a considerable quantity of pus present and spontaneous evacuation occurs, suffocation may result. What is the treatment of retropharyngeal abscess ? Where pus has formed evacuation by means of an incision at the most dependent portion of the abscess is indicated. This can be done by means of the laryngeal knife. As soon as the incision is made the head should be promptly bent forward to prevent the pus from entering the larynx. To avoid this danger some advocate the use of the trocar. Where suppuration has not taken place, ice should be applied exter- nally and internally. In children with a tubercular diathesis internal treatment by the administration of cod-liver oil, syrup of the iodide of iron, etc. should not be neglected. SYPHILIS OF THE PHARYNX. Give the etiology. Primary syphilis of the pharynx (chancre) is rare, though a number of cases are reported. It is usually the result of direct inoculation through kissing, through the use of improperly cleansed eating utensils which have been used by a syphilitic individual, or it may be the result of certain unnat- ural practices. Secondary and tertiary syphilis of the pharynx are more common than the primary. What are the symptoms? In the primary form the symptoms are, as a rule, very slight. The glands under the angle of the jaw are often found painful and swollen. On inspection there is seen ulceration, which is superficial. The mucous TUBERCULOSIS OF THE PHARYNX. 165 membrane may be slightly swollen, and on touching the ulceration the base is found to be indurated. In the secondary form there is a slight dryness of the throat, with some pain on swallowing. On inspection an erythema of the pharynx may be noticed, which is usually well defined. Mucous patches are present in a large number of cases. These are usually seen on the anterior pillars and the fauces, though they may show themselves in any portion of the mouth. At first they are ele- vated, but later become slightly ulcerated, changing in color to a gray- ish-white. They cause considerable pain on swallowing. In the tertiary form a gummatous tumor is first noticed, which soon breaks down and ulcerates. The ulceration may be situated on one of the pillars of the fauces, on the tonsils, or on the soft palate. The ulcerations have sharply-cut edges and are covered with an ichorous- looking pus. Ulceration of the soft palate is liable to lead to perfora- tion. When ulceration occurs on the posterior wall of the pharynx, adhesion with the soft palate may result, the parts healing together. The subjective symptoms are, as a rule, not well marked in the tertiary form. Pain is not usually present. Where there is destruction of the soft palate the voice becomes impaired. What is the prognosis? The prognosis as regards life is favorable, except where there are extensive destruction and ulceration in the tertiary forms and the pro- cess spreads to the base of the skull or vertebral column. What is the treatment of syphilis of the pharynx ? In the secondary form, where mucous patches are present, iodine or the solid nitrate-of-silver stick should be applied. Internally mercury should be given. In the tertiary form the ulcerations should be touched with the nitrate of silver applied in the form of the solid stick. Insuf- flations of iodoform are often useful. Internally, iodide of potassium, beginning with small doses and gradually increasing the dose, should be administered. TUBERCULOSIS OF THE PHARYNX. Give the etiology. Whether tuberculosis of the pharynx ever occurs as a primary affection is still an open question. It is generally admitted to be a secondary manifestation of tuberculosis occurring in some other organ of the body. Describe the objective symptoms. Tuberculosis of the pharynx is seldom seenin the stage of infiltration. Usually the_ process has already advanced to the stage, of ulceration. The ulcerations are lenticular in shape, and their extension is more superficial than deep.