Charles Gottleib Raue.

Special pathology and diagnostics : with therapeutic hints online

. (page 14 of 65)
Online LibraryCharles Gottleib RaueSpecial pathology and diagnostics : with therapeutic hints → online text (page 14 of 65)
Font size
QR-code for this ebook


case, should the swelling extend under the sternum, or the sternal
portion of the clavicle, or in case the muscles underneath the hyoid
bone prevent its extension exteriorly.

In regard to the combination of struma with tuberculosis we may say
that, where struma is developed, these tubercular afl'ections of the
lungs may be found, but they do not reach the stage of softening or
phthisis, so that struma excludes tubercular phthisis.

Therapeutic Mints.

Bell., heat and rush of blood to the head ; pain in swallowing; gland
painful to touch.



PHARYNX AND (ESOPHAGUS. 127

Brom., in juvenile subjects, with light liair, blue eyes, fair skin,

Caic. c, in scrofulous persons, worse towards new moon.

Jodium, inveterate cases; the harder they feel, and the more other
symptoms are wanting, the better fits Jodium ; dark hair, dark eyes,
dark skin.

Natr. c, pressing pain; round, hard swelling on the upper right part
of the gland.

Spongia is recommended by Hahnemann for goitre in persons who
live in valleys.

Pharynx and (Esophagus.

The upper part of the pharynx we have spoken of already, under
the affections of the fauces. Its lower portion being continuous with
the oesophagus forms a continuous canal which conducts the food,
already prepared in the mouth, into the stomach.

As these parts lie out of the reach of ocular inspection, we must
infer from other symptoms what their condition is. The introduction
of the probe, or probing, teaches by mediate palpation merely, whether
the passage is open or closed, and, if closed, at what point. In all
other respects little can be learned from this sort of exploration.

Its special affections are :

■ Pharyngitis, CEsophagitis, Dysphagia inflammatoria.

Exactly in the same way as the mucous membrane of the fauces is
subject to catarrhal and croupous inflammations, so also is its contin-
uation into the pharynx and oesophagus. As, however, these parts
are much less sensitive than the fauces, (of which fact we may easily
convince ourselves by swallowing a hot morsel,) slight inflammations
are scarcely noticed. In higher degrees, however, such as are usually
induced by swallowing rough, pointed bodies, scalding hot or corrod-
ing fluids, we observe a pain higher or lower in the chest and towards
the back, according to the seat of the lesion. There is also difficulty
or impossibility in swallowing, dyspnoea, anguish, great thirst and
vomiting of slime and pus. As a consequence of such lesions we
meet

Suppuration, Ulceration, Softening, Widening of the

(Esophagus.

All of which, however, are not easily diagnosticable during life. An-
other conseq^uence of such morbid processes is



128 NECK.

True Stricture of the (Esophagus,

When caused by cicatrization of wounds, sores or ulcers. The parts
of the organ gradually grow together and become impervious to food
or drink. Then the patient cannot swallow any thing ; it may go
down a certain distance, but is always thrown up again ; it never
reaches the stomach, and the patient becomes emaciated from want of
food. If such a stricture cannot be overcome, and the canal widened
again by the gradual introduction of bougies, whilst the life of the
patient is kept up in the mean time by injections of nourishing sub-
stances per anum, death from starvation is sure to follow. Another
variety of this affection is

Stricture from Spasm,

In which the patient likewise experiences a difficulty in swallowing ;
the food stops somewhere in its course and is brought up again.
The distinctive feature of this variety is immediate return of food ;
very few mouthfals — perhaps but a single one — can be swallowed,
when the food is ejected immediately ; and it does not matter
whether it be solid or fluid, nothing can pass until the spasm ceases.

Therapeutic Hints.

Aeon., violent pain in the middle of the chest through into the
back; worse from motion. When swallowing, it feels as though the
food stayed lodged in the region of the heart •, lying on the back is
impossible.

Arsen., dryness ; thirst ; anguish ; restlessness ; burning when swal-
lowing ; food goes down only to the region of the larynx, when it is
ejected again.

Beilad., pressing pain, like contraction, and a feeling as though a
foreign body had lodged fast in the oesophagus.

Kali bichr., burning in the entire oesophagus ; solid food is painful
and difficult to swallow, leaving a sensation as though something
remained there.

Lachesis, the attempt to swallow solids causes a feeling as though
something had gone the wrong way, bringing on violent gagging.

IVlezer., violent burning and soreness in the upper half of the
oesophagus ; deglutition painful and difficult, especially after the
abuse of mercury.

