the face. The treatment otherwise involves the removal of all local causes of irritation, such as the distension of the gums and the retention of fecal matter, avoidance of causes inducing mental excitement, and measures to invigorate the system.

Spasm of the glottis occurring in children over two years of age, accompanied by laryngeal irritation and cough, is a frequent affection, known as spasmodic croup. A child is suddenly attacked during the night, having, perhaps, gone to bed apparently in perfect health. The breathing is labored and sonorous, the cough presents, in a marked degree, the shrill, ringing, croupal character. Great alarm is produced, and the physician is sent for in urgent haste. The surface of the body is cool; the pulse is small and perhaps not accelerated; the voice or cry is not hoarse or husky as in laryngitis the affection, in short, is purely spasmodic. It is unattended with danger. When the violent symptoms are relieved, the respiration is found to be unobstructed. There is no liability to its eventuation in so-called true croup. It is to be discriminated from the latter affection. The points involved in this discrimination are as follows: the abruptness of the attack, which is not preceded by symptoms denoting laryngitis; the violence of the attack, in this respect differing from so-called true croup; the absence of hoarseness or huskiness of the voice, of febrile movement, and of exudation in the larynx; and, finally, the speedy and complete relief. The paroxysms may return for two or more successive nights.

The treatment consists of a mild emetic, if there be reason to suppose that the stomach is overloaded, a hot foot-bath, and warm fomentations to the neck. These measures are uniformly successful. The treatment of these cases is sometimes needlessly active, under the impression that a serious affection is threatened; and practitioners are apt to congratulate themselves and the friends of the patient on their success in preventing true croup.

Spasm of the glottis may occur as a functional affection in the adult. It is occasionally incidental to hysteria, and may simulate, as regards some of the symptoms, laryngitis, or oedema of the glottis. The diagnostic points are as follows: The coexistence of hysterical phenomena; the absence of huskiness or hoarseness of the voice; intermittency of the difficulty of breathing; the speed relief obtained by anodyne remedies, and the sudden development of the affection.

The measures of treatment are anodyne or antispasmodic remedies for immediate relief, and afterward those indicated by the general condition, and which are employed in analogous nervous affections.

Spasm of the glottis may be occasioned by irritation of the recurrent laryngeal nerve from the pressure of a tumor or other causes. It is one of the symptoms of aortic aneurism, and, occurring in a person over forty years of age, should always excite a suspicion of aneurism. I have reported a case of aortic aneurism in which the life of the patient was destroyed by frequently recurring paroxysms of laryngeal spasm.1

I have been consulted in two cases in which spasm of the glottis occurred in male adults without any evidence of disease within the larynx or intrathoracic disease. In one case the patient was a young medical student; the other patient was a gentleman of middle age. The attacks in these cases were of short duration, and resembled the paroxysms which occur in young children. The cases did not continue under my observation, and the subsequent history was not ascertained.

American Medical Times, 1864.

NERVOUS APHONIA.

Loss of voice, or aphonia, is incidental to the several varieties of laryngitis which have been considered. But it occurs when not dependent either on inflammation or lesions within the larynx; in other words, as a functional affection. It is then known as nervous aphonia. The loss of voice is due to paralysis affecting the nerve of phonation, viz., the spinal accessory. The affection is limited to the voluntary movements of the laryngeal muscles, the reflex movements involved in respiration being unaffected.

This form of aphonia is met with not infrequently in females, and is usually associated with more or less of the phenomena embraced under the name hysteria. As a purely neurotic affection, that is, not dependent on any lesion of the nervous system, it must be extremely rare in the male sex. I have met with it in a case in which the lower extremities and one upper extremity were affected with paralysis, and in a case of hemiplegia. A distinction is to be made between loss of voice and loss of speech, the latter occurring in a certain proportion of the cases of hemiplegia, and dependent, not on the loss of power to produce vocal sounds, but on either a defect in articulation or the loss of memory of words. Aphonia occurs from pressure on the recurrent laryngeal nerve of an aneurismal or other tumor, and the loss of voice should direct attention to this as a possible or probable cause. The diagnosis of nervous aphonia may be made by attention to the character of the whispered voice. The patient speaks in a pure, soft whisper, without effort. On the contrary, if the aphonia be due to laryngitis, the whisper is stridulous or husky and labored. Moreover, in aphonia due to laryngitis, there is more or less cough and expectoration, symptoms generally absent in nervous aphonia. As the question is usually to decide between nervous aphonia and chronic laryngitis, and as the latter affection is generally associated with pulmonary tuberculosis, the absence of the symptoms and signs of the latter disease will serve to confirm the diagnosis.

If the aphonia be purely neurotic, in other words, involving no lesion of the nervous centres, nor pressure on the par vagum or recurrent laryngeal nerves, recovery may be expected after a duration of the affection varying much in different cases. The voice is sometimes restored instantaneously and unexpectedly. I have met with cases in which repeated attacks had occurred.

