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lingual tonsil. On at least two occasions I have treated wives of promi-
nent medical practitioners who were sufferers from annoying symptoms
of this origin, although previous to my seeing and treating them the
nature of the trouble had not been recognized. In these cases there was
no chest affection and no apparent throat trouble sufficient to cause the
distressing cough, or other symptoms. There was no evident local
disease elsewhere in one case ; in the other there were joint symptoms of
rheumatic gout. In one case the cough had resisted many usual reme-
dies given internally, and the repeated employment of sprays and
inhalation of balsamic vapors.

The cough in these cases is frequent, dry, paroxysmal. Anodynes,
even in moderately large doses, fails to afford relief. At times the cough
is occasioned by the sensation of a foreign body lodged at the base of

1 Read before the Climatological Association, June 14, 1895.



ETIOLOGY AND TREATMENT OF COUGH. 59

the tongue, like a bristle, a bread crumb, or a bit of meat, but it is
impossible to dislodge anything or get rid of the annoying sensation.

Accompanying the cough there may be a continuous desire to swallow
constantly, and the effort of deglutition may be performed with some
difficulty. Indeed, I have had one case under my care in which the
difficulty of swallowing was so great as to excite much apprehension lest
choking should occur, and the young woman soon lost flesh and strength
to a marked degree, through dread of taking her meals. With the diffi-
culty of swallowing there may be a feeling of a constricting hand around
the throat, which occasionally seems as if it would throttle the patient.
This sensation is greatly increased when the patient lies down at night,
and, of course, increases his terror.

But these are very exaggerated cases, and frequently nothing betrays
the evidence of local irritation of the larynx from lymphoid hypertrophy
at the base of the tongue, except an almost continuous cough. I have
known such cases to be regarded for some time as phthisical, and again
as hysterical.

When the obstinate cough is thought to be evidence of incipient
phthisis, change of air, absence from business or household cares, cod-
liver oil, and creosote begins to loom up as the only remaining means of
helpfulness. If the patient be supposed to suffer from hysteria — and
how often is the so-called " globus hystericus " made to account for what
is caused by pressure from an offending mass — little or no treatment is
insisted upon. The patient is often spoken of as an imaginary sufferer,
for whom a cold douche, valerian pills, and some moral education sum
up about everything which can be done. 1

When these cases are examined with the laryngoscope, and it is only
with the laryngoscope that they can surely be made out, we note the
following conditions: The epiglottidean fossa, i. e., the fossa between
the epiglottis and the base of the tongue, is more or less completely filled
up and distended by a slightly irregular but rounded mass of lymphoid
tissue. This mass is sometimes deep red, sometimes pink, and again pale
in color. It is often covered with irregular cauliflower excrescences not
larger than a very small pea. Again, it is relatively smooth and
glistening like certain forms of enlarged faucial tonsils in children. The
mass may simply fill the fossa, pressing against the entire anterior sur-
face of the epiglottis ; or it may be so much larger on one side than it is
on the other that the pressure on the epiglottis is only partial, and on the
opposite side to the one where this is evident the fossa is not wholly filled
up. Frequently the free border of the epiglottis is, to a more or less
considerable extent, caught in or covered by the overtopping tonsillar

1 .1 am more inclined to the belief than ever that the nervous cough of adolescents described
graphically by the late Sir Andrew Clarke was simply a cough caused by an enlarged lingual
tonsil.



60 ETIOLOGY AND TREATMENT OF COUGH.

mass ; and it would seem to be particularly this portion of the mass
which occasions the troublesome cough. When the patient phonates
the mass occasionally separates from the free margin of the epiglottis ;
occasionally it shows no separation at all, but adheres under vocal
efforts closely to it.

Frequently there are quite large veins distinctly defined on the ton-
sillar mass, and not seldom these veins will burst and allow more or less
blood to come into the mouth and be expectorated, which I have known
to cause the liveliest apprehension on the part of the physician and the
patient. Fortunately, the bleeding soon stops, and the patient is none
the worse for it, except mentally.

These enlargements of the lingual tonsil are uncommon among young
children ; they are also infrequent among young men and women ; but
toward middle life, in men and women, I have had numerous cases —
more among women than men.