Natr. mur., only fluids can be swallowed ; solid food reaches only a



LAEYNX AND TRACHEA. 129

certain place, whence it is ejected witli fearful gagging and suffocation ;
hawking up of phlegm in the morning ; obstinate constipation.

IMitr. ac, in syphilitic persons.

Plumb., fluids can be swallowed without difhculty ; solids come
back into the mouth again. Some hours after eating, burning in
stomach and oesophagus; constipation; prostration; emaciation.



Bellad., when too large a morsel or a bone incites contraction of the
oesophagus and keeps it fast, Belladonna generally relieves this spasm
and iets the swallowed body down.

Cicuta, when, after swallowing a sharp piece of bone, the oesophagus
closes and there is danger of suffocation.

Hydrophobinum, periodical spasms of the oesophagus, with constant
painful urging to swallow, but impossibility of doing it ; abhorrence
of fluids, especially of water ; burning, stinging in the throat ; cough ;
gagging ; difficult and incorrect speech.

Hyosc, spasmodic contractions after a previous injury of the oeso-
phagus ; solid and warm food can be swallowed best ; fluids cause
spasms in the throat, stop respiration, talking; hiccough, nausea,
spasmodic cough, and stiffness of the muscles of the neck.

For paralysis of the throat compare Bar. c, Mur. ac, Caust.; Con,,
Arsen., Calc. c, Hepar, Jod., Veratr.

Larynx and Trachea.

Auscultation of these Organs.

On putting the ear to the stethoscope, which must be evenly
placed upon the larynx, we hear the rushing in and out of the air
during the act of respiration much louder than on any other place.
It may be imitated by blowing with compressed lips through the
bore of the stethoscope, and is called laryngeal or tracheal respiration,
for at the trachea too it is heard in the same degree.

Some authors lay great stress upon the necessity of auscultating
these organs. I cannot attach such great importance to it, either
diagnostically or still less therapeutically. The only benefit afforded
by auscultation in diseases of the larynx and trachea, properly
so called, is the capability of localizing the source of obstruction^ if
there be any ; but whether that obstruction arise " from inflam-
matory engorgement of the lining membrane, from solid effusion
upon the internal surface, or from fluid effusion beneath it, or if in
consequence of preceding ulceration any contraction exist, either in
the rima glottidis, or in the course of the trachea, which gives rise to



130 NECK.

constriction of tlie tube, and thereby impedes the free ingress and
egress of air, or whether a foreign body, fixed in the oesophagus and
pressing upon the trachea, or situated in the trunk itself of the air-
passages, or a tumor, or a mere spasmodic action, be the cause of
this constriction — auscultation telleth not. In each of these cases the
noise is usually sufficiently obvious, and the evidence of obstruction
is sufficiently clear, ilidependently of auscultation. By the steth-
oscope we are enabled merely to say that obstruction exists and to
indicate its seat ; but the nature of that obstruction is not revealed by
it." Hughes.

Special Diseases of the Larynx and Trachea.

Spasmus Glottldis.

In books this affection has been described under various names :
Asthma spasmodicum, or laryngeum infantum, asthma periodicum,
acutum infantile, laryngismus stridulus^ laryngitis stridulosa. The
most prevalent, however, and at the same time the most inappropriate
names are asthma Millari and asthma thymicum Koppii. It is quite
difl&cult to understand how the description which Millar gives of a
certain affection of children, and which he himself styles asthma
acutum, could ever have been applied to spasmus glottidis, as it por-
trays quite clearly what we may express by the terms croup or
laryngitis mucosa. He even recognizes the ''''white, tough, jelly-like
stuffs'''' with which the vessels of the windpipe were found filled after
death.

The term asthma thymicum Koppii is likewise inadmissible ; for
the assumption which it implies, that these spasmodic fits are caused
by a swelling or enlargement of the thymus gland, has, in conse-
quence of late pathologic-anatomical researches, become quite doubtful.

The objective symptoms of spasmus glottidis are as follows: It
commences with slight and short attacks of dyspnoea, attended by a
wheezing noise during inspiration, whereby the children move un-
easily and show an anxious expression. Soon all is over ; and if the
attacks happen in the night they may be overlooked altogether.
By-and-by, however, these spells increase in number, intensity, and
duration. The child is suddenly attacked after a little fright, or
whilst crying, laughing, drinking, or especially in the moment of get-
ting awake ; its inspiration becomes whistling, crowing, and so
difficult that it strains all the respiratory muscles to draw the air
through the spasmodically-closed glottidis into the lungs. Ex-



