Chapter VI: Part 6

Cases dependent upon malignant growths within the cranium are absolutely beyond the reach of treatment. Paralysis dependent upon bony tumors, even though they are benign in character, are also for the most part beyond the reach of surgical interference. If the paralysis is complete--that is, if all the muscles are involved--there are no indications for any operative procedure. If, however, only the nerves that supply the posterior crico-arytenoids are involved, as occasionally happens, tracheotomy should be resorted to even though the dyspnoea is not urgent. This operation places the patient in a condition of temporary safety, and gives time to resort to other means if the indications for their use can be found.

The second group of cases includes all those in which the cause of the paralysis is due to the presence of disease of the nerve-trunks, or to pressure upon the nerves between their emergence from the cranium and their terminations in the muscles of the larynx. Malignant growths and benign tumors situated along the tract of the nerves, and pinching them, are readily recognized, and when not contraindicated by other facts they should be removed. Enlargement of the thyroid gland may in some cases press upon the nerve and cause paralysis. This is occasionally relieved by appropriate treatment directed to it. Among those means which have occasionally been found efficacious for this purpose iodine or some of its compounds, and especially electricity in the form of galvanism, seem to be entitled to the most confidence. For paralysis dependent upon cicatricial pinching of the recurrent nerve-trunks relief may possibly be obtained by dissecting out the bands by which the nerves are compressed. This is hardly indicated for the partial derangements which do not endanger life, as in unilateral paralysis of the recurrent. Where the trunk of the nerve is entirely obliterated nothing can be done, and in many cases of injuries along the trunk of the recurrent it will be impossible to know that the nerve has not been destroyed in the mechanical lesion.

Paralysis caused by pressure upon the intra-thoracic portion of nerve is beyond the reach of surgical interference. When this is aneurism, disease of the apex of the lung, or pleuritis, as may possibly happen, the paralysis or paresis must of course have a history coeval with the thoracic disease. The causes themselves are unfortunately persistent and tend to terminate in death; the paralyses are therefore persistent and beyond the reach of medical or surgical relief. In cases where the posterior crico-arytenoids are especially involved, tracheotomy, as in the same condition from intra-cranial disease, should be performed. It is certainly true that there may be a morbid {90} condition of one or both of the pneumogastrics or recurrent nerves without macroscopic changes in their structure; in such cases the use of the faradic current together with general tonics is indicated.

The third group is made up of those cases in which there is disease of the nerves or muscles of the larynx itself. It seems to be true that in most of these patients there is a derangement of the general nutrition; but this is not all: there is also a special morbid condition of these special structures. For degeneration of the muscles of the larynx there is probably no remedy; for atrophy there may be something done by different methods of exercising the muscles. The use of electricity when the muscles are still responsive to the current should be attempted. Regular applications by which they are thrown into action may result in the improvement of their nutrition. The use of them so far as they are phonators, without carrying it to the extent of producing fatigue, is also indicated. In addition to these local measures, tonics for the purpose of improving the general condition may be administered. Strychnia, with the purpose of stimulating the centres, will also be found in some cases useful. When the disease is partial, as in the case of the posterior crico-arytenoids, such operative measures as have been already indicated must be resorted to. The purpose is to prolong life, even though we cannot cure the disease.

