CHAPTER XV

THE RESPIRATORY SYSTEM

THE UPPER RESPIRATORY TRACT

SYNOPSIS: Remarks on the Clinical Pathology of Respiration. Methods Employed in Examining the Respiratory Organs.-Rhinological and Laryngological Memoranda.Catching Cold.—Nasal Obstruction.—Pharyngitis.-Laryngitis.—Simple Erosions and Ulcers. Syphilis of the Nose, Pharynx, and Larynx.-Tuberculosis of the Nose, Pharynx, and Larynx.-Benign and Malignant New Growths.--Foreign Bodies in the Upper Respiratory Tract.-Hæmorrhage from the Upper Respiratory Tract.-Nasal Deformities, Septum Deviation, Enlargement of Turbinated Bodies.-Disease of the Accessory Sinuses.-Diseases of the Tonsil and Lingual Tonsil.-Circumtonsillar Abscess. Respiratory Obstruction.-Neuroses and Paralyses of the Upper Respiratory Tract. Hay Fever.-Formulæ for Office Treatment.

REMARKS ON CLINICAL PATHOLOGY OF THE RESPIRATORY TRACT

THE life of the cells and of the organism depends upon the absorption of oxygen and elimination of carbonic dioxide. This gas exchange we may call in a broad sense respiration. External respiration takes place in the lung, internal respiration takes place in the various other tissues. As a prime condition of life, pure air must have free access to the lung, and Nature attempts to expel foreign elements in the respiratory tract by the coughing effort and by means of a centrifugal propulsive power of the ciliated epithelia of the trachea and bronchi.

The natural secretion of the mucous lining of the respiratory tract also aids in the expelling process, as do the sense of smell and the act of sneezing and coughing. Any marked disturbance of this complicated mechanism will favor infection or inflammation, be it localized in the nasopharynx, larynx, trachea, bronchi, or lungs and pleura.

Cough is a reflex phenomenon transmitted through the vagus nerve. The act of coughing is composed of a deep inspiration and an expulsive expiration, with a momentarily closed glottis. The rush of air is due to the high pressure in the lung during the act of coughing.

The centre for the act of coughing is located in the medulla near the centre of respiration. It It is not known whether or not cough can be incited by direct cerebral irritation, but the impulse to cough is increased or diminished by various pathological conditions of the respiratory tract itself and changes in the sensory as well as the motor respiratory apparatus modify the power to cough (weak cough in muscular inertia). A weak cough in young infants and feeble, aged people allows of undue accumulation of secretion in the lungs, with great danger to life. Inactivity of the respira

tory functions, as well as inactivity of the gastrointestinal tract, means stagnation and danger.

Abnormal irritation with undue and fruitless cough is also a danger, harassing the patient, destroying the elasticity of lung tissue (emphysema), and producing undue arterial pressure.

The normal oxidation process in the lungs is interfered with whenever there is obstruction in the nose or windpipe. Nasal obstruction means mouth breathing with its sequelæ. Nasal obstruction in young infants. interferes with the sucking power and with nutrition.

Respiratory obstruction in the larynx and trachea, of whatsoever nature, is of grave importance, be it acute (pseudocroup, spasmus glottidis, attacks of whooping cough) or of a more chronic nature (tumors, membranes, compression from without, etc.). Under such conditions, the blood becomes overcharged with CO, and respiratory disturbances take place owing to the active play of respiratory muscles against atmospheric pressure, an inspiratory depression in the epigastric, jugular, and other regions is induced, inspiration and expiration are prolonged, and there is noisy respiration as a phenomena of such conditions. When the obstruction is due to paralysis of the postici muscles (openers of the glottis), inspiration is difficult and expiration is free. In unilateral bronchial obstruction, as in membranous croup, auscultation shows diminished respiratory murmur on the affected side. The subjective distress is greater in acute obstruction than in that of slow onset.

As a type of general respiratory obstruction we may mention bronchial asthma, also hay fever. The pathology of the asthmatic attack has not, however, been cleared up, notwithstanding the vast amount of study as to its nature. Nerve degeneration or paralysis is frequently the cause of immobility of the thorax and lung. Abnormal respiratory phenomena frequently take their origin in the respiratory centre in the bulb (CheyneStokes respiration) and may be due to autointoxication (uræmia, diabetes) or to foreign intoxication (hydrocyanic acid) or to reflex irritation (asthma dyspepticum et uterinum).

Respiration is also interfered with in consequence of inflammatory changes in the lungs or accumulations of fluid in the air cells and in the thoracic cavity (hydropyopneumothorax, atelectasis of the lungs, tumors). Abnormal chemical and physical conditions of the lung epithelia and variations in atmospheric conditions, such as diminished or increased air pressure, have a marked influence on breathing and tissue oxidation (mountain sickness).

Variations of atmospheric pressure influence tissue oxidation by means of a self-regulating process through the agency of the oxyhæmoglobin of the blood. Thus blood pressure, quality of blood, and the degree of its circulation are all of great importance for respiration.

Tissue respiration, or internal respiration, is the exchange of gases between the blood and the tissues. In anæmic persons the oxygen of the blood is diminished; thus, we notice a marked dyspnoea on exertion. A primary disturbance of internal, or cell, respiration may take place in consequence of changes in the parenchyma of cells or owing to toxic substances being contained in the circulating fluids (carbonic acid gas, phosphorus,

EXAMINATION OF THE UPPER RESPIRATORY TRACT

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hydrocyanic acid); moreover, the medulla is extremely sensitive to faulty metabolism (suboxidation or toxæmia).

