is greatly diminished, or may even be destroyed. Physical Signs.—These are obtained satisfactorily by the use of the rhinoscope, which reveals the actual condition of the mucous surface of the nasal fosse, and upon this the diagnosis is based. Exciting Factors.—The disease is thought to result from repeated attacks of acute rhinitis, or from acute involvement of the nasal mucous membrane that has not been successfully treated. Abel believes that the “bacillus mucosus ozenz” is often an exciting factor in this condition. DISEASES OF THE LARYNX. ACUTE CATARRHAL LARYNGITIS (ACUTE ENDOLARYNGITIS). Pathologic Definition.—An acute catarrhal inflammation of the mucous surface of the larynx. Predisposing and Exciting Factors.—Exposure to cold and wet, excessive use of the voice, inhalation of irritating vapors, injury, exces- sive smoking, foreign bodies, and swallowing of corrosive substances are potent factors. The disease may be primary, but is more commonly asso- ciated with, and frequently follows, inflammation of the nose and pharynx. Principal Complaint.—The voice is husky or completely lost; there is a sensation of tickling in the larynx, with a frequent dry cough; and there may be a feeling of a sense of pressure over the larynx and upper portion of the chest. Laryngeal spasm may be present in selected cases (see Spasmodic Laryngitis). Dyspnea is an annoying symptom in severe types of the disease. Physical Signs.—The surface involved may be covered with a mucous secretion and is reddened and swollen. The vocal cords are swollen and reddened and lack their normal movements. Thermic Features.—Fever may be slight, fluctuating between 99° and 101° F. Diagnosis.—This is based upon the history of one or more of the pre- disposing factors, together with the characteristic changes in the voice. A laryngoscopic examination serves as a positive means of diagnosis. SPASMODIC LARYNGITIS (LARYNGISMUS STRIDULUS; FALSE CROUP). Pathologic Definition.—A spasmodic affection usually seen in chil- dren during the course of acute catarrhal inflammation of the laryngeal mucous surface. Predisposing and Exciting Factors.—Conditions that predispose to acute laryngitis are also to be considered in connection with spasm of the larynx. It is sometimes excited by strong passion or emotion, and it may be associated with tetany. Rachitic subjects are especially liable. “The spasm of the adductors that causes the urgent dyspnea is probably reflex and due to peripheral irritation” (Anders). TUBERCULOUS LARYNGITIS. Principal Complaint.—Two clinical varieties are to be distinguished: (a) Nervous type: That in which the larynx is free from inflammation. This variety is characterized by sudden brief attacks of dyspnea either by day or night. General convulsions have been noted, but there is neither cough, fever, nor hoarseness. A repetition of these attacks may be ex- perienced during the day. (6) Spasm of the larynx associated with mild catarrhal laryngitis. The spasmodic attacks usually begin suddenly, upon awakening from a sound sleep. Positive evidence of the affection is afforded by the croupy, ringing cough, combined with the hard, stridulous breathing. A hoarse cough is often a precursor of the approaching spasm, as is also slightly stridulous breathing during sleep. Harsh breathing (stridor) is a vibrating noise produced by air passing in and out of the larynx or trachea, when one or both of these air-passages are partially obstructed. The following table is designed to set forth the various causes for this type of breathing: Causes Witmn mz Larynx or THE Tracuea. Foreign bodies. Rupture of caseous glands. Plugging by mucus. Pus. AFFECTIONS or THE WALLS. Diphtheria. Acute staphylococcal laryngitis, erculous ulceration. Potassium iodid poisoning. Posttyphoidal ulceration. Syphilitie ulceration. ‘Acute edema, Malignant ulceration. Bright s disease. Traumatic ulceration. ‘Acute streptococcal laryngitis. Bpithelioma of the vocal cords, ‘Acute pneumococcal laryngitis. Fibroma of the vocal cords, Stenosis after tracheotomy or cut Syphilitic stenosis. hroat. Epithelioma of the trachea. Compnasston rnom Wirsovr. ‘Thoracic ancuryem. Malignancy of glands in the neck. Mediastinal new growth. Enlarged thyroid gland. Epithelioma of the esophagus. Enlarged thymus gland. Physical Signs.—The respirations are seen to be altered, the neck is short and thick, and the auxiliary muscles of respiration are brought into action. The child prefers to sit or inclines slightly forward. Cyanosis may become extreme during the spasm and convulsive seizures may be observed. Differential Diagnosis.—Spasmodic laryngitis is to be distinguished from laryngeal diphtheria, and the distinctive features are that laryngeal diphtheria develops more gradually and persists over a longer period than does spasmodic laryngitis. Prostration is also extreme in diphtheria, and moderate fever is present. (See p.868.) The detection of a false membrane on the mucous surface of the nose or throat goes far to support the existence of diphtheria. Prognosis.