The treatment in these cases should be directed mainly to the general condition. Tonic remedies and invigorating hygienic measures are indicated. Moderate counter-irritation may be useful. Cases have been reported in which the application of the electric current to the laryngeal muscles proved efficacious.

MORBID GROWTHS.

The laryngeal mucous membrane, especially at the vocal chords, is sometimes the seat of morbid growths in the form of warty vegetations, or tumors, which are generally epithelial, but sometimes fibro-cellular and pedunculated, the latter called polypi. These occasion inconvenience, suffering, and death by producing obstruction. Surgical interference becomes necessary when the obstruction is sufficient to endanger life. A tube may be worn in the trachea for an indefinite period. In a case in which a permanent artificial opening becomes necessary, it may be a question whether a large fistulous orifice might not be established, rendering the tracheal tube unnecessary. As bearing on this question, the following case is of interest: A patient, aged

about forty, admitted into one of my wards in Bellevue Hospital suffering from the effects of a debauch, had a fistulous orifice in the anterior portion of the trachea large enough to admit the end of the forefinger. This fistula followed a wound received in a fracas, and had existed for seventeen years. It occasioned little or no inconvenience in respiration. There were no symptoms of inflammation or irritation of the trachea or bronchial tubes, and he was entirely free from pulmonary disease. The only inconvenience which it occasioned was in speaking. In order to direct a current of air through the glottis sufficiently for the production of voice, he was accustomed to approximate the chin to the sternum, and in this way he was able to close the fistula.

CHAPTER X.

PULMONARY TUBERCULOSIS.

Anatomical Characters-Clinical History-Pathological Character-Causation.

THE term pulmonary tuberculosis denotes an affection characterized by the deposition in the lungs of the morbid product called tubercle or tuberculous matter. This affection is commonly known as consumption, or, sometimes, the decline, names which are significant in view of the wasting of the body which attends its march, but yet not distinctive, inasmuch as progressive emaciation belongs to the history of other affections. The name phthisis, or phthisis pulmonalis, has the same significance, that is, expressing wasting or emaciation, and is open to the same objection. The term tuberculosis expresses the character, and pulmonary, the seat of the affection. Of the diseases which afflict the human family, this is one of the most important, prevailing, more or less, in almost every quarter of the globe, and occasioning, exclusive of those which prevail epidemically or endemically, a larger proportion of deaths than any other disease.

ANATOMICAL CHARACTERS.-The nature of the tuberculous deposit, the changes which it undergoes, etc., have been considered in the first part of this work (vide p. 37). It will suffice here to mention the anatomical points, pertaining to the deposit, which are important in a practical view, and the morbid conditions incidental to the local affection.

cases.

As regards the amount of deposit, it varies much at the outset, in different Different cases, also, differ much as regards its progressive accumulation. In some cases the deposition goes on steadily, that is, without intermission; in other cases, after a certain amount has occurred, there is no further increase for an indefinite period. Not infrequently, successive deposits occur at epochs more or less remote. The disposition of the deposit varies. In some cases it is disseminated in nodules, or tubercles, of small or moderate size. In other cases, the nodules, at first isolated, become aggregated by accretion, multiplication, and coalescence, forming irregular masses of considerable size.

The deposit takes place first, at or near the apex of one lung, in the vast majority of cases, and, in the progress of the affection, extends downwards, more or less, towards the base. But, sooner or later, the deposit occurs at or near the apex of the other lung, thence extending downward. Different

collections of cases analyzed in order to determine whether the right or left lung is most liable to be first affected, have furnished discrepant results, showing that there is no fixed law with respect to this point. Exceptionally, the deposit commences at the base and extends upward. These exceptional cases are exceedingly rare, occurring, probably, not oftener than once in an hundred cases.

In the early period of the affection, there is a marked difference in different cases in respect of the latency of the deposit. In some cases the deposit, although considerable, occasions but little local disturbance; in other cases, it causes irritation and inflammation in the surrounding tissues. Circumscribed bronchitis occurs sooner or later, and is more or less marked. Inflammation of the parenchyma, extending over a limited number of lobules (circumscribed pneumonitis), is another morbid condition incidental to the deposit in some cases, increasing, for a time, the degree and extent of solidification, and sometimes contributing to the breaking down of the pulmonary structures. Attacks of circumscribed pleuritis occur almost invariably. They may occur early in the history of the deposit. They may recur at variable periods, leading to the exudation of lymph, without liquid effusion, and adhesion of the pleural surfaces, by means of intervening organized membrane. The occurrence of successive attacks of dry circumscribed pleuritis explains the firm attachment of the pleuritic surfaces over portions of the lungs corresponding to the sites of the tuberculous deposit, which are generally found in examinations after death. Diminished volume of the affected portions of the lungs is another anatomical change incidental to the deposit, even before softening of the deposit has taken place, due to collapse of pulmonary lobules. Emphysema of more or less of the lobules in proximity to the deposit, is another morbid condition not infrequently observed.