SPECIAL DISEASES OF THE LARYNX AND TRACHEA. 131

piration is quite impossible, and thus the breathing ceases for a while
altogether. The face of the child expresses the greatest agony and
sense of suffocation ; becomes purple ; cold perspiration comes out
upon the forehead ; the veins of the neck become turgescent, and the
thorax is motionless. The pulse falls at this stage and is small and
intermitting. This fearful condition lasts in severe cases a minute or
more ; generally, however, only a few seconds ; then, with a loud,
crowing cry the child gets breath again ; is exhausted ; cries and
sobs, but shows no signs of fever or any catarrhal affection. The
number of attacks may amount to ten, twenty, even fifty, in the
course of a day ; and if the complaint be not arrested it may termi-
nate in general convulsions and death.

The age in which children are attacked by this disease lies, in
most cases, between the fourth and fourteenth month. In adults it is
of rare occurrence, and happens only to young women as a symptom
of hysteria.

Its pathological character is a distu:rbed action of the nervus vagus
or recurrens, either from central or peripheric irritation, both of an
obscure nature. Post-mortem examination shows the larynx entirely
healthy.

Therapeutic Hints,

Chlorine, crowing inspiration and expiration impossible.

Cuprum, bluishness of face and lips ; convulsions ; after fright of
mother or child.

Geiseminum, inspirations long, with croupy sound ; expirations
sudden and forcible.

iodium, rachitic children ; swelling of the bronchial glands; thymus
gland (perhaps) enlarged.

Plumbum, spasmodic closure of the rima glottidis.

Laryngo-tracheitis, Catarrh of the Mucous Membrane of
the Larynx and Trachea.

Catarrh exhibits everywhere the same features : hypersemic state,
abnormal secretion and swelling of the mucous membrane, casting off
of epithelial cells and abundant formation of new ones. This is
exactly the case in laryngitis. Its extension, however, varies ; it some-
times invests only small portions, or patches ; at other times the whole
tract of the mucous membrane which lines the larynx and trachea,
and sometimes it extends into the nose, or into the luns-s.

7 O



132 NECK.

A predisposition to sucTi catarrhal affections seems to exist in per-
sons who perspire easily, who are weakly, cachectic, and who keep
themselves too warmly clad, or tod much housed up, &c.

Exciting catises are, all irritating agencies^ such as breathing of cold
air, dust, acrid vapors, screaming, singing, &g. ; talcing cold; getting
the feet cold; sudden exposure of the neck to cold air, &c. ; catarrhs,
colds i7i the head, influenza, which merely by spreading affect the
larynx and trachea; and some constitutional diseases, as measles, exan-
thematic typhus, syphilis, and especially tuberculosis ; which latter
generally causes a constant disposition to " catch cold in the throat."

Its symptoms are, tickling, hui-ning, soreness in the larynx, worse
from talking and coughing. In cases where the covering of the
epiglottis is also inflamed, swallowing is also painful.

The voice is always more or less altered, becomes deep, hoarse, or
entirely suppressed. This arises from the swelling of the chordte
vocales, by which their elasticity is destroyed.

Cough, at first mostly dry, later moist ; sometimes spasmodic, with
dyspnoea and a hoarse sound ; waking one up suddenly at night, thus
simulating croup. The expectoration is in the beginning mostly thin
and slimy ; later, thick, muco-purulent.

Such an acute attack lasts in some cases a few (eight or nine) days ;
in others weeks, and in still others it becomes chronic, the main symp-
toms of which are chronic hoarseness ; intervening coughing spells ;
wheezing respiration ; fever, emaciation, night-sweats.

As regards differential diagnosis between catarrh of the larynx and
croup, it is well enough to remember that a catarrh in the head (run-
ning of the nose) suggests a catarrhal affection of the larynx, whilst
a croupous exudation in the fauces denotes a similar affection in the
larynx.

Therapeutic Hints,

Aeon., during its earlier state in children, after exposure to cold
west wind ; also after straining the voice by singing.

Bell., barking cough; waking suddenly about midnight; pain in
larynx, headache, fever.

Bryonia,, cough worse from motion, from entering a warm room, and
with pain in the pit of the stomach.

Ca'c. c, in teething infants; in leucophlegmatic persons.

Carbo veg., with hoarseness, which is worse in the evening; cough
coming in spells ; old chronic cases.



SPECIAL DISEASES OF THE LARYNX AND TRACHEA. 133

Dulcam., when tlie trouble gets renewed as soon as the weather
changes suddenly from warm to cold.

Hepar, cough worse in the morning ; hoarseness ; mucous rattling
in the larynx.

Merc, chilliness ; easily perspiring without improvement ; cold in
the head.

