SOME REMARKS ON THE DIAGNOSIS AND 
TREATMENT OF INCIPIENT PHTHISIS. 
Read, before the Philadelphia County Medical $0tiety, May 12th, 1S50. 
CARL SEILER, M.D. 
Lecturer on Diseases of the Throat at the University of Pennsylvania^, 
The subject of the diagnosis and treatment of phthisis-4>as 
been so often and so extensively discussed that I feel somS1 
hesitancy in again bringing it forward; and I would not do so 
if I had not something to offer which I think has as yet not 
received sufficient attention from the general practitioner, and 
which, if fully recognized, will aid him very much in the treat- 
ment of this wide-spread malady. 
The diagnosis of the earliest stages of phthisis, when but 
little structural change has as yet taken place in the tissue of 
the lung, is, as we all know, often very difficult, because both 
percussion and auscultation give almost negative results. In 
this stage, as well as in later stages of the disease, the mucous 
membrane of the larynx affords in almost all cases an index to 
the condition of the lungs; and the changes which have taken 
place in the color and shape of the larynx are so characteristic 
that when once seen they are not easily forgotten or mistaken 
for anything else. 
These changes consist, first, in a peculiar ashy-gray discolor- 
ation of the mucous membrane lining the pharynx and larynx, 
which is different from the mere aneemic paleness so often seen 
in other diseases, and is very difficult to describe, but when 
once seen is not easily forgotten. 
Second, they consist in a peculiar swelling of certain parts 
in the larynx, especially of the arytenoid cartilages and epi- 
glottis, which differs materially in shape and appearance from 
ordinary oedema of the parts. The arytenoid cartilages, either 
on one side or the other, or on both sides, assume the shape of 
a pear, the largest amount of swelling being near the inter- 
arotenoid commissure, while it tapers off in the line of the ary- 
epiglottic folds. Usually we notice this pyriform swelling on 
that side which corresponds with the lung most affected, but 
occasionally we find cases in which the reverse is true. Less 
frequently we find a turban-Y\ke swelling of the crest of the 
epiglottis, which at the same time assumes a horseshoe bend. 
These two conditions have been observed to stand in a certain 
relation to the disease of the lungs, so that in the cases where 
we observe the pyriform swelling of the arytenoid cartilages the lung-tissue has not as yet begun to break dovvn; but as 
soon as the breaking down takes place in the lung the epiglot- 
tis begins to be affected. In the literature of the subject I find 
that but two authors (Cohen and Seiler) make mention of these 
facts, while all others either do not refer to them at all or 
merely hint at them by speaking of the phthisical oedema of 
the larynx. 
In the laryngeal mirror these swellings do not give to the 
observer the impression of simple oedematous tumefaction, and 
free scarification of the parts does not relieve the symptoms— 
aphonia and dysphagia—caused by them. 
Microscopical examination of a number of larynxes showing 
these swellings reveals the fact that the loose submucous tissue 
is largely infiltrated by a small-celled infiltration, with a ten- 
dency to the formation of depots with cheesy centres, and, 
what is rather remarkable, an hypertrophy of the glands and 
follicles, so as to amount almost to an adenomatous growth. 
There is also a certain amount of serous infiltration into the 
net-work of the submucous tissue, which only tends to increase 
the swelling. It is true there are some few cases in which the 
larynx does not participate in the lung disease, and where we 
do not find either the pyriform swelling or the turban and 
horseshoe shape of the epiglottis, and, strange as it may seem, 
these latter cases are more frequently affected with acute tuber- 
culosis than with pulmonic phthisis. 
Frequently, after having seen the laryngeal evidences of phthisis, 
I have been unable to obtain signs of lung disease by the ordinary 
methods of auscultation and percussion. Only by percussing the 
lung as a whole, so as to obtain the fundamental tone of the 
air contained in the whole lung, have I been able to demon- 
strate a variance between the two lungs greater than in health, 
or a decided difference in pitch between the diseased lung and 
a healthy one, taking size and chest-expansion of the patient 
into consideration. 
The pitch of the percussion-note, even when small areas of 
the lung are examined, forms the best and surest indication of 
changes taking place in the lung-tissue, and it is much more 
easy to remember it than a peculiar character of the tone, be- 
cause we can give it a place in the musical scale and thus write 
it down, which we cannot do with a peculiar timbre or quality 
of tone. I am fully aware that but few persons, not musicians 
are able to place any tone in its proper place in the musical 
scale without the help of some instrument upon which they 
can sound a tone corresponding to the tone to be located, and 
I have found that the so-called xylophone is the best means 
for placing or recording the percussion-pitch of the chest, be- 
cause the little pieces of wood when struck lightly with a wooden hammer covered with some soft substance, such as 
cloth or felt, will give a tone remarkably like the percussion- 
note of the chest. By tapping one after the other of the 
pieces of wood composing the xylophone, we can easily find 
the one which corresponds nearest in pitch to the percussion- 
note, and thus can identify it. A change for the better or 
worse, indicated by a fall or rise in the pitch of the percussion- 
note, can thus be determined with great accuracy at a subse- 
quent examination of the patient. 
