Complete Text (Part 21)

They have slightly raised edges, and their floor is studded with granulations covered with unhealthy pus. (See Fig. 1, 166 THE THROAT. Plate I. ) In the neighborhood of the margins of the ulcers are often seen miliary nodules. The glands of the neck are, as a rule, swollen. What are the subjective symptoms ? Pain is the chief symptom present. It is most intense on swallowing. The pain may extend to the ear through Jacobson's nerve. The other symptoms are loss of appetite, emaciation, loss of strength, night-sweats, cough, and hoarseness. Give the diagnosis of tuberculosis of the pharynx. The only disease the physician is apt to mistake it for is syphilis. The differential diagnosis between syphilitic _ and tuberculous ulcerations is given below. (It is Bosworth's classification somewhat modified by Lennox-Browne. ) Syphilitic Ulcers. Tuberculous Ulcers. Deeply excavated. No apparent excavation. Few granulations, and those highly Much indolent granulation. inflammati try. Deep-red areola. Faint areola. Sharply-cut edges. Irregular and ill-defined edges. Distinct demarcation. Demarcation indistinct. Yellow purulent secretion. Grayish, ropy mucous secretion. Discharge profuse. Discharge scanty. Penetrating to deeper tissues. Superficial, with lateral in place of deep extension. No fever. Fever. What is the prognosis? The prognosis is unfavorable. What is the treatment of tuberculosis of the pharynx ? In the local treatment the main object to be sought for is the allevia- tion of pain. This is best accomplished by the application of a 10 per cent, solution of cocaine. Insufflations of morphine are also useful. For the^ destruction of the ulceration Krause of Berlin recommends the application of lactic acid, first scraping away the granulations by means of a curette. Lennox -Browne recommends the use of the galvano- cautery. Steam inhalations are grateful, especially those containing menthol. Sucking of ice. often alleviates the pain. The food should be soft in quality, such as thick soups, broths, etc. Where the dys- phagia is extreme the patient should be fed by means of Delavan's tube or per rectum. Constitutional treatment should receive special atten- tion, and consists chiefly in the administration of cod-liver oil, the hypo- phosphites, etc. NEUROSES OF THE PHARYNX. 167 NEUROSES OF THE PHARYNX. Give a short description of anaesthesia of the pharynx. Anaesthesia of the mucous membrane of the pharynx can either be central or peripheral in its origin. Among the central lesions with which it occurs may be mentioned tumors of the brain, lateral sclerosis, bulbar paralysis, etc. It occurs in epileptic seizures, in cholera, typhus, and in hysteria. It is most frequently observed, peripherally, as a sequel of diphtheria. Certain drugs, such as cocaine, morphine, chloral, the brom- ides, may induce anaesthesia. The diagnosis is made by objective examination. The affected por- tion is insensible to chemical or mechanical irritation. As a rule, the reflexes are reduced or completely lost. ' The^ treatment consists in the local application of electricity and the administration of strychnine. Describe hyperesthesia of the pharynx. Hyperesthesia is an increased sensitiveness of the mucous membrane, especially when an attempt at a laryngoscopy or rhinoscopic examination is made. It may be due to an elongated uvula or chronic pharyngitis, and is seen in excessive drinkers, smokers, and nervous individuals. The treatment consists in the application of cocaine when a laryngo- scopy or rhinoscopic examination is desirable. Chloral hydrate and bro- mide of potassium are recommended. What is paresthesia of the pharynx ? Paresthesia consists in abnormal sensations in the pharynx. These may be a pricking or burning, a feeling of soreness, but most commonly as if a foreign body, such as a hair, a needle, a piece of bread, etc., were present. It occurs in chronic catarrh, chiefly in granular pharyngitis. It is seen in anaemia, chlorosis, phthisis, neurasthenia, and in hypochon- driacs. Lennox-Browne is of the opinion that these sensations are symptomatic of some objective, but not always discovered, cause. Among the causes he mentions are — 1 , varicose veins at the base of the tongue ; 2, hypertrophy of the pharyngeal tonsil ; 3, slight enlarge- ment of the thyroid gland. What is the treatment of paresthesia of the pharynx ? It consists in the removal of hypertrophied tissue by means of the galvano-cautery, the internal administration of bromides, and the local treatment of any catarrhal conditions present in the nose or pharynx. To what are motor paralyses due ? They may be of cerebral origin. When they are, they are the result of injury or disease of the brain and pneumogastric ; if of peripheral origin, they are the sequel of various local diseases. 