becomes swoUen and there is copious irritating discharge from the nostrils.
The conjunctivae are also involved as is shown by suffusion and increase of
HAY FEVER. 609
lachrymal secretion, and in marked cases the catarrhal condition may spread
to the ears as evidenced by tinnitus and impairment of hearing. There are
often severe headache and marked mental depression.
In certain patients the attack is characterized by cough, with or without
expectoration, and asthmatic dyspnoea.
Rhinoscopy reveals a tiirgescence of the nasal lining which is glossy, opales-
cent in hue and covered with a thin, viscid serous secretion.
Treatment. With regard to prophylactic and interparoxysmal treatment
it is sufl&cient to insist that aU pathological intranasal conditions should
receive proper treatment by the rhinologist. The septum and the turbinates,
particularly, should be carefully examined for abnormality.
The constitutional dyscrasia, nervous or lithsmic, should receive careful
attention, especially for the month or so before an expected attack. The
former may be benefited by combinations of the zinc salts, belladonna, phos-
phorus and arsenic. For the management of the latter see p. 252 and ff.
The prevention of an attack by change of climate, when convenient, is
always advisable. A sea voyage taken at the time of an expected paroxysm
wiU often prevent its occurrence as wiU residence in various mountain or sea
side resorts such as those provided by the White, Catskill and Adirondack
mountains and Beach Haven, N. J., Nantucket, Mount Desert, etc. The
same climate wiU by no means be efficacious in aU patients, consequently
experimentation may be necessary before the proper one for an individual
case is found.
The local treatment of the attack consists in the use of various sprays and
local applications of which probably the best is adrenalin chloride. This
agent acts by constricting the swollen and inflamed mucous membrane and
diminishing the secretion. It may be best applied by means of the nasal
applicator or spray in strength of i to 2000 or i to 4000 in pure olive oil. An
oily solution of i to 1000 strength is obtainable and may be diluted as the
case requires. Before the use of the oily solution the nasal mucous mem-
branes should be cleansed of secretion by means of an alkaline spray.
Cocaine sprays or applications, 2 to 4 percent, in strength, are useful but
the danger of engendering the cocaine habit renders their routine employ-
ment iU-advised.
Suprarenal extract may also be given internally in doses of 5 to 10 grains
(0.33 to 0.66) every two hours during an attack but should be stopped as soon
as the physiological action of the drug, as evidenced by palpitation or vertigo,
is noted. When these symptoms have disappeared the extract may be again
administered in less frequent dosage, every three or four hours for instance,
and the intervals gradually increased as the nasal symptoms become ameli-
orated.
Quinine in doses of 10 to 20 grains (0.66 to 1.33) a day may be given during
39
6lO DISEASES OF THE RESPIRATORY SYSTEM.
an attack and belladonna and potassium iodide are said to be of benefit at
times. The nervousness and restlessness to which patients suffering from
an attack of hay fever are prone may be controlled by the bromides, hyoscya-
mus or chloral, and the conjunctivitis may be relieved by the application
of a saturated solution of boric acid or by dropping into the eyes every two
hours a drop or two of the following formula: Zinc sulphate, i grain
(0.065); camphor water, i drachm (4.0); saturated solution of boric acid to
I ounce (30.0).
Recditly there has been an attempt to elaborate antitoxins from the pol-
lens of certain plants, notably, ragweed and golden-rod, which may be used
as immunizing agents, and Dunbar asserts that he has prepared an effi-
cacious serum by inoculating horses with a substance prepared from pollen
and drawing from them the blood-serum. This antitoxin may be used in its
fluid form, or dried to a powder, as a snuff, and excellent results are reported
from its employment.
DISEASES OF THE LARYNX.
ACUTE CATARRHAL LARYNGITIS.
.etiology. Acute laryngitis may be caused by exposure to cold and wet,
or by the inhalation of irritating gases or dust. It is predisposed to by exces-
sive smoking, the abuse of alcohol, excessive use of the voice and by previous
attacks. It may complicate the acute infectious diseases. With it are fre-
quently associated catarrhal inflammations of the nose, throat, trachea and
bronchial tubes.
Pathology. Early in the inflammation the mucous membrane lining the
larynx is reddened, congested and dry, after about twenty-four hours there is
an increased exudation of mucus and a diminution of the redness and con-
gestion; examination by means of the laryngoscope reveals swelling and red-
ness of the lining of the larynx and of the true and false vocal cords.
Symptoms. Of these the most prominent is hoarseness; the voice is husky,
reduced to a whisper, or lost. There is cough, at first dry and husky, later
with the expectoration of mucus. At times it may be stridulous. There
may be pain in the larynx which is increased on swallowing and in the severer
cases there is a moderate rise of temperature. Dyspnoea may be present.