Nux v., in the commencement; with chilliness, headache, stoppage
of nose.

Phos., constant tickling cougli from the larynx, also with headache,
as though it should burst; cough dry; worse in the evening until
midnight; tightness across the chest.

Puis., chilly, thirstless; worse in the evening and in a warm room.

Rhus t., tickling under the middle of the sternum; worse from talk-
ing or laughing ; pain in all the bones ; worse when being quiet.

Rumex c, dry couglx in paroxysms induced by harried or deep
inspirations, speaking, inhaling of colder air than usual, or any pres-
sure upon the trachea in the pit of the throat.

Sulphur, in chronic cases, cough m the evening before and when
going to bed ; catarrh on other mucous membranes. Compare Bron-
chitis.

Tart, em., rattling of mucus when coughing or breathing; pulse
trembling; sticky perspiration; no thirst; pale face; peevishness;
drowsiness.

Group.

This affection is an inflammation of the larynx, including the fauces
and trachea, which results in an exudation that coagulates, forming a
pseudo-membrane on these parts. It is therefore nearly related to
diphtheria, which, indeed, sometimes extends into the larynx, caus-
ing all the various croup symptoms. It differs, however, entirely
from diphtheria, in that the exudation never leaves any scars behind.
It is an exudation upon the mucous membrane, whilst in diphtheria the
mucous membrane becomes infiltrated b}^ it ; and, in severe cases, the
mucous membrane, as well as the submucous tissues, is destroyed,
leaving 'cicatrices on healing. Croup may commence in the fauces,
and extend downwards ; or in the larynx, and spread upwards. In
almost all cases there is, accompanying croup, a hyper^emic state of
the whole mucous membrane of the bronchial tubes, a bronchial
catarrh, circumscribed pneumonia, or vesicular or interstitial em-
physema.



134 NECK.

Ocular inspection reveals the pseudo-membrane in tlie fauces, if it
commences there first ; auscultation, however, reveals nothing but
what we can hear, even at a distance, — labored breathing, with a
sawing sound.

Croup generally attacks children in early childhood, — from two to
seven years.

Symptoms.

Premonitory signs are sometimes peevishness, feverishness, sore-
ness of the throat, inflammation of the tonsils and fauces, with patches
of exudation, as in diphtheria. In just as many other cases there are.
no such forebodings.

The child is aroused suddenly out of a sound sleep, generally about
midnight, by a hoarse, dry, croupy cough. It exhibits restlessness and
fright, puts its hands to the windpipe. Soon, however, it falls asleep
again, to be again roused by the same dry, hoarse cough, alternating
in this way until morning, when usually a remission of these symp-
toms takes place, and the child seems to be lively and playful. When
evening approaches, the child becomes worse again, and, in addition
to the cough, we observe the breathing to be getting impeded be-
tween the coughing spells. Not only can we see the labored action
of the respiratory muscles, but we can also plainly hear a sawing
noise, which the ingress and egress of the air causes in the stuffed-up
air-passages. This difficulty increases from hour to hour. The child
involuntarily bends its head and neck backwards, in order to free the
windpipe as much as possible from all pressure ; the alse nasi move
strongly up and down like wings ; the epigastric region does not, as
is usual during the act of inspiration, bulge out, but is drawn in, in
consequence of a deficiency of air in the lungs on account of the
obstruction in the larynx. For the same reason we find the xiphoid
process and the cartilages of the lower ribs during inhalation drawn
strongly inwards, instead of gliding gently downwards, as is natural.
When we find inhalation and exhalation equally difficult, there is
surely coagulated exudation around the glottis ; when, however, as is
sometimes the case, only the inhalation is difficult and exhalation
easy, it is a sign that the difficulty does not lie in the presence of a
pseudo-membrane, but in a paralytic state of the muscular structure
of the glottis ; whereby the epiglottis, during inspiration, is not lifted
up from the glottis, thus hindering the free ingress of air ; whilst
during exhalation the paralyzed parts easily give way to the re-
turning stream of air.



SPECIAL DISEASES OF THE LARYNX AND TRACHEA. 135

Thus the child struggles terribly for air ; raises up, wants to be
carried about, until from sheer exhaustion and the poisoned state of
the blood, by carbonic acid gas, it sinks into drowsiness and stupor.
The face being at first red, grows pale, finally cyanotic, covered with
cold sweat ; the pulse, at first quick, hard and strong, grows very fre-
quent, small, irregular, intermitting, until at last this fearful scene is
closed by a gradual general paralysis or suffocation.