168 THE THROAT. What is the treatment? The treatment consists in the application of electricity and the admin- istration of strychnine and tonics. TUMORS OF THE PHARYNX. What tumors are occasionally met with in the pharynx ? Carcinoma, sarcoma, cysts, fibroma, lipoma, papilloma, and angioma. Give the symptoms and treatment. The symptoms vary according to the size and situation of the tumor. When sufficiently large it gives rise to disturbances of speech, difficulty in swallowing, and difficulty in respiration. The treatment consists in extirpation where this is possible. This can be effected by means of the galvano-cautery, snare, or knife. FOREIGN BODIES IN THE PHARYNX. What foreign bodies may lodge in the pharynx ? Fish-bones, chicken-bones, needles, pins, tacks, bread, false teeth, etc. What are the symptoms? The symptoms vary according to the size, situation, and character of the foreign body. Pointed articles cause sharp pain when swallowing or speaking. They may cause inflammation, oedema, and ulceration, and, through piercing a blood-vessel, serious hemorrhage. Large foreign bodies in the lower portion of the pharynx may give rise to difficulties of breathing, and even to suffocation by pressure on the epiglottis. For- eign bodies may also lodge in the sinus pyriformis. Patients may swal- low a foreign body and eject it again. This fact should not be lost sight of during the examination. What is the prognosis ? The prognosis is, as a rule, favorable, but serious consequences may ensue, even leading to death by asplryxia, or by hemorrhage when a blood-vessel has been perforated. What is the treatment for foreign bodies in the pharynx? The foreign body should be first located by examination, the laryngeal mirror serving as an aid. Where this is impossible the finger should be used, and the foreign body often can be removed by its means. When seen it should be extracted by means of forceps. DISEASES OF THE TONSIL. What are the causes of acute tonsillitis ? Among the predisposing causes of this affection may be mentioned a rheumatic or tuberculous diathesis, hereditary influences, and sudden DISEASES OF THE TONSIL. 169 changes of temperature. It is most prevalent between the ages of twelve and thirty. The usual exciting cause is exposure to cold and dampness. Lennox-Browne mentions as other causes those which are septic in their nature, such as the drinking of impure water and the exhalations of sewage gas. What are the symptoms ? The disease may involve the parenchyma of the organ, parenchyma- tous tonsillitis, usually leading to the formation of an abscess when deep seated. When the crypts of the tonsils are involved, with the exudation of a cheesy matter from the follicles, it is called follicular tonsillitis. Subjective symptoms are, as a rule, present, a chill marking the onset of the disease. This is followed by fever, headache, pains in the back and limbs, and loss of appetite. A feeling of dryness is experienced, soon followed by pain which is severe in character, especially on swal- lowing, and often extends to the ear. The speech becomes thick and unintelligible. Hearing may be impaired, as also the senses of taste and smell. Some difficulty is experienced in making an examination, owing to the pain caused by movements of the jaw. The tongue is heavily coated, and the affected tonsil or tonsils will be seen swollen and inflamed. In some cases there is considerable peritonsillar swelling, especially if there be formation of pus. In the follicular form the mouths of the follicles are covered with a creamy, cheesy exudation. With the finger one may be able to detect whether suppuration has taken place. What is the prognosis? The prognosis is, as a rule, favorable, a fatal termination being the exception. What is the treatment of acute tonsillitis ? A cathartic should be administered at the beginning of the attack. Guaiacum, given early, is regarded as a specific. _ It may be given in the form of lozenges, powder, or the ammoniated tincture. A teaspoon- ful of the latter should be given at a dose, and can be taken in a half glass of milk. After two or three days, scarification, when much inflam- mation exists, has been recommended. This practice is condemned by some authors. The application of warm poultices is beneficial. Ger- man authors recommend the application of cold. This can be applied by taking a cloth, wringing it out in cold water, and applying over this a perfectly dry cloth. Gargles, steam inhalations, sucking of ice, warm drinks, have all proved serviceable. In the follicular form Bosworth recommends 2 drachms of the tinc- ture of chloride of iron to 2 ounces of glycerin. Of this a teaspoonful should be administered every two hours without water. Where suppu- ration has taken place incision with a bistoury is indicated. 