This symptom varies in intensity from time to time and in rare instances
respiration may cease and death result. Cases complicated by oedema of the
glottis also suffer from dyspnoea depending upon the degree of the oedema.
Usually the disease lasts from ten days to two weeks. Recovery is the rule.
Treatment. In the milder cases the patient need not be confined to bed
nor need the diet be restricted, but he should be kept in a slightly damp
SIMPLE CHRONIC CATARRHAL LARYNGITIS. 6ll
atmosphere at a temperature from 70° to 75° F. (20.5° to 24.0° C.)- The
pain and discomfort may be relieved by the application of hot or cold com-
presses or the ice coil to the throat. The cough may be controlled by the
following formula: I^ codeinse, gr. v (0.33); aquse amygdalae amarae, §ss
(15.0). Misce et signa 5 to 15 drops (0.33 to i.oo) every two hours; small doses,
gr. i^ (o.io) of Dover's powder are also useful. The dryness of the mucous
membrane and the hoarseness may be rendered less distressing by the adminis-
tration of tartar emetic in doses of ■j'ho to 5-V (0.0006 to 0.0012) of a grain.
As a sedative inhalation the following formula may be employed. I^ potassii
bromidi, gr. x (0.66); cocainas hydrochloridi, gr. v (0.33); aquae destillatae, 5v
(20.0).
Frequent inhalations of medicated steam often afford relief. Many sub-
stances have been used a few of which are appended. Compound tincture
of benzoin i to 128 of boiling water. Compound tincture of benzoin and
paregoric of each i part to 128 parts of boiling water. Turpentine and
eucalyptus may be used in the same fashion.
As the acuity of the inflammation subsides applications of tannin or alum
mixed with an equal quantity of starch, should be made to the larynx, by
means of the powder blower, or astringent sprays, such as zinc sulphate,
gr. XXX (2.00) or zinc chloride, gr. xv (i.o) to the ounce (30.0) of water or
liquor antisepticus or tincture of iron chloride, rr^xxx (2.00) to the ounce (30.0)
of water, should be employed,
In the prolonged cases change of climate and the administration of tonics
are indicated.
SIMPLE CHRONIC CATARRHAL LARYNGITIS.
-Etiology. Chronic catarrhal laryngitis may be the result of any of the
causes predisposing to acute laryngitis, such as abuse of the voice in public
speaking or singing, and it may follow repeated attacks of acute laryngitis.
It is also predisposed to by nasal obstruction.
Pathology. Examination of the larynx reveals moderate swelling of the
vocal apparatus, the mucous membrane is yellowish-red in color, the vocal
cords are thickened, their edges are irregular and there is thickening of the
mucous membrane lining the posterior commissure. Ulcers or erosions,
when present always bilateral, may be observed over the processus vocalis.
Either or both of the vocal cords may be relaxed.
Symptoms. Of these the most noticeable is hoarseness which may vary
from a slight huskiness of the voice to almost complete aphonia. Use of
the voice may cause pain. Cough, due to laryngeal irritation is a frequent
symptom, and the patient may raise mucoid or muco-purulent sputum in small
or, at most, moderate quantity.
6l2 DISEASES OF THE RESPIRATORY SYSTEM.
Treatment. Persons subject to throat disorders should avoid undue ex-
posure to cold and wet and excessive use of the voice. The abuse of alcoholic
beverages and tobacco should be forbidden and the patient warned against
the inhalation of dust and irritating vapors. In this connection the wearing
of a respirator may be recommended, and, if convenient, a change of climate
advised.
Any constitutional condition which may influence the local lesion should
receive appropriate treatment, and all functional disturbances — digestive,
etc. — sfiould be regulated, as well as all pathological conditions of the nasal,
naso-pharyngeal, or pharyngeal structures.
The local inflammation may be best treated by astringent sprays such as
the following: Zinc chloride or sulphate 30 grains (2.0) to the ounce (30.0)
of water or liquor antisepticus; iron and ammonium sulphate one drachm
(4.0), or silver nitrate 10 grains (0.66), or tincture of iron chloride one to two
drachms (4.0 to 8.0) to the ounce (30.0) of water; 2 to 3 percent, solutions
of alum or I to 2 percent, tannic acid solutions are also useful. While the
larynx is being sprayed the patient should be directed to inhale so that the
medicament may be drawn into contact with the inflamed area; also it should
be remembered that in order that the application may have its full effect,
the larynx should be sprayed with an alkaline solution (dilute liquor anti-
septicus for example) before the use of the astringent.
