THROAT DISEASES. These form a large and import-ant class, and include some of the most serious and fatal of maladies (see CROUP and DIPHTHERIA). The present article will be devoted mainly to a general account of the more common diseases affecting the upper part of the re-spiratory passages, but certain morbid conditions of the back of the mouth and of the gullet will also be referred to. The diagnosis of not a few of these diseases has been greatly aided by the introduction into medical practice of the laryngoscope ; but, while the use of this instrument is a part of the education of every well-equipped medical practitioner, the minute investigation and the treatment of the more occult and serious maladies affecting the throat are by general consent, and with much advantage, relegated to the specialist.

Laryngitis, or inflammation of the mucous membrane of the Larynx, may be either acute or chronic.

Acute laryngitis is usually produced by exposure to cold directly, or by a catarrh extending either from the nasal or from the bronchial mucous membrane into that of the larynx. It is an occasional accom-paniment of certain of the infectious diseases in which the throat is liable to suffer, such as small-pox, measles, scarlet fever, and erysipelas. Excessive use of the voice, as in loud speaking or sing-ing, sometimes gives rise to laryngitis. Further, the inhalation of irritating particles, vapours, &c, and the local effects of swallowing very hot fluids, are well-recognized causes. The chief changes in the larynx are great redness, with swelling of the parts, which affect the whole interior of the cavity, but are specially marked where the tissues are lax, such as the neighbourhood of the epiglottis and of the vocal cords. The effect is to produce narrowing of the channel for the entrance of air, and to this the chief dangers are due. The symptoms vary with the intensity of the attack, hut, along with more or less feverishness and constitutional disturbance, there is usually a sense of heat, dryness, and pain in the throat, attended with some difficulty in the act of swallowing. Cough is a constant symptom, and is cither loud, barking, or clanging, or else husky and toneless. It is at first dry, but afterwards is ac-companied with expectoration. The voice; like the cough, is rough or husky. The breathing shows evidence of laryngeal obstruction, both inspiration and expiration being prolonged and difficult, with a somewhat hissing sound, and with almost no interval between the two acts. In severe eases the face and surface generally become livid, and suffocation threatens, particularly during the paroxysms of coughing. In favourable cases, which form the majority, the attack tends to abate in a few days, but on the other hand death may occur suddenly in a suffocative paroxysm, particularly in the case of children. Many cases of acute laryngitis are so compara-tively slight as to make themselves known only by hoarseness and the character of the cough; nevertheless in every instance the attack demands serious attention. The treatment consists in keep-ing the patient in bed in an atmosphere of 60° to 70° F., made moist by steam. The use of warm gargles, and the frequent inhalation of the vapour of hot water, containing such soothing substances as benzoin, conium, hop, &c, and the application of hot fomentations to the throat, will be found of much value. Internally diaphoretics, such as small doses of antimony or Dover's powder, are also to be recommended. Such remedies usually suffice to re-lieve the attack, but in very severe cases more active interference may be necessary. When there is much swelling of the mucous membrane in the upper portion of the larynx, scarification of the parts with the aid of the laryngoscope may afford relief, but tracheotomy should not be neglected where death appears to be imminent from suffocation. Attacks of laryngitis may be largely prevented in those liable to them by a regimen calculated to in-vigorate the system, such as the cold bath, regular open-air exer-cise, &c.

Chronic laryngitis may occur as a result of repeated attacks of the acute form, or may arise independently from such causes as habitual exposure (especially where along with this there is over-indulgence in alcohol), the habitual overuse of the vocal organs, &c. The changes taking place in the parts are more permanent than in the acute form, consisting mainly in thickening of the mucous membrane, vocal cords, &c. With it may be ulceration, and also sometimes destruction, of the cartilaginous parts of the larynx. The symptoms vary according to the extent and amount, as well as the duration, of the inflammation. Thus there may simply be a certain huskiness or hoarseness on attempts at the use of the voice, this condition being well exemplified in the so-called clergyman's sore throat (dysphonia clericorum); while, on the other hand, there may be, not oidy complete loss of voice, but severe pain in the act of swallowing and great difficulty in breathing, accom-panied sometimes with expectoration of large quantities of matter in the cases where ulceration is present. Under this variety of the disease may be included the ulceration due to syphilis and that occurring in the course of phthisis, both of which are attended with the symptoms now mentioned. The diagnosis and the treat-ment of all such cases is greatly aided by the use of the laryngo-scope, by which a view of the affected parts can be obtained, and the proper remedies more readily applied. In the treatment of .the chronic forms of laryngitis rest to the parts is essential, any attempts at continuing the use of the voice only aggravating the condition; while tonic remedies and regimen should be diligently employed to strengthen the system generally. Applications to the affected parts in the forms of solutions of silver, alum, zinc, tannin, &c, either by means of a sponge-probang introduced into the cavity or by the simpler method of spraying, are often beneficial. The insufflation of powders, such as iodoform, or starch mixed with a minute quantity of morphia, is also of service, as are likewise inhalations of vapours of iodine, carbolic acid, turpentine, eucalyptus, &c. In aggravated forms of this disease tracheotomy is occasion-ally necessary to relieve threatened suffocation.