The treatment of cases of pulmonary phthisis which has of 
late been adopted by myself and others, and which has been 
crowned with remarkable success, is based upon a clear under- 
standing of the pathological changes taking place in the lung- 
tissue. 
If a section of lung from a patient who has suffered from 
chronic pneumonia be placed under a microscope, it will be 
found that the air-cells are filled with a granular debris, in 
which large, swollen epithelial cells, in various stages of fatty 
degeneration, may be seen. These cells, which originally lined 
the inner surfaces of the air-cells, have become loosened from 
their site, thus leaving the walls denuded of their protecting 
covering. These unprotected walls, being in close contact 
with the products of decomposition taking place in the debris 
of infiltration, must necessary yield to their corroding influ- 
ence and break down, so that soon two neighboring air-cells 
merge into one. It is evident that a lung or portion of a lung 
thus infiltrated cannot supply the necessary oxygen to the 
blood, nor can it eliminate the carbonic acid, and the effect of 
this soon becomes evident in a general lowering of vitality, 
which, if a predisposition exists, leads to the formation of 
tubercles in the part of least active circulation,—the affected 
lung. 
We see, therefore, at a glance that if we can remove the ob- 
struction to the entrance of air into the air-cells, we may hope 
for a regeneration of the epithelial covering of these air-cells 
and a re-establishment of the normal function of the lung, 
which, if the lowered vitality be raised by proper nourishment, 
majr become permanent in time. 
This I have in a number of cases found to be possible by 
simple inhalations of some stimulating vapor and by 
the administration of rich animal food, both internally and ex- 
ternally. 
The manner in which the inhalations are taken is of very 
great importance, and the directions which I give my patients 
are, to inhale from any convenient vessel, such as a teapot or 
a funnel placed over a cup, or from an inhaling-bottle contain- 
ing a mixture of hot water and tar, tinct. benz. comp., balsam of tolu, or something similar, with a deep inspiration, so as to 
till all available space in the lung, and then to hold the breath 
as long as possible. In order to insure this latter direction, I 
tell patient to count the number of seconds he can hold his 
breath, thus making him cognizant of the improvement which 
is sure to follow within a few days. 
The effect of such forcible inhalation is to force a small 
amount of air into the obstructed air-cell, which, in the form 
of a small bubble, insinuates itself into the centre of the semi- 
fluid mass of debris. The subsequent forcible expiration will 
cause this air-bubble to seek an outlet, and in doing so will 
force a small portion of the debris into the capillary bronchus 
in connection with the air-cell. This is repeated over and over 
again until the amount of air in the formerly completely ob- 
structed air-cell is sufficient in quantity to force the plug of 
debris into the larger bronchioles, from whence it is expector- 
ated. A proof of this theory may be found in the fact that 
the expectoration of the patient soon becomes white and frothy 
where it had previously been yellow and viscid, and also that 
after a few weeks the pitch of the whole lung will be found 
lower on percussion, indicating that a greater amount of air is 
contained in it. 
Besides these medicinal inhalations, the respiration of plenty 
of fresh air, both day and night, and moderate exercise in the 
open air, are strongly to be recommended. One of the prin- 
cipal causes—in my estimation at least—of the great lowering 
of the vitality of the whole system must be looked for in the 
retention of a large amount of effete material which cannot be 
thrown off by the lungs. The skin must therefore be made to 
act as the main channel through which this waste material is 
carried out of the and at the same time may with ad- 
vantage be made use of to carry new and nutritous material 
into the system, especially when the digestive organs are 
weakened. 
Great benefit will be found from daily inunctions of oil over 
the chest and back, and from rubbing whisky into the skin of 
the arms and legs of the patient. 
The local lesions in the larynx should be treated according 
to well-known principles, and very great relief can thus be 
afforded the patient from the often distressing symptoms. In- 
ternally, cod-liver oil, alcoholic stimulants, extract of malt and 
beef, as well as tonics, should be exhibited ; but care should be 
exercised so as not still more to derange digestion; and for 
that reason expectorants and syrups of any kind should be 
avoided, especially as they can be of little use.