In those cases in which dissolution of the false membrane, or the
tearing, loosening and ejection of it, permits recovery to take place,
we frequently find a long-continued hoarseness, which is caused by a
catarrhal affection of the larynx, or bronchitis or pneumonia — com-
plications which have, indeed, been already existing during the whole
attack, and which made it only so much the more serious.

Thercijjeutie Hints.

Aconit., high fever, dry skin, restlessness; the child is in agony,
impatient, throws itself about.

Apsen., worse about midnight; great restlessness; bloated face, cov-
ered with cold perspiration.

Bromine, when, after Spongia, aggravation occurs again next even-
ing; especiall}^ in children with blue eyes and light hair.

Hepap, cough worse in the morning; mucous rattling and yet no
getting rid of the phlegm ; hoarseness, or dry, barking cough ; the
child cries when coughing ; after exposure to cold west wind.

Jodine, as Bromine follows well after Spongia, so does Iodine after
Hepar ; cough worse in the morning, rattling and no getting loose ;
hoarseness ; especially in children with black eyes and dark hair.

Kali bichr., worse early in the morning ; inflamed fauces ; membran-
ous deposition ; hoarseness.

Lachesis, the child cannot bear any thing touching its neck ; aggra-
vation in the afternoon; after sleep; patches of exudation in the
fauces ; commencing paralysis of the lungs.

Phos., when there is a combination with bronchitis ; great weakness.

Spongia, very dry; crowing sound of cough; always commencing
to get worse in the evening ; sawing sound, also, during remission.

Tart, em., face cold, bluish, covered with cold perspiration ; pulse
very frequent ; rattling in the chest ; great sinking of strength.



According to pathological anatomy, this is a dropsical infiltration
iuLo the submucous cellular tissue of the glottis, epiglottis and the



136 NECK.

adjoining ligaments. It is mostly a collateral oedema of some inflam-
matory processes in the larynx, either acute or chronic ; such as ulcers
of different nature, syphilitic, tuberculous, &c., or accompanying small-
pox or typhus ; but it is likewise found as part of general dropsy in
consequence of kidney diseases or scarlet fever. Its occurrence is
much more frequent in grown persons than in children.

Post-mortem examination has frequently revealed oedema and infil-
tration at and. around the introitus laryngis, without any previous
indication of such affection during the life of the patient. Its inconve-
nience and danger arises from the degree of swelling, by which respi-
ration is more or less impeded. It may in some cases increase so
extensively that the glottis becomes entirely closed, and death ensues
in a short time in consequence of suffocation.

Symptoms: difficulty of breathing^ which may increase to the extent
of making respiration possible only by the most desperate exertion.
The inhalation is slow, difficult, whistling, whilst expiration goes on
much easier and without any noise. The reason of this is, that during
inhalation the air presses the swollen parts around the introitus laryn-
gis together, thus closing its aperture, whilst during expiration the
outrushing air drives the swollen parts asunder, thus removing the
obstacle. If, however, the glottis and the internal parts of the larynx
themselves are infiltrated, there will not be much difference between
the facility of inspiration and expiration, the obstacle to both being, in
such cases, alike. To make the diagnosis still more certain, it is
necessary to examine the parts. The patient should, whilst a strong
light is directed into his mouth, put his tongue out as far as possible ;
then he is made to gag by pressing the tongue tightly with a spatula,
near its root. At this moment the larynx rises, and we are enabled
to see the existing swelling at and around its aperture. This settles
the question.

Therapeutic Hints. — Difficult inspiration and short, easy expi-
ration indicates China, Ign., Staphis., and Stramonium, of which China
and Stramonium are, perhaps, the most important.

Compare, also, Apis, Ars., Arum', tr., Laches.



INSPECTION — OCCLAE EXAMINATION. 137

THORAX.

This is a chapter of great importance, and at the same time of diffi-
culty. Its exploration we will have to undertake on different roads.
We must know what is to be learned by inspection, palpation, percus-
sion, and auscultation.

I. Inspection — Ocular Examination.

If we consider that the thoracic cavity holds within itself the
lungs and heart, the organs of respiration, and of circulation, we
shall understand why it is that the first phenomenon which strikes
the eye is the continuous motion in which we find its walls engaged.

This respiratory motion of the chest in men is greatest in the region
of the lower ribs on each side ; in ioo7nen, on the upper part of the
chest ; and in children, towards the abdomen.

- The number of respirations varies according to age, sex, and
individuality ; so that we might put down the normal number of



Online LibraryCharles Gottleib RaueSpecial pathology and diagnostics : with therapeutic hints → online text (page 14 of 65)