The causes of the enlargement are certain menstrual derangements,
continued constipation, and an underlying rheumatic or gouty state.
No doubt, micro-organisms may infect as readily, perhaps even more
easily, this tonsillar mass than they do those masses at the faucial en-
trance.

In rare cases syphilis has doubtless localized itself in this region, either
causing marked hypersemia or a congestive condition, upon which a
mucous patch may readily develop, as it does upon the faucial tonsils.

How should we treat this engorged lingual tonsil ? Internally, we
must give the salicylates in fairly large doses, and usually we shall
obtain from their use very evident benefit. It is not essential in giving
the salicylates to be able to discover some other manifest rheumatic
symptoms; nor, indeed, should we feel compelled to obtain a clearly
rheumatic history. Despite the absence of either the one or the other,
we often get good results from this treatment.

In prescribing salicylic acid or the salicylates, it is very important to
get salicylic acid obtained from the proper chemical source. That
made directly from the oil of wintergreen is the only one which is safe
and judicious to use. The other is very apt to cause pain and nausea
or other symptoms of stomachal intolerance. While I believe sprays of
some benefit, especially those of carbolic acid combined with the essential
oils and boric acid, still these will not cure by themselves the lingual
hypertrophy. Local applications of a stronger kind are necessary.
Among these, I place foremost the galvano-cautery and compound tinc-
ture of iodine.

Excision of the tonsil by a specially devised knife or guillotine
(Chappell's) has been recommended highly by a few prominent throat
specialists, but thus far has not commanded general favor. The site of
the disease makes it awkward for operation with the guillotine unless it



ETIOLOGY AND TREATMENT OF COUGH. 61

be imperatively required, and the risk from annoying bleeding, or some
other accident following excision, is not, in my judgment, as small as has
been affirmed. Formerly, I treated these cases with repeated applica-
tions of the galvano-cautery, and, upon the whole, my results were grati-
fying; still, owing to the soreness and swelling which lasted for several
days subsequent to the use of the cautery, I had reason occasionally to
be troubled in mind.

I do not remember to have had an abscess from the peritonsillar
structure after cauterization, but I know that several times the tonsil
was so much inflamed that I sought relief for my patient through re-
peated lancing with a curved knife. 1 The great objection, however, to
the use of the cautery in this region is the risk of burning the epiglottis,
and particularly its free border. Unless the patient is phlegmatic and
obedient, and holds himself very steadily, we may inadvertently pro-
duce an ugly sore which will give any amount of trouble before it heals.

Latterly, by repeated applications of compound tincture of iodine
to the tonsillar mass with a curved brush or sponge-holder, and by the
use of the salicylates internally, I have been able in a few weeks to
reduce these enlarged tonsils so that they ceased to occasion cough or
other symptoms of local distress. The applications of iodine may be
repeated daily with considerable advantage, or as frequently as can be
made without causing marked local soreness. Even when the cough
disappears, or the obstructed deglutition is no longer present, the voice
may be more or less hoarse and discordant for some time.

In using the galvano-cautery it must always be borne in mind that
an unfortunate burning of the margin of the epiglottis may bring on a
cough even more troublesome than the one we are trying to cure, and
for this reason, after considerable experience, I am inclined to reserve
its use for those cases in which internal treatment and the local use of
compound tincture of iodine remain without curative effect.

Another form of cough occurs in young children, and is often ignored,
or, if not ignored, the treatment is at least ineffectual, as it does not reach
the cause of it. Frequently children cough repeatedly, and at night
especially, on account of one of two conditions : either there is a dropping
of thick mucus, or muco-pus, from the nasopharynx upon or into the
larynx, or there is an irritation of the posterior turbinated bodies
brought on by local congestion. The first condition is made evident
frequently by the examination of the pharynx with an ordinary tongue
spatula. So soon as the tongue is moderately depressed the child has
an effort of gagging, and a large mass of mucus is seen between the free
border of the palate and the pharyngeal wall, squeezed downward by

1 1 have had two cases under my care in whom an abscess formed in this tonsil, and after
causing great distress, i. e.. dyspnoea and choking, burst spontaneously, to the great and imme-
diate relief of the patients.