Long standing cases with considerable hypertrophy of the tissues may be
benefited by sprays of zinc iodide 15 grains (i.o) to the ounce of water or
liquor antisepticus or of such a mixture as the following: I^ iodi, gr. iv (0.24);
potassii iodidi, gr. x (0.66); zinci iodidi, gr. xx (1.33); zinci phenolsulphonatis,
gr. XX (1.33); liquoris antiseptici, §iv (120.0).
Applications by means of a brush are useful and any of the above astringents
added to a half -ounce (15.0) each of glycerin and water may be used. A
10 percent, resorcinol solution may also be applied by this means.
Such applications as the above should be made daily at first, but later the
interval may be lengthened, depending upon the success of the treatment.
The use of medicated steam inhalations such as those described under the
treatment of acute laryngitis (p. 611) may be advisable, or solutions of alum i
to 10 grains (0.065 to 0.66), iron perchloride, 2 to 5 grains (0.13 to 0.33) or
zinc sulphate i to 5 grains (0.065 to 0.33) to the ounce (30.0) of water may
be employed in the same manner.
Lozenges or troches may be employed for local effect and they may also
have, through the stimulation of the mucous membrane of the throat, a reflex
action upon the larynx. The drugs which may be used by this means are
cubeb, ammonium chloride, benzoic acid, guaiac, rhatany, potassium chlorate
and lactucarium. An astringent troche consisting of tannic acid i grain
(0.065), gallic acid, catechu and kino each 2 grains (0.13), is often useful and
SPASMODIC LARYNGITIS. 613
convenient where for any reason local treatment by sprays or direct applica-
tion is not readily applicable. When irritating cough is present tablets of
heroine — ^V to Y2 o^ ^ grain (0.0027 to 0.0055) — ^^7 ^^ prescribed.
Powder insufflation is found useful in many cases. Powders of equal
parts of alum and starch, tannic acid and starch or borax and starch may be
employed as well as sedative powders such as morphine acetate 2 to 10 grains
(0.13 to 0.66) to iodoform 4 drachms (15.0).
Gargles are less effective than the foregoing means since it is very difficult
to reach the site of the lesion by this form of treatment. They may be em-
ployed, however, if considered advisable, and may consist of alum, i drachm
(4.0); zinc chloride, ^ drachm (2.0); zinc phenolsulphonate, 2 drachms (8.0);
potassium chlorate, 2 drachms (8.0); phenol, 20 grains (1.33); acetic acid, 2
drachms (8.0) or boric acid, 4 drachms (15.0) to 8 ounces (250.0) of water.
SPASMODIC LARYNGITIS.
Synonyms. Catarrhal Spasm of the Larynx; False Croup; Spasmodic
Croup.
Definition. An acute catarrhal inflammation of the laryngeal mucous
membrane accompanied by a spasm of the laryngeal muscles.
.Etiology. This condition occurs in children from six months to five years
of age; it is rarely met later. It is predisposed to by the presence of adenoids
and enlarged tonsils, the breathing of over-heated or impure air and certain
children seem more prone to attacks than others. The exciting cause is usu-
ally exposure to cold or a digestive disturbance.
Pathology. The mucous lining of the larynx, especially that part above
the true vocal cords, is red and congested, later there is an excessive secretion
of mucus. At the time of the attack there is superimposed upon the inflam-
matory condition a spasm of the laryngeal muscles, particularly the adductors.
Symptoms. During the day the patient suffers from little, except slight
hoarseness and nasal discharge. The laryngeal spasm usually occurs at
night and often without warning. There is difficult and stridulous breathing
and a croupy cough; at times the dyspnoea is so great that the child is in marked
distress, the accessory muscles of respiration come into play, the face and
extremities may become livid and the condition seems very alarming to the
casual observer. There is rarely more than a slight febrile movement. The
paroxysm lasts for several hours. During the following day the patient does
not appear ill but the attack is likely to return for two or three nights, unless
prevented by treatment, after which the symptoms, other than moderate
hoarseness or cough, disappear. The condition, although distressing while
it lasts, is never fatal.
Treatment. Prophylactic treatment consists in the removal of adenoids
6 14 DISEASES OF THE RESPIRATORY SYSTEM.
and hypertrophied tonsils, attention to the condition of the digestion and to
the diet and general hygiene of the patient.