The fourth group, the paralyses of reflex origin, are generally within the reach of treatment; at least, they usually recover. They depend for the most part, as will be remembered, upon some disorder of distant organs. There is primarily no disease of the larynx, and not necessarily even a secondary disorder of its structures. It is true that long inaction may result in atrophy of the muscular structure, but this is, I am convinced, a rare exception to the rule that in hysterical paralysis there is maintained a complete integrity of the muscles of the organ, even though the parts have been for years in a state of inaction. For some reason, the nutrition is maintained much better than in paralysis from other cases. The trophic nerves are evidently not involved. The treatment should be both local and general. It should be directed to the larynx and to the distant part upon which the motor disorder of the larynx depends. So far as the larynx is concerned, we know of nothing better than electricity. The faradic current, by which the muscles are stimulated and the nervous energies awakened, seems to be most useful. The method of applying electricity to the larynx may be varied according to the nature of the case and the age of the patient. In young children the current should be directed through the walls of the larynx from side to side or from before backward. It should be repeated every day if possible. In adults the current may with advantage be passed through the larynx from within outward or from one side to the other. This may be accomplished by the use of Mackenzie's laryngeal electrode. The instrument is either single or double. Armed with a sponge and bent to the proper curve, one pole is introduced into the larynx, the other placed upon the neck, and then by pressing a spring the circuit is closed, permitting the current to pass through the parts from one pole to the other. In using the instrument with two electrodes, as in paralysis of the arytenoids and constrictors, the instrument with two branches, each armed with a sponge, and to which the two poles are attached, is introduced with one branch in one of the depressions in one side of the larynx, and the other on the opposite side in the corresponding depression. The circuit is now closed as before, with the muscles between the two poles as part of the circuit. The electrodes may be carried down into the organ and the stimulus applied directly to the vocal bands. In some cases the first shock is followed by distinct phonation; in others repeated applications are necessary; while in still others all efforts of this kind fail entirely. Both the galvanic and the faradic current may be used. When the object {91} is to stimulate the dormant energies of the nerves or muscles, the faradic is probably the more useful; if it is desired to modify the nutrition of the parts, the galvanic is preferable. The strength of the current should be carefully tried upon the surface of the hand of the operator before introducing it into the larynx. The shock to the nervous system from the dread of the operation has sometimes resulted in the recovery of the voice before anything has been done. The morbid spell is broken and the patient speaks. This is true in spasm even, as shown in a case reported by Lefferts, where it was thought that tracheotomy was necessary for the purpose of saving life. The patient, frightened at the thought of the operation, recovered, and respiration became easy. There was no reason to think that the case was one of simulation.

For the general condition, which is usually one of asthenia, nerve-stimulants are indicated, and the bitter tonics, with iron and strychnia, good generous diet, outdoor exercise, change of surroundings, travel, moral impressions, in short everything that tends to promote general good health,--these are among the most important requirements. If there is local uterine trouble, this of course requires attention, or if there is any other derangement which serves as the point of departure for the morbid phenomena, this will also demand consideration. In fact, no organ suffers alone. There is a community of function and there is a community of suffering. This subject has been perhaps sufficiently discussed in the consideration of the treatment of hysterical disorders of sensation and of spasm, to which the reader is referred.

The fifth group comprises paralyses toxic in their origin. When the cause is typhoid fever or diphtheria, we may confidently expect the paralysis to disappear with the other manifestations of adynamia. Time and tonics, with attention to diet, and in the more protracted cases electricity, will generally be all that is required. Cases depending upon the toxic effects of lead or arsenic demand the treatment appropriate for the other manifestations of these forms of paralyses. The iodide of potassium internally, with attention to the general health, and especially to the functions of the excreting organs, constitute the most important measures. In addition, strychnia may be administered, and the faradic current applied through the larynx. It is certainly possible that laryngeal paralysis may be produced by arsenic, as shown in the case reported by Mackenzie, and probably also by copper or mercury. Such cases, however, must be exceedingly rare. The potassium iodide, as suggested for lead-paralysis, may be resorted to in case mercury is supposed to be the cause. For arsenic- and copper-poisoning the reader is referred to articles upon these subjects elsewhere. Cases in which there is evidence of a local lesion due to syphilitic intoxication should receive both local and general treatment.

{92}

ACUTE CATARRHAL LARYNGITIS (FALSE OR SPASMODIC CROUP).

BY A. JACOBI, M.D.