62 ETIOLOGY AND TREATMENT OF COUGH.

the forced effort which just precedes its appearance. Usually this con-
dition in children is due to more or less development of the pharyngeal
tonsil or lymphoid tissue at the vault of the pharynx. It can be cured
by a moderate scraping with the finger-nail of the right index-finger
introduced behind and above the soft palate. If the finger be properly
protected by a thick rubber nipple (i. e., such a one as is used to cover
the mouth of a nursing bottle) it will not be wounded by the child's
teeth. No anaesthesia is required. The pain from the scraping is very
slight, and the operation lasts but a few moments. To be thorough, two
or more scrapings should be made at the time, or if the child is very
restive after the first operation further interference may be delayed until
a later and more favorable occasion. In some of these cases there is
quite an amount of bleeding for a few moments during and immediately
after the operation ; but in my experience it has quickly ceased. If it
were to continue I would advise swabbing the post-nasal space with a
little of Mackenzie's tanno-gallic powder (three parts of tannin and one
part of gallic acid). Indeed, I have made this application on more
than one occasion as a simple matter of precaution, and with obviously
a satisfactory astringent effect.

In the event of the hemorrhage being at all abundant or continuing,
for any length of time, the proper thing to do would be to place a plug of
iodoform or sterilized gauze in the post-nasal space with the finger or a
pair of post-nasal forceps, allowing a string to remain attached, so that
the tampon could be removed at any moment it seemed advisable to
do so.

For a few days subsequent to the scraping it is wise to spray the nasal
and post-nasal passages with a mild antiseptic spray composed in part
of carbolic or boric acid.

Sometimes there is really no adenoid tissue in the post-nasal space to
account for the obstinate cough, and there is practically no hypersecre-
tion of mucus or muco-pus from this region.

The nasal passages may be either tolerably pervious, or they may be
notably occluded. Sometimes the occlusion is but little noticed in the
day-time, but at night it becomes greatly aggravated, and especially
when the patient is lying on his back, he is restless aud uncomfortable,
throws himself about the bed, coughs frequently, and yet apparently there
is not sufficient evidence in an ordinary inspection of the fauces and
pharynx to account for these morbid phenomena.

At times the cough is relieved very much for some time by a suitably
formulated nasal spray or a few applications of moderate severity to the
nasal mucous membrane.

I have found albolene with camphor and carbolic acid one of the best
combinations as a spray or vapor, and applications of carbolic acid and
glycerin (from 1 part to 8 to equal parts of each ingredient) as the most



ETIOLOGY AND TREATMENT OF COUGH. 63

useful local application by means of a nasal carrier, I have hitherto
employed in these cases.

Whenever the cough is not altogether relieved by these means used in
the manner referred to, I find it is most useful to paint over the posterior
end of the turbinated bodies (as much as I am able;, and also the vault
of the pharynx, with carbolic acid and glycerin (1 part carbolic acid
to 6 or 8 parts of glycerin). In this way we are able surely to relieve
the congested condition which is so distressing, and no doubt, by dimin-
ishing the sensitiveness of the peripheral nerve filaments here distrib-
uted, to cure the reflex attacks of coughs which have proved so dis-
tressing.

It is most important, however, in just such instances to avoid over
loading the child's stomach at bed-time with heavy, rich, or, indeed, too
abundant food. A light supper, mainly composed of bread and milk,
with a little stewed fruit, is about all that such a child should be allowed
to take at its evening meal. If the liver be engorged from a too large
food supply, the result is temporary blocking of the circulation ; and
hence, in many cases, nasal obstruction and cough. Am I not borne out
in my statement when many of us acknowledge that certain cases of fre-
quent, obstinate nasal hemorrhage are only permanently arrested by a
rigid dietary and repeated counter-irritation, or depletion over the hepatic
region.

Just in the same way as a hyper- sensitive area may be discovered in
some portion of the nasal passages or nasopharyngeal space, so I find
occasionally sensitive areas in the pharynx, in the tonsillar region, upon
the soft palate, in the hyoid, or epiglottidean fossa, which will occasion
cough as soon as we touch the irritable point.