170 THE THROAT. Give the etiology of hypertrophy of the tonsils. Hypertrophy of the tonsils is usually a disease of early life, rarely occurring after thirty. It may occur as a sequel of scarlet fever, measles, or small-pox. Repeated attacks of catarrh in tuberculous chil- dren are said to lead to this condition. What are the symptoms ? Where there is considerable enlargement nasal respiration is inter- fered with, and, as the condition is usually associated with adenoid vegetations in children, the patient sleeps with the mouth open and snores loudly. Speech is thick and full, and hearing is often impaired. The face where there is considerable enlargement assumes the expres- sion so pathognomonic of adenoid vegetations. On inspection the con- dition is easily recognized. What is the treatment of hypertrophy of the tonsils ? Where there is but slight enlargement astringents may be used, such as the perehloride of iron (5j to sj), alum, or tannin. Where sufficiently large the tonsils should be removed. This can be effected by means of the tonsillotome. The tonsillotomes chiefly used are those of Matthieu and Morell Mackenzie. Each of these has its advocates. When the tonsil is so large that the application of the tonsillotome is impossible, then the wire-loop ecraseur may be used. Serious hemorrhage is rare, and can usually be checked by ice-water or the gargle of tanno-gallic acid recommended by Mackenzie. It is composed of 6 drachms of tan- nic acid and 2 drachms of gallic acid in an ounce of water. Half a tea- spoonful of this should be sipped at short intervals. Lefferts recom- mends in severe cases of hemorrhage pressure within the mouth and counter-pressure outside. The galvano-cautery is highly praised by some, and is advocated by Knight in patients with a hemorrhagic tendency. DISEASES OF THE UVULA. What are the causes of relaxed throat or elongated uvula ? This condition is frequently met with in those affected with chronic catarrh or those addicted to excessive smoking, overuse of the voice, and drinking. Also gastric disturbances are mentioned as causes. What are the symptoms? These vary. A desire to clear the throat is present on rising in the morning ; cough as a result of irritation ; and when lying down at night the relaxed uvula causes considerable trouble, and may even occasion spasm of the glottis. The voice is easily fatigued, and there is often pain after using it, On inspection, the patient holding his tongue, the uvula is seen lying on the tongue. ADENOID VEGETATIONS. 171 What is the treatment of relaxed throat ? First is the use of astringents, and of these alum in the proportion of gr. xx to Sj may be used every two or three hours as a gargle. (Gargle of chlorate of potassium is^ often useful.) The application of chloride of zinc gr. xxx to 3J, combined with internal treatment, often effects a cure. Where these fail and the symptoms continue troublesome, abla- tion of the uvula should be performed. In this operation the uvula is well drawn out with forceps, and removed just above the point of junc- tion of the mucous membrane with the body of the uvula by means of scissors. Uvulotomes have been devised, and are used by some. The bleeding may be excessive, but is easily checked. The diet after the operation should be liquid or soft. Soothing gargles should also be given. ADENOID VEGETATIONS (HYPERTROPHY OF THE PHARYNGEAL TONSIL). What is the etiology? This condition occurs chiefly in childhood and adolescence, and is rarely seen after the age of twenty. A "lymphatic temperament," ac- cording to Loewenberg, predisposes to it, Acute and chronic inflamma- tions of the nose and pharynx, occurring as sequels to scarlet fever, measles, and whooping cough, may give rise to it. What are the symptoms ? These consist in change in voice, with loss of resonance, the words sounding dull and muffled ; inability to breathe through the nose, there- by compelling the patient to breathe through the mouth. The patient, as a rule, sleeps with the mouth open and