Respiratory disturbance is accompanied by a disagreeable sensation called dyspnea and an indefinite vague sensation of pain which is difficult to localize clinically. Sufferers from chronic dyspnoea eventually reach a certain stage or degree of tolerance, particularly during muscular rest. The respiratory tract is the portal of entrance for many infectious. diseases, and all abnormal conditions of its lining favor infection. For methods of prophylaxis, see the chapter on Nasopharyngeal Toilet.

Aside from local causes, hyperemia of the upper air passages may result from abuse of alcohol and tobacco, cardiac, renal, hepatic, or pulmonary disease, pressure of a goitre or mediastinal tumor, gastroenteric disease pleuritic exudates, tympanites, constipation, constitutional disease, and chronic infections.

Nose and throat symptoms in anæmic, chlorotic, and neurasthenic subjects are seldom remedied by local treatment alone.

To sum up from a clinical standpoint, we find that, apart from malformations and injuries, the various disturbances of the respiratory organs take their origin in transitory congestive conditions, in infection, and in inflammation. We encounter obstructive phenomena due to foreign bodies, swellings, tumors, and parasites, and we frequently encounter hæmorrhage and neurotic affections.

RHINOLOGICAL AND LARYNGOLOGICAL MEMORANDA

EXAMINATION OF THE UPPER RESPIRATORY TRACT

To illuminate the cavities to be examined, sunlight or artificial light is reflected by means of a head mirror. Phillips's electric headlight is convenient and can be worked by the street current and current controller. A very convenient and portable source of light is a condenser with a reflector attached (McKenzie light). The source of light should be to the right of the patient, a trifle higher than the mouth. In examining the mouth and pharynx the patient's tongue is depressed with a glass spatula or a spoon handle.

In examining the larynx and trachea the patient's tongue is held with the left hand and the light is thrown upon a warmed laryngeal mirror. The distance from the laryngeal mirror to the vocal cords is about two inches and a half. The posterior aspect of the soft palate or vomer must not be overlooked, as it is occasionally the site of ulcer, etc. To secure. relaxation of the soft palate, the patient must breathe quickly through the nose or make a nasal sound. Anterior rhinoscopy is practised by means of a hollow speculum.

In order to allay sensibility and subdue obstructing erectile tissue in the nose which interferes with the vision, we apply a mixture of equal parts of cocaine solution, 10 per cent, and suprarenal solution, by means of a cotton carrier. In order to avoid constitutional effects, the solution should be used carefully and sparingly.

Gargling with potassium bromide solution (5 per cent) or spraying

sparingly with cocaine solution (2 per cent) will subdue intolerance and irritability. For examining the nasopharynx, a palate hook is a convenient accessory. A digital examination is readily made in children with the index finger, nail side up. The epiglottis in children can readily be seen by

FIG. 128.-EXAMINATION OF THE ANTERIOR NOSE BY MEANS OF A NASAL SPECULUM AND REFLECTED LIGHT.

The light should be on the right side of patient.

depressing the tongue, and by means of an epiglottis lifter the larynx may be rendered visible.

In difficult or obscure cases an examination by means of transillumination and Röntgen rays is indicated.

Autoscopy and Tracheoscopy

In tracheoscopy the patient is examined with the head erect and high. In favorable cases the trachea and bifurcation and several rings of the bronchi can be seen.

In examining the upper air passages one should bear in mind that

congestive conditions are not only due to local lesions or disturbances, but are frequently associated with constitutional troubles or obstruction to the circulation in regions far from the respiratory organs, therefore local treatment has its limitations.

An examination of the deep respiratory organs embraces the various methods of physical diagnosis. The recognition of fluid within the chest. is best accomplished by puncture. Exploratory incisions will probably be done in this region in the future by means of Sauerbruch's apparatus, under suction. The fluoroscope and x ray prints also aid us in diagnosis.

Catching Cold

A "cold" is an everyday occurrence concerning which a satisfactory explanation has not as yet been advanced. Areas of minor resistance or irregularities of capillary circulation are inherent or brought on in various individuals. If cold feet produce catarrh of the upper air passages, or hair cutting an angina or

amygdalitis, the irritation is reflected or transmitted to the area of minor resistance, and the resulting local hyperæmia favors infection or the invasion of such microbes as happen to be present, though latent. It is a

well known fact that the mouth and upper air passages harbor microbes at all times, and chilling of the body destroys the antibodies in the blood and favors infection. In this manner we probably contract "colds" of the upper air passages.

Nan

Breathing cold air is not of itself a source of danger. sen, the Arctic explorer, reports the absence of "colds " among his officers and crew while in the ice region, whereas almost all contracted "colds " " upon their return to civilization. The writer and a number of his friends have been exposed to cold and damp weather for weeks on moose hunting expeditions in Canada without contracting cold, whereas two days after the landing of the party in the dusty, hot streets of New York City in September almost all had contracted the ordinary nasopharyngeal catarrh, or "cold."

FIG. 129.-LARYNGOSCOPY AND POSTERIOR RHI

NOSCOPY.

On the other hand, lumbermen in the North and Northwest, who spend the night in an overcrowded and overheated lumber camp, and farmers,