Symptoms similar to those already described are produced by tumours aud other growths in the larynx. Such growths may be of simple character, in the form of isolated fibrous formations attached by a peduncle to some portion of the laryngeal mucous membrane, or as warty excrescences occurring upon or in the neigh-bourhood of the vocal cords. They are detected by means of the laryngoscope, and can often be dealt with effectually by the surgeon. In the more serious malignant tumours (epitheliomatous or cancer-ous), which either take origin in the larynx, or spread into it from adjacent parts, interference by surgical measures can only afford temporary relief.

Certain affections of the larynx are of purely nervous origin, and occur independently of any local disease. One of the most import-ant of these is laryngismus stridulus, otherwise called child-crow-ing or spasmodic croup. This condition,occurs chiefly during the early yeais of childhood, often in infants during dentition, and manifests itself after premonitory symptoms of a common catarrh, lasting a day or two, by the occurrence of a violent suffocative attack due to sudden spasmodic approximation of the vocal cords, and consequent interruption to the breathing. The symptoms are not connected with any local inflammatory condition, but are the result of reflex irritation affecting the nerves supplying the laryn-geal muscles. Such disturbance appears specially apt to occur in rickety or otherwise unhealthy children, in connexion either with dentition or with disorders of the alimentary canal. The onset is sudden, resembling a convulsive seizure, and symptoms of suffoca-tion are at once developed. The child makes strong efforts to inspire, which are accompanied with stridulous or crowing sounds, but, notwithstanding, very little air can enter the chest owing to the spasm of the glottis, and unless relief speedily comes death may be very rapid. In most cases, however, the attack quickly passes off, and the child seems little the worse. A liability to this disorder is sometimes observed in families, and in such instances the attacks are apt to occur in their more serious and fatal forms. Treatment to be of any avail must be promptly applied. It con-sists mainly in the employment of means to allay the spasm. The use of the warm bath is very serviceable for this purpose, as is also chloroform inhalation. But one of the simplest and most effec-tual measures is putting the finger back into the child's mouth, which is sufficient in many cases to relax the spasm of the glottis, and permit the entrance of air. In impending asphyxia the dashing of cold water over the face and chest, and the use of artificial respiration, should be tried, and even tracheotomy or laryngotomy if practicable. In all cases every effort should be made to discover any causes likely to produce nervous irritation, such as teething, intestinal worms, &c, and to deal with these by appropriate remedies.





Symptoms not unlike those now described sometimes occur in adults as the result of irritation of the recurrent laryngeal nerve, by the pressure upon it of a thoracic aneurism or other tumour. Such pressure, if long continued, results in paralysis of the nerve, occasioning more or less constant trouble in breathing.

In the condition known as nervous aphonia, which occurs mostly in women of hysterical habit or in circumstances of enfeebled health, the voice becomes reduced to a whisper, but there is seldom any affection of the breathing, or cough, and the laryngo-scope reveals a perfectly healthy state of the parts. In such cases the remedies must be directed to the improvement of the general health. The use of electricity (faradism) applied to the neck is often attended with marked benefit.

Diseases affecting the Trachea are usually associated with laryngeal affections on the one hand or bronchial on the other, and their separate consideration is unnecessary.
The Tonsils are frequently the seat of inflammation, and acute tonsillitis or quinsy is one of the most common forms of sore throat. This affection is usually induced by cold, but it would appear to arise under other conditions also, such as digestive disturbances, &c. It is said to be more common in persons of rheumatic constitution, and one attack predisposes to others. The symptoms come on somewhat suddenly fina, sharply, with chill followed by fever, the temperature frequently attaining a high point of elevation. Pain is experienced in the act of swallowing from the outset. The inflammation is usually at first confined to one tonsil, but on examining the throat there is seen to be considerable redness and swelling of the whole surrounding mucous membrane, the uvula, soft palate, &c, while a copious secretion accumulates at the parts, and causes much discomfort. The act of swallowing becomes increasingly difficult, and fluids are apt to regurgitate through the nose. Pain is felt along the Eustachian tube towards the ear, and there are tenderness and swelling in the neck about the angle .of the jaw on the affected side. The voice acquires a peculiar aud very characteristic snuffl-ing tone, and there may be some embarrassment to the breathing. In a few days the inflamed tonsil shows signs of suppurating, and an abscess is seen to be bulging forward into the mouth. When this bursts or is evacuated, speedy relief is obtained, and the patient is soon restored to his usual health. Occasionally, however, the inflammation passes from the one tonsil to the other, and a similar experience has to be gone through again. An attack of quinsy rarely lasts beyond a week or ten days, and is not as a rule attended with danger to life, although it is said that suffocation has occasionally occurred owing to the bursting of a large tonsillar abscess during sleep, and the passage of its contents into the trachea. The treatment for a quinsy is much the same as that for an ordinary catarrh or cold,—confinement to the house, the employ-ment of diaphoretics or mild laxatives, together with light diet, being all that is necessary as regards general management. For the relief of the local inflammation the frequent employment of warm gargles of milk and water or glycerin and water or the inhalation of vapour afford much relief, as do also hot applications to the neck. Some authorities recommend the sucking of ice and the external application of cold compresses, but on the whole warmth appears to be the more soothing remedy. When an abscess lias formed it may be punctured, but care requires to be observed in doing this that no injury be inflicted on any important blood-vessel.