Softening, the discharge of the liquefied tuberculous matter by ulceration into the bronchial tubes, and its expectoration, take place after a period which varies much in different cases. The affection has now advanced to the formation of cavities. When the tuberculous matter first deposited has in this way been removed, the matter subsequently deposited is undergoing softening, and at length is, in like manner, removed. Hence, as the affection progresses, new cavities are formed. In examinations after death, cases differ much as regards the number and size of the tuberculous cavities. The greater part of the upper lobe of one lung, and sometimes of both lungs, may be converted into a single cavity or a series of cavities. These cavities are generally irregular in form, with ridges of pulmonary tissue and depressions, and, hence, distinguished as anfractuous. Not infrequently they are traversed by bands of pulmonary tissue containing blood vessels, and the rupture of these is the source of the hemorrhage which occurs in certain cases. The cavities become lined with a membrane which is thick and dense in proportion to their age. The destruction of lung is, of course, in proportion to the number and size of the cavities, and their formation leads to still further reduction of the volume of the portions of the lung in which they are seated. Exceptionally, the liquefied tubercle is evacuated, by ulceration through the pleura, into the pleural sac, giving rise to pleuritis with effusion, and allowing the entrance of air, thus causing pneumo-hydrothorax. The adhesions resulting from the successive attacks of dry circumscribed pleuritis, are conservative as regards protecting against this accident, which occurs in only a small proportion of cases.

A simple and convenient division of this affection into stages is based on the marked difference, as regards the anatomical characters, before and after the formation of cavities. The first stage embraces the period occupied by the accumulation of the deposit and the softening, up to the evacuation of

liquefied tubercle. The second stage extends from the time when cavities are formed to the termination of the affection. A stage of softening, distinct, on the one hand, from the period during which the tubercle remains solid and is said to be crude, and, on the other hand, from the cavernous stage, is superfluous, for the existence of such a stage cannot be predicated with any degree of certainty on the symptoms and signs. As regards the two stages, viz., before and after excavation, it is to be borne in mind that frequently, if not generally, both are represented at the same time in different portions of the lungs. After cavities have been formed in certain portions, a more recent deposit in other portions is still crude or undergoing the process of softening.

In this division into two stages, it is assumed that the affection goes on to the formation of cavities. This, unhappily, is the rule; yet, excep tions to the rule are not very infrequent. If the deposit be disposed in small, disseminated nodules or tubercles, it may be absorbed. In some cases the animal constituents of the deposit are absorbed, leaving the mineral portion, and the latter become hard calcareous bodies which may remain imbedded in the lung, or, ulcerating into the bronchial tubes, they are expectorated. In these modes a cure of the local affection takes place in a certain proportion of cases. But a cure may also take place after the affection has gone on to the second stage. It is well ascertained that cavities, even of considerable size, may gradually contract and, at length, perfectly cicatrize. In some cases in which cicatrization does not take place, cavities become lined with a non-secreting membrane, and remain nearly innocuous for an indefinite period.

Of late, some writers have recognized, as a stage of the disease, a period, anterior to the tuberculous deposit, which has been called the pre-tuberenlous stage. It has been supposed that such a stage may be determinable by symptoms and signs. That a general and local morbid condition precedes the deposit, can hardly be doubted, but that anatomical changes take place, which are represented by symptomatic phenomena, and which may be appreciated by physical exploration, cannot be considered as established by clini cal observation.

CLINICAL HISTORY.-In sketching the clinical history of this affection, the symptoms attending its development, and the first stage, will, in the first place, claim attention.

The affection is often remarkably insidious in its development. In a certain proportion of cases, the pulmonary symptoms are preceded, for several weeks or months, by deteriorated general health, as denoted by loss of weight, impaired muscular strength, and a pallid aspect. These premonitions, however, are not constant, and, if they exist, are rarely sufficiently marked to excite the attention of the patient or others. It is stated by Drs. James Clark, Bennett, Tweedy, Todd, and others, that certain dyspeptic ailments are apt to precede the development of the affection. If this be so, the ailments are not, as a rule, of a striking character. In a pretty large proportion of cases, the pulmonary symptoms which may be considered as denoting the occurrence of the tuberculous deposit, are neither preceded nor accompanied by ailments of any description which lead the patient to suppose that he is affected with any disease. In the majority of cases, when the patient first comes under the cognizance of the physician, the previous history renders it probable that a deposit has existed for several weeks, or, perhaps, months. The researches of Mr. Hutchinson and Dr. E. Smith, appear to show that persons who become tuberculous, are apt to have a dislike for fatty articles of food, before and after the deposit takes place, to