—A fatal termination is unusual, although repeated attacks are to be expected where spasm of the larynx develops in children. TUBERCULOUS LARYNGITIS. Pathologic Definition.—A subacute or chronic inflammation of the mucous surface of the larynx excited by the tubercle bacillus, and characterized further by congestion, edema, and ulceration. . Predisposing and Exciting Factors.—In the vast majority of in- stances tuberculous laryngitis develops secondary to pulmonary tuberculosis, certain authors regarding this form of tuberculosis as a complication of the pulmonary variety in from 18 to 30 per cent. of cases. DISHASES OF THE NOSE AND THROAT. Principal Complaint.—The earliest symptom is that of hoarseness, which is followed by almost complete loss of the voice. After ulceration has become extensive and the surface of the epiglottis and pharynx are involved, swallowing is painful, and it is extremely difficult for the patient to take food. Cough is decidedly painful, and may be more or less persistent. Cough is apt to be excited by talking. Laryngoscopic examination shows the surface of the laryngeal membrane to be pale, and a variable number of broad, grayish, irregular, tuberculous ulcers are visible upon the posterior surface of the epiglottis and aryepiglottic folds. . . ifferential Diagnosis.—In ill-defined cases laryngoscopic examina- tion is a necessary aid to distinguish between syphilitic and tuberculous laryngitis. The various tuberculin tests (p. 808) and the Wassermann reaction are deciding factors. SYPHILITIC LARYNGITIS. Remarks.—A variety of laryngitis developing during both secondary and tertiary forms of syphilis. It may appear in those where the luetic taint is inherited. Principal Complaint.—Hoarseness is persistent and aphonia and dysphagia are also likely to develop. If it develops in secondary syphilis, the lesion is probably an erythema with superficial ulceration and a variable degree of catarrhal laryngitis. During the tertiary form of syphilis the lesion of the larynx is apt to consist in small gummata. Rather deep-seated ulceration may develop in this form of the disease and may result in more or less extensive destruction of the laryngeal tissue. Laryngeal stenosis may result from syphilitic involvement of this organ where there are extensive cicatricial contractures. EDEMATOUS LARYNGITIS. Pathologic Definition.—An infiltration of the mucous membrane of the larynx by serum. Predisposing and Exciting Factors.—Rarely it follows acute laryngitis, and develops during the course of erysipelas, diphtheria, scarlet fever, typhus and typhoid fevers, and acute phlegmonous inflammation of the adjacent structures; during the course of syphilis, acute and chronic nephritis, and chronic heart ’and liver diseases. Pressure from within the thorax may also cause laryngeal edema. Principal Complaint.—The most prominent symptom is a rapidly developing dyspnea and huskiness of the voice, increasing from the onset. The respirations become stridulous. Diagnosis.—The diagnosis is made immediately by drawing the tongue forward, when swelling of the glottis is apparent. Laryngoscopic examina- tion is of service in selected cases. The clinical history is of moderate value in connection with laryngeal edema. CHRONIC LARYNGITIS. Pathologic Definition.—A chronic inflammatory process involving the mucous surface of the larynx, and chatastariaed pathologically by thickening and congestion of the laryngeal mucosa, while in certain cases there may be a variable degree of ulceration. DATA OBTAINED BY INQUIRY. 37 Predisposing and Exciting Factors.—Chronic laryngitis follows repeated acute attacks, especially in those who speak much in public or in the open air; excessive smoking and chronic alcoholism are also potent factors in the production of this condition. Rarely it follows acute laryn- gitis, while nasal stenosis and chronic pharyngitis are occasional causes. Principal Complaint.—The voice is husky, roughened, and in severe types of this trouble there is almost complete aphonia. Cough is the rule and may be either mild or severe, paroxysmal, and is usually preceded Rs a peculiar tickling sensation in the larynx. Pain is an occasional com- aint. Laryngoscopic examination reveals slight swelling with moderate redd of the mucous membrane and prominence of the mucous glands of the epiglottis. Patches of superficial erosion may be detected. TUMORS OF THE LARYNX. Among the symptoms of laryngeal tumor should be mentioned hoarse- ness, cough (laryngeal in nature), and aphonia. Difficulty in swallowing and urgent dyspnea are also annoying symptoms where the tumor is un- usually large. Laryngoscopic examination serves as a positive means of diagnosis. DISEASES OF THE BRONCHI, LUNGS, AND PLEURA. METHODS OF EXAMINATION. DATA OBTAINED BY INQUIRY. Probably in no other clinical division is history-taking of so great im- portance as it is in connection with affections of the pleure and lungs, and the method of obtaining clinical evidence from the patient will, therefore, be outlined. Family History.