snores loudly. As a result there is drooping of the lower lip, and the face assumes that heavy, stupid expression so pathognomonic of this condition. Sense of hearing- may be affected, varying from slight ringing in the ears to a high degree of deafness. The senses of taste and smell also suffer. The patient may complain of pain in the occipital or a sensation of pressure in the frontal region. In children, if the condition be allowed to progress, the patient becomes anaemic ; chest remains flat, undeveloped, and sunken in. The diagnosis is, as a rule, easily made. The history of the case, with the characteristic facial expression, aids greatly in making a diagnosis. Where examination is possible the growths are readily seen. Where this is impossible, the index finger passed into the naso-pharynx will confirm the diagnosis. What is the treatment of this condition ? The treatment consists in its removal. For this purpose the cautery has been recommended where the growths are not large. Guye of Am- 172 THE THROAT. sterdam uses his finger-nail to scrape away the growth. Lennox-Browne of London uses a curette connected to the finger by means of a cylinder, which also acts as a finger-shield. Chiari of Vienna uses a cold snare, introduced through the anterior nares. This method is effective, and has the advantage of causing but little bleeding. Probably in the ma- jority of operations the post-nasal cutting forceps are used. They con- sist of a pair of curved forceps with sharp cup-shaped blades at their ends. These require to be introduced several times before the growths Fig. 59. Fig. 60. Fig. 61. are completely removed, and also the use of an anaesthetic. An instru- ment which of late has proved highly effective for the removal of these growths is Gottstein's newly-improved curette. This instrument has a curvature specially adapted to the anat- omy of the naso-pharynx, so that there is no danger of removing or injuring any of the structures other than the hyper- trophied pharyngeal tonsil. In perform- ing the operation the instrument is intro- duced sideways into the patient's mouth, passed beneath the soft palate and up along the anterior wall of the nasophar- yngeal space, with the cutting edge di- rected toward the posterior wall, until the vault of the pharynx is reached. The physician then places his left hand behind the patient's head in order to hold it securely, depresses the handle of the instrument so that the cutting edge is brought directly in front of the growth, and with a backward and downward movement of the in- strument removes it. The advantages are — quickness, no necessity for an anaesthetic, and thoroughness, provided the instrument be properly introduced. By reference to Figs. 59, 60, 61 , and 62 the instrument and its method of introduction can be seen. THE LARYNX. Fig. 62. 173 Gottstein's Curette. THE LARYNX. ANATOMY OF THE LARYNX. Give the anatomy of the larynx. The larynx is situated between the trachea and base of the tongue. It is composed of cartilages connected by ligaments and membranes and acted upon by muscles. The cartilages are nine in number — three sin- gle and three pairs. The single are the thyroid, cricoid, and epiglottis ; the pairs are two arytenoid, two cartilages of Santorini, and the two car- tilages of Wrisberg (Fig. 63). The thyroid cartilage consists of two plates united at an acute angle, forming a projection known as the pomum Adami. To the angle are attached the vocal cords and the thyro-arytenoid muscles. The superior horns are connected with the hyoid bone by the thyro-hyoid ligaments and the thyro-hyoid membrane. The epiglottis is attached to the upper margin of the thyroid by the thyro-epiglottic ligament ; below the thyroid is connected with the cricoid cartilage by the crico-thyroid membrane, and to the arytenoids it is united by the vocal cords and the thyro-arytenoid muscles. The cricoid cartilage, receiving its name from its resemblance to a ring, is connected with the thyroid, as seen above, and on it rotate the aryte- noids ; it also serves for the attachment of muscles. The arytenoid cartilages are situated at the back of the larynx, and articulate by their bases with facets on the upper and posterior part of the cricoid. Each has two processes — one, external, the processus mus- 174 THE THROAT. cularis ; the other anterior, the processus vocalis, which is visible through the laryngoscope. The arytenoid cartilages are connected with the epiglottis by the ary- epiglottic folds, and with the thyroid by the thyro-arytenoid ligaments.