The tonsils are frequently the seat of permanent enlargement (chronic tonsillitis), which may result from frequent attacks of quinsy or may exist independently. They are often seen in delicate young people, and, in the case of some at least, denote a strumous tendency. They give trouble from the mechanical impediment they present to swallowing and clear articulation, and when very large they cause the breathing to be more or less noisy at all times, but especially during sleep, while again they may give rise to a measure of deafness. They are treated by remedies which promote the general nutrition, such as cod-liver oil, iron, &c, by the use of astringent gargles, and when necessary by excision.

The Pharynx or upper portion of the gullet (seen to a largo extent on looking at the back of the mouth) is frequently the seat of a chronic inflammatory condition, usually associated with derangements of the digestive organs, and sometimes the result of excessive tobacco smoking. On inspection the mucous membrane is seen to be unduly red and glazed looking, with the enlarged follicles standing out prominently. It produces considerable irritation, cough, and discomfort, which may be of long continu-ance unless subjected to appropriate treatment. This consists in removing any local source of irritation, in rectifying by diet and other remedies (see STOMACH DISEASES) any gastric disturb-ance, and by the application to the parts of silver or other mild caustic solution.

The Oesophagics or gullet may be the seat of catarrhal or inflammatory conditions, but the more important ailments affect-ing this tract are those which arise from local injuries, such as the swallowing of scalding or corrosive substances. This may cause ulceration followed with cicatrization which narrows the passage and produces the symptoms of stricture of the oesophagus,—namely, pain and difficulty in swallowing, with regurgitation of the food. The severity of the case will necessarily depend upon the amount of narrowing and consequent mechanical obstruction, but in some instances this has occurred to such an extent as practically to occlude the canal. Cases of oesophageal stricture of the kind now referred to may sometimes be relieved by the diligent use of the bougie, but not unfrequently, in order to prevent death by starvation, surgical interference is requisite to form an opening into the stomach by means of which food may be introduced.

A still more serious and frequent cause of oesophageal stricture is that due to cancerous growth in the canal, which may occur at any part, but is most common at the lower end, in the vicinity of the entrance into the stomach. The symptoms of this condition are increasing difficulty in the passage downwards of the food, the steady decline in strength, and the development of the cancerous cachexia, together with enlargements of the glands in the neck ; while the diagnosis is rendered the more certain by the absence of any cause, such as local injury, for the formation of a stricture, and by the age (as a rule at or beyond middle life). Treatment here can only be palliative while life continues, which in general is not long. Feeding by the bowel (enemata) may be advantageously resorted to as supplementary to efforts to admin-ister liquid nutriment in the usual way. It is to be observed in all cases of organic stricture that the food does not necessarily return at once, but seems as if it had passed into the stomach. In reality, however, it has passed into the dilated or pouched portion of the canal, which is almost always present immediately above the seat of stricture, where it remains until, from its amount, it regurgitates back into the mouth, when it can be seen, by the absence of any evidence of digestion, that it has never been within the cavity of the stomach. While in this way a large quantity of the food returns, it often happens that a small amount of the liquid portion does trickle through the narrowed canal into the stomach, and thus life may be prolonged for a considerable time.

Strictures of the oesophagus may also be produced by the pres-sure of tumours or aneurisms within the cavity of the chest but external to the canal. Further, a variety of oesophageal stricture is not unfrequently met with which is due entirely to nervous causes, and is quite unconnected with organic disease,—namely, that form occurring in hysterical females termed spasmodic stric-ture. Here the attack of difficulty in swallowing comes on usually when the patient is at meals, and the food cannot pass down. The absence, however, of all history of any organic source of disease, and especially the perfect facility with which the oesophageal tube or bougie is passed, together with other manifestations of hysteria com-monly present, serve readily to establish the diagnosis. The remedies most suitable are tonics and the frequent passage of the stomach-tube, which as a rule soon entirely removes the tendency to spasm.

Finally, difficulty in swallowing sometimes occurs in certain serious nervous diseases from paralysis affecting the nerves supplying the muscular coats of the oesophagus, which thus loses its propulsive power. When such complications occur they usually denote an advanced stage of the central disease with which they are connected, and a speedily fatal termination. (J. O. A.)