—Heredity doubtless plays an important part, although with the advance of science the tendency at present is to regard heredity of less importance than it was considered twenty years ago. It should, however, hold first place in the findings obtained by inquiry. It is important to know whether or not any members of the patient’s immediate family have suffered from pulmonary or pleural diseases, and it is likewise equally important to ascertain whether the male or the female members of the family are the ones so afflicted. When the women of a household (particularly the one who does the cooking) are tuberculous, the disease is more likely to be conveyed to other members of the family than it is when the males are the afflicted subjects. The fact that asthma occurred in previous generations is of moderate importance, for in certain families both asthma and emphysema may exist for generations before tu- berculosis becomes a family disease. The general physique of the members of a family is quite an important fact to be ascertained, since tuberculosis and other diseases of the respiratory tract are to be expected in those cases in which narrow and contracted chests are family characteristics. Personal History.—The patient should be questioned carefully as to his general physical condition, for some years antedating his present ill- ness, and in pulmonary affections it is of vital importance to ascertain the 38 DISEASES OF THE BRONCHI, LUNGS, AND PLEURA. patient’s weight during health, and whether fluctuations in weight were observed during different seasons prior to the onset of the present malady. Should the patient’s weight have been below the normal for one of his height, this should be taken into consideration and the cause for it ascer- tained whenever possible. A comparatively light weight with reference to height may be a family characteristic, and will then be of but little or no clinical significance. Loss of weight, especially when such loss dates from the onset of the affection and is progressive in nature, is highly significant of pulmonary disease. Previous Diseases.—Those who have suffered from lobar pneu- monia are greatly predisposed to pleurisy, bronchitis, and pulmonary tu- berculosis. Rheumatism seems to bear an intimate relation to pneumonia and to diseases of the pleura. Intercostal neuralgia is also at times a precursor of pleurisy and of pulmonary disease. Children and even adults who have suffered from adenitis (glandular tuberculosis) are subject to pulmonary or other forms of tuberculous involvement later in life. Sup- puration of the bones, hip-joint disease, etc., in early life are often expres- sions of tuberculosis. Valvular heart disease is to be taken into consideration in connection with diseases of the lung, although cardiac and pulmonary maladies occurring in the same individual are by no means common. Pul- monary symptoms (dyspnea, cough) may often be secondary to organic disease of the heart. (See p.172.) Previous attacks of pleurisy are always suggestive of tuberculosis of the pleure, and are likely to be followed by tuberculous involvement of the lung substance. Social History.—A general outline of the patient’s mode of living and of his habits and customs is of great importance, and the present health of the other members of his family is to be considered in formulating a diagnosis. Age and sex exercise marked influence, and will be discussed at length under each particular disease. Occupation.—It is an established fact that persons exposed to the inhalation of particles of dust, e. g., stone-cutters, instrument-makers, diamond-cutters, brass-finishers, miners, glass-workers, and those employed in foundries, are especially likely to develop pulmonary tuberculosis, asthma, bronchitis, and pleurisy. Persons following indoor occupations, who do not get sufficient exercise, such as bookkeepers, barbers, clerks, seam- stresses, and cooks, are also likely to contract pulmonary afflictions. Oc- cupations that necessitate exposure to cold and wet may at times contribute toward the development of pulmonary diseases, but, as a rule, those who live out-of-doors are less likely to become tuberculous than are those who are deprived of exercise and of invigorating air. Source of Infection.—If a patient suffering from tuberculosis has been intimately associated with other tuberculous patients, it is to be presumed that the source of infection is that of contact. In the majority of instances tuberculosis is not transmitted directly from one member of a family to another, but may be conveyed by infected members or by food that has been handled by tuberculous persons, who, during coughing, would send their sputum in a spray about the room where the food was handled. The routes through which tubercle bacilli may enter the human body are manifold, and no one particular mode of infection need be emphasized here. Cough.