In what manner it is best to destroy these areas of cough is hard to
affirm absolutely. Sometimes I have found one agent, sometimes another,
relieve most. Nor is it always true that astringent or caustic applica-
tions will do better than soothing anodyne ones, or vice versa.

All local remedies at times remain futile, and cough persists and
annoys until an entire change of air and scene are obtained.

Of the internal remedies from which I have derived most benefit, I
would mention codeia and terpin hydrate. Codeia does not simply re-
lieve hyper-sensitiveness for a while, it is also directly curative ; more-
over, it does not constipate the bowels much, as a rule, or upset the
stomach, as morphine or opium almost invariably do. Terpin hydrate
may have, in addition to its well-known modifying action on diseased
mucous membrane, a mild antimicrobic power that perhaps is useful.
It always remains true that codeia in doses of gr. y 1 ^, more or less fre-
quently repeated, and terpin hydrate in tablet form of 1 or 2 grs. each,
every two or three hours, given internally, have been of great service
in my hands.



64 ETIOLOGY AND TREATMENT OF COUGH.

I have not been able to determine invariably the cause of these sensi-
tive areas. I meet them occasionally in young girls of marked nervous
temperament, who are also ansemic and somewhat exhausted from too
much work, study, or pleasure. I also encounter them when the general
health is excellent, and it is impossible to get at a satisfactory cause.

Every practitioner is familiar, at least theoretically, with the fact that
paroxysmal cough may be occasioned by irritation in the auditory canal.
Most physicians have known the mere introduction of a probe or ear
speculum to be followed by an outbreak of cough, which only terminated
when the offending instrument was withdrawn. Sometimes the condi-
tion of the ear is such that we can readily account for cough produced
by examination, or, indeed, for the cough which previous to the aural
examination had remained a great mystery. Frequently, an impacted
mass of cerumen explains the cough, apparently, and after complete re-
moval of this substance the cough will speedily disappear.

There are numerous occasions, however, in which there is no
impacted cerumen and no symptoms of aural disease prior to direct
investigation by the physician. Then it is, and only then, that we first
discover that there is some impairment of the auditory function. But
what interests us particularly to state is that, one or more points of the
auditory canal are especially sensitive, and appear to have some connec-
tion with the appearance or continuance of the cough. In any event,
when the sensitiveness of the aural canal is diminished by suitable local
applications, the cough tends to diminish or disappear. The point most
frequently sensitive is that on the posterior inferior wall of the canal
very close to the membrane of the tympanum. Accompanying this
sensitiveness, there is pronounced redness of the surface of the canal,
with slight furfuraceous exfoliation of the cutaneous layer, which shows
distinctly inflammatory action.

Repeated applications of alcohol, or a mild solution of bichloride of
mercury (1-1000), or of nitrate of silver (1-100), will cure this condi-
tion after a time, as well as ameliorate, if not cure, the paroxysmal cough
from which the patient suffers. In many such cases, however, there is a
marked lithsemic condition, and we will help not only the condition of
the auditory canal, but also the secondary or concomitant congestion of
the pharynx and larynx by frequent doses internally of lithia and
bicarbonate of potash, together with some heart tonic like caffeine, which
is also useful in promoting urinary excretion.

Of course, in many cases like those of which I have been writing, the
aural inflammation and a catarrhal condition of the upper air-passages,
with marked increase of secretion, may exist together, and it is almost
impossible to say that the ear is in any sense the source of the cough, as
this symptom may be wholly caused by an independent laryngitis or
tracheitis which is present.



ETIOLOGY AND TREATMENT OF COUGH. 66

In speaking on this subject of aural reflexes, it may be remarked with
a feeling akin to surprise how no attention is paid to it in late editions
of works on aural disease, like Politzer and Buck ; Dench, it is true,
speaks about the reflexes originating in the auditory canal, in his
chapter on impacted cerumen, but, so far as I could discover, nowhere
else; 1 and yet it is a matter of common knowledge, almost, that "ear
cough " exists. Despite this statement, I trust in a practical way my
reference to it in this paper may still be found suggestive and useful.