The lar}Tigeal spasm may be relieved by emesis which may be brought about
by the administration of wine of ipecac in doses of ^ to i drachm (2.0 to 4.0)
ever}' five or ten minutes until effective, or of tartar emetic and powdered
ipecac each -^wo of ^ grain (0.0006); the latter, however, should be repeated
with caution because of the depressing effect of the antimony. Repeated
doses of alum (gr. 5 — 0.33) in a little syrup or molasses are also an excellent
emetic.^ Not only does the emesis relieve the spasm of the larj^ngeal muscles
but if the attack is due to digestive disturbance it relieves the stomach of any
irritating contents.
If constipation is present the bowels should be emptied by means of an
enema. Further attacks may be prevented by the administration of anti-
pyrine of which a child of two years may receive 2 grains (0.13) every four
hours for two or three doses. During the next day the ipecac and tartar emetic
may be continued in dosage given above every four hours and the tendency to
a parox}'sm during the next nights may be combated by giving a dose of anti-
pyrine at bed time. The inhalation of steam from a croup kettle, the child
being in a tent made by pinning blankets over its crib, is an excellent means
of treating the lar}mgeal inflammation. To the water in the kettle a drachm
(4.0) of compound tincture of benzoin or of oil of eucalyptus or five grains
(0.33) of menthol may be added. Hot or cold compresses or poultices of
flax seed or very weak mustard may be applied over the \a.rynx with good
effect and to relieve the excitability of the patient, 5 to 10 grains of sodium
bromide (0.33 to 0.66) may be given.
Cases which resist ordinary treatment may be temporarily intubated.
TUBERCULOUS LARYNGITIS.
iEtiology. This affection may be primary or secondary. Rarely, however,
is the former the case since the laryngeal tissues seem not to afford a favorable
site for the growth and development of the tubercle bacillus. More fre-
quently is the disease secondar}' to tuberculous infection of the lungs, bacilli
from the sputum finding lodgment and setting up the inflammation. , Laryn-
geal involvement is said to occur in about twenty percent, of cases of
pulmonary tuberculosis.
Pathology. The first stage of tuberculous larj'ngeal inflammation is an
anaemia of the tissues due to the occlusion of the blood-vessels of the part con-
sequent upon the gro^wth of new tuberculous tissue. This is followed by a
thickening resulting from further gro'^'th of and infiltration by this tissue.
This infiltration is especially noticeable over the arytenoid cartilages, in the
posterior commissure, on the edges of the vocal cords and upon the epiglottis.
TUBERCULOUS LARYNGITIS. 615
The stage of infiltration usually lasts about a week and is followed by ulcera-
tion. The ulcers occur in the same situations as the infiltration. They are
shallow, their color is that of the surrounding parts with which their edges
are flush, there are few signs of acute inflammation and the ulcerating sur-
faces are covered with a ropy semi-opaque mucus. The flnal stage of the
morbid process is necrosis.
It must be remembered that not aU inflammations of the larynx which
occur in tuberculous patients are due to the specific infection of the disease.
Symptoms. These are engrafted upon those of the primary inflammation
of the lungs if this be present. The first symptom calling attention to the
larynx is hoarseness which increases even to entire loss of voice. This is
due during the stage of infiltration to the impossibility of approximation of
the vocal cords as a result of this condition, later it is due to the ulceration.
In this stage the voice is permanently lost and the patient can but whisper.
Dysphagia is also a characteristic symptom, though a later one, and does not
appear until the ulceration has spread beyond the lar}Tigeal cavity. The
pain is often very severe when the swallowing of food is attempted and the
patient's state is most pitiable. There are rapid emaciation and loss of strength
and the chances for recovery are distinctly not good. In cases where the
laryngeal condition is primary the course of the disease is likely to be more
rapid than in the cases secondary to pulmonary disease.
Treatment. The treatment of this condition consists in the employment
of aU means in our power to sustain the patient and to improve his general
condition, just as in pulmonary tuberculosis uncomplicated by larjmgeal
disease, in the medicinal treatment of the pulmonary lesions (see p. 167)
and in the local treatment of the lar}mgeal lesion. This last consists of thor-
ough cleansing of the lar}mgeal mucous membrane by means of a spray of
an alkaline and antiseptic solution such as the following: I^ sodii boratis,
sodii bicarbonatis, aa 5i (4-o); glyceriti phenolis, 3ii (8-o); aquas, Sviii
(250.0), followed by astringent sprays such as zinc chloride 5 grains (0.33) to
the ounce (30.0) of water. The inhalation of medicated steam (see p. 611)
or of the vapor of i to 5 percent, phenol, i percent, lysol or i percent, creolin
solutions may be employed.