—Correlatively speaking, cough is reflex in origin. The me- chanism is that of a deep inspiration, which is immediately followed by closure of the glottis, when an expiratory effort suddenly follows, the glottis is forced open, and the sound is produced by the forcible escape of the air. DATA OBTAINED BY INQUIRY. 39 Cough is a symptom of many pleural, pulmonary, and remote pathologic conditions, and may also occur as a hysteric manifestation. Cough of physiologic origin is seen during the early months of gestation. Causes.—(1) Either acute or chronic irritation of the bronchial mucous membrane is sufficient to excite cough. The act of coughing may also be a physiologic process, serving to expel mucus, pus, and any foreign substance that may have collected in the bronchi. Among diseases in which cough is an almost constant symptom should be mentioned pleurisy, empyema, pulmonary tuberculosis with cavity formation, bronchitis, asthma, and emphysema. In diseases of the larynx cough is a cardinal symptom. Pressure upon the recurrent laryngeal nerve gives rise to cough and aphonia. (See Aneurism, p.314.) In thoracic aneurism the cough is quite characteristic, being harsh and rasping, and having a brassy or metallic ring. The cough of aneurism may be non-productive, or, as is often the case, paroxysms of coughing are followed by copious expectoration of mucopurulent material. Mediastinal and thoracic tumors may excite cough in persons in whom the lungs and pleure are healthy. In organic heart disease, the result either of valvulitis or of myocarditis, cough not infrequently occurs as the result of imperfect circulation and venous stasis in the lungs. Incorrect posture in those of lowered vitality results in hypostatic congestion at the bases of the lungs, and such congestion, in tum, is often productive of cough. This variety of cough is commonly encountered in those suffering from acute and chronic febrile and afebrile maladies. The character of the cough, as previously stated above, is equally significant in pleurisy and in lobar pneumonia. The cough of pleu- risy is short, non-productive, and hacking in character, and is accompanied by extreme pain in either side of the chest. In lobar
Key Takeaways
- The rhinoscope is a crucial tool for diagnosing laryngeal conditions, such as acute catarrhal laryngitis.
- Tuberculous laryngitis can develop secondary to pulmonary tuberculosis and often presents with hoarseness and aphonia.
- Cough can be a symptom of various diseases, including pleurisy, bronchitis, and laryngeal tumors.
Practical Tips
- Learn to use the rhinoscope for examining the nasal fosse and larynx in cases of suspected laryngitis or other respiratory issues.
- Take detailed personal histories from patients, especially regarding family history and previous diseases, as these can provide important clues for diagnosis.
- Be aware that cough can be a symptom of many conditions, so consider the context and patient's overall health when diagnosing.
Warnings & Risks
- Do not assume that cough is always due to respiratory issues; it can also be caused by gastric irritation or other non-respiratory factors.
- Tuberculous laryngitis can have severe consequences if left untreated, so prompt diagnosis and treatment are crucial.
- Be cautious when interpreting physical signs in patients with underlying heart conditions, as cough may be a secondary symptom.
Modern Application
While the techniques described in this chapter rely on historical medical practices, the principles of thorough patient history taking, physical examination, and differential diagnosis remain fundamental to modern medicine. The use of advanced imaging and laboratory tests has improved diagnostic accuracy, but the importance of understanding the patient's context—such as family history and occupation—remains critical for effective treatment.
Frequently Asked Questions
Q: What is the significance of the suprasternal notch in diagnosing laryngeal conditions?
The suprasternal notch, located at the level of the second and third thoracic vertebrae, serves as a key landmark for counting ribs and can also indicate the presence of swelling or inflammation in the neck area, which may be relevant to conditions like laryngitis.
Q: How does chronic laryngitis typically present?
Chronic laryngitis often presents with a hoarse voice, roughness in the voice, and possibly complete aphonia. It is usually preceded by repeated acute attacks or associated with excessive smoking, alcoholism, or public speaking.
Q: What are some common causes of cough mentioned in this chapter?
Common causes of cough include irritation of the bronchial mucous membrane, pleurisy, pulmonary tuberculosis, laryngeal tumors, and even gastric irritation. The chapter also mentions that cough can be a symptom of various other conditions such as diphtheria or pharyngitis.