One of the most interesting facts connected with cough — originating
evidently in the upper air-passages — is how little we can judge, at times
of the source or nature of the cough from visible appearances ; some of
the worst-looking throats give, at times, literally no symptoms, and, for
one, I am disposed to regard these throats as usually, if not always,
normal. Symptoms are evidences of disordered function, and are appre-
ciated by our organs of sense and the reports given us by the patients
themselves. If, therefore, none can be found and none are accused, is
not this sufficient proof that the organ itself is probably healthy ? Again,
we shall have all the appearances of a healthy mucous membrane, and
yet, strange to say, the patient is always complaining of abnormal or
unpleasant sensations, or functional disability in the vocal muscles.
These statements are not always .exaggerated ; they are probably often
true, and, if rightly interpreted, lead us to a correct explanation and
treatment of them.

Many years ago I reported a case of chronic laryngitis, which served
to illustrate how the mucous membrane of the vocal cords may be in an
objectively morbid condition, though their physiological functions be re-
stored (The American Journal of the Medical Sciences, October,
1875). In an analogous way, I might also show at present how certain
patients affected with redness and swelling of the larynx cough a great
deal, and others do not. Of course, we can readily affirm that in the
one case there is some point of continuous irritation elsewhere which
causes constant cough, and in the other there is not. Such explanation
is, however, nothing more at times than a surmise, and we are thrown
back upon our inadequate knowledge at present to give a complete and
satisfactory solution of such examples.

In just such instances I have found the best curative effects in a
change of air and scene. I am not confident that it is of essential im-
portance that the change shall be from the city to the country, or to a
seaside resort. Sometimes the change from one city to another will rid
the patient of an obstinate cough which may have lasted for weeks and
resisted much and various medication. Frequently, however, I send

1 1 do not wish to mislead, so that I would add that Dench has a most excellent chapter on
" Aural Reflexes," but all due to disease elsewhere, and not in the canal itself.



66 ETIOLOGY AND TREATMENT OF COUGH.

these patients inland to breathe the air of pine forests, and where the
soil is porous and well drained, and thus obtain most satisfactory-
results. I know, however, of one seashore resort, i. e., Atlantic City,
N. J., which even during the winter months has been most beneficial
to cases of " cough " which had resisted other remedial agencies.
The special value of this shore climate appears to consist, singular to
relate, in its relative dryness as compared with many other places on
the ocean.

In the early spring there is nothing which will remove a harassing
cough of this kind sooner than a few days' trout-fishing with rod and
reel. In the summer, when I am able, I like to send those who cough
obstinately to some good sulphur-spring, as I am satisfied that not only
the air in the vicinity of sulphur-springs, but also the sulphur-baths and
inhalations are very useful in building up impaired nervous constitutions
in which such coughs often predominate.

Alongside of these individuals there are others who are apparently in
good health and yet are constantly hawking, coughing, and expectorat-
ing. Usually these patients are lithsemic to an intense degree, and after
a while the lithsemic state is complicated by the presence of an elongated
palate and a thickened, congested pharynx and larynx. Lithsemia, if
continuously neglected, may become, or find expression in, an evident
rheumatic or gouty state. Under these circumstances it is not uncommon
to find the mucous membrane of the upper air-passages much infiltrated.
Frequently this extends far down the trachea, and tenacious mucus is
pretty constantly present and is expelled with difficulty.

Such a condition and the cough dependent upon it is helped more by
salicylate of soda or the salts of lithia than by local applications or
anodyne cough mixtures. I have already on a former occasion pointed
out the marked influence of malaria in producing congestive conditions
of the respiratory passages which occasion rebellious cough. This mani-
festation is often with difficulty traced to its cause, and medication alone
seems to establish the diagnosis.

In a few such cases it has seemed evident to me that quinine and
arsenic would not benefit, when bark, in tincture or fluid extract, fre-
quently repeated and in sufficient doses, was certainly curative. 1

The obstinate cough due to a dilated heart, or one affected at the
orifices with organic changes, is very frequent, and should be constantly
kept in mind. Not seldom, when I have not known what else to do, I
have freely stimulated a somewhat weak cardiac action and thus stopped
a bad cough in a few days. Previously the patient had taken numerous

1 In this connection I would remark that certain cases of pneumonia are evidently malarial


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