■ The pain may be eased by the inhalation of analgesic powders, or sprays
such as morphine acetate 5 to 10 grains (0.33 to 0.66) to the drachm (4.0)
of starch; morphine sulphate 5 to 10 grains (0.33 to 0.66) to the ounce (30.0
of water, or morphine hydrochloride 15 grains (i.o), sodium bicarbonate
45 grains (3.0), to 6 ounces (180.0) of water.
"V\^en ulceration has taken place the insufflation of morphine sulphate
10 grains (0.66), tannic acid 2 drachms (8.0), iodoform 6 drachms (24.0), or
morphine hydrochloride 7^ grains (0.50), iodoform and starch of each 75 grains
(5.0), is useful as well as a spray of 20 grains of menthol (1.33), to the drachm
6l6 DISEASES OF THE RESPIRATORY SYSTEM.
(4.0) of olive oil. To lessen the pain attendant upon the swallowing of food
the throat shoiild be anaesthetized, after an alkaline cleansing spray, by a spray
of cocaine hydrochloride 5 to 10 grains (0.33 to 0.66), water a half drachm
(2.0), to which an ounce (30.0) of albolene is added, or by direct application
by means of the laryngeal brush of a 10 to 15 percent, cocaine solution. Such
a procedure will bring about an anaesthesia lasting from ten to fifteen minutes
during which the patient can eat in comparative comfort.
It is often advisable to feed by means of the stomach tube and forced feed-
ing by gavage often accomplishes excellent results. The food is prepared
as follows: Lean meat from which all the tendon and gristle and as much
of the fat as is possible have been removed should be used. The meat is to be
finely chopped and dried in an oven at 150° F. (66° C.) until it has become
absolutely dried. The oven temperature is now raised to 170° F. (77° C.)
and the powdered meat allowed to remain for several hours; it is then ground
in a mortar and sifted. Six parts of raw meat thus treated will furnish about
one part of beef powder.
After a thorough cocainization of the throat and larynx the tube is passed,
the stomach is washed by a pint of artificial Vichy water and the patient is
fed by pouring through the tube f of a pound (312.0) of the beef powder
to which three times as much milk has been added. At first such a meal
should be given twice a day and the amount gradually increased until the
patient takes from i to 2 (450.0 to 900.0) pounds of the powder and 4 or 5
pints of milk (2000.0 to 2250.0) per day. If there is difficulty in digesting
this the milk may be omitted and a little dilute hydrochloric acid, with suffi-
cient water, added to the meat powder.
Surgical treatment is contraindicated when the pulmonary and laryngeal
inflammations are advanced and progressing, it may be employed when the
laryngeal disease is quiescent and there is no progressive destruction of tissue
or perichondritis. For the technique of the various operations applicable
the reader is referred to special works upon the subject.
(EDEMA OF THE GLOTTIS.
Definition. A submucous serous transudate into the tissues surrounding
the laryngeal opening.
-Etiology. This condition may complicate acute or chronic inflammations
of the larynx, acute infectious diseases such as typhoid fever or smallpox, or
any constitutional condition of which oedema is a feature, notably cardiac and
renal disease. The affection may occur at any period of life but is less com-
mon in children. The transudation of the serum takes place into the sub-
mucosa of the aryteno-epiglottidean folds, of the epiglottis or of the ventric-
ACUTE BRONCHITIS. 617
ular bands, and may be so marked as to entirely close the superior opening
of the larynx.
(Edema of the glottis may also result from the inhalation of irritating vapors
or from the swallowing of caustic fluids and rarely from ivy poisoning.
Symptoms. Of these the most prominent is a sensation of oppression,
which may be intensified to actual suffocation. The face is anxious, there
may be cyanosis of the lips and extremities and there is visible action of the
accessory muscles of respiration. The breathing is rapid and stridulous.
Treatment. The milder cases in which the distress is but moderate may be
relieved by depletion by means of a hydrogogue cathartic such as magnesium
sulphate or citrate and the inhalation of steam which may be medicated by
the addition of a little compound tincture of benzoin or menthol. Astringent
sprays such as alum i part, to 24 of water, or alumnol i to ij parts to 24 of
water may be employed. Leeches or blisters over the larynx may relieve the
milder degrees of this condition. Cold applied in the form of compresses to
the neck or by means of ice bags or coils is an excellent remedy and it may be
applied internally as well, by giving the patient pieces of ice to hold in the
mouth. Pilocarpine in dosage of J of a grain (0.016) given hypodermati-
caUy is said to have achieved excellent results but the drug should be used with
caution especially if the heart tends toward weakness, since it may bring about
oedema of the lungs.
Hot packs may be given but unless the therapeutic methods above described
succeed in ameliorating the condition scarification of the infiltrated tissue