PATHOLOGY.--Catarrhal inflammations of the mucous membrane and the submucous tissue of the larynx are of frequent occurrence. They are either general or local; that is, confined to the epiglottis or the vocal cords, etc. The affected parts are red (only less so where the elastic fibres are developed to an unusual degree and capable of compressing the dilating capillaries) and more or less tumefied. Sometimes small hemorrhages occur. The secretion is either changed in character or in quantity. It is either mucous or purulent, or (mainly in passive congestions produced by interrupted venous circulation) serous. The epithelium is either thrown off or accumulated in some spots, particularly on the vocal cords, so as to form whitish conglomerates which may become the abode of schizomycetæ. The muciparous follicles are enlarged and dilated; to this condition is due the granular form of laryngitis, with the nodulated condition of the epiglottis or the fossæ Morgagni or the inferior vocal cords.[1]

[Footnote 1: Ziegler, _Pathol. Anat._]

When the catarrhal process is of longer duration, the capillaries and small veins become permanently enlarged; round cells are deposited between the epithelium and cellular tissue; the cellular tissue becomes hypertrophied; papillary elevations are formed on the vocal cords. The disintegration of the epithelium and the bursting of the tumefied muciparous glands lead to the formation of erosions and ulcerations; the chronic swelling and hypernutrition of the muciparous follicles to their destruction by cicatrization or simple induration; and to atrophy of the mucous membrane.

Many of the specific causes of inflammation of the larynx exhibit no peculiar alterations of their own. Scarlatina, measles, and exanthematic typhus are complicated with either a catarrhal (in most cases) or a diphtheritic laryngitis. Variola, however, has a peculiar form of its own, with red, pointed, whitish stains or nodules, consisting of a cellular infiltration or of a deposit upon or into the upper layers of the mucous membrane, composed of necrotic epithelia and pus-corpuscles or of coherent membrane. Hemorrhages or abscesses are but rare, and chondritis seldom results from it. Even syphilis has not always changes which are characteristic. The laryngitis accompanying it is often but catarrhal, without anything pathognomonic about it. But whitish papules consisting of granulation-tissue (plaques muqueuses), gummata often changing into sinuous ulcerations, particularly on the epiglottis and posterior wall of the larynx, also perichondritis with loss of cartilage and deep cicatrization, such as are not found in either carcinosis or tuberculosis of the larynx, are frequently met with. Typhoid fever shows different forms of laryngitis, from the catarrhal to the ulcerous. Epithelium is thrown off at an early period of the disease; erosions and ecchymoses follow; rhagades on {93} the margins of the epiglottis, and a deposit on the anterior wall of the larynx and the vocal cords, consisting of epithelium and round cells, are frequent. That they should be mixed with micrococci and bacteria is self-understood. Not so that these bacteria are to be considered as the cause of the disintegration which is taking place, the less so as no specific typhoid bacterium has been demonstrated, and several varieties of them are found both in the mouth and in these ulcerations. These changes are apt to terminate in ulceration of the epiglottis and false vocal cords; these will extend in different directions, and to the deeper tissue down to the cartilage.

In tuberculosis, laryngitis is a frequent occurrence. In most cases it is secondary to the pulmonary affection, and due to the direct influence of the contagious sputum--according to Heinze, however, not to contagion, but to the influence of the infected blood. In other cases it appears to develop spontaneously, before any pulmonary affection is diagnosticated, and may then be due to some poison circulating in either blood or lymph. Tubercular laryngitis, according to Rindfleisch, commences in the excretory ducts of the muciparous glands. That this is so in a great many cases is undoubted. The first changes visible are small cellular subepithelial infiltrations or real subepithelial tubercles, which, while growing, undergo gaseous degenerations and ulcerate. These ulcerations are either flat and small or deeper with an infiltrated edge, and are apt to terminate in secondary nodulated infiltrations and abscesses. Large tumors are not met with, but oedema and phlegmonous inflammations are by no means rare.

ETIOLOGY.--The predisposition varies according to individuals, ages, and seasons. Some mucous membranes appear to be more sensitive than others. The hereditary transmission of peculiarities of structure of all or some tissues or organs is apparent, in the case of laryngitis, in the fact that many children in the same family or the children of parents who were sufferers themselves are affected. Children are more liable than adults, infants more than children: 20 per cent. of all the cases are met with under a year, 25 from the first to the second, 15 from the second to the third. Not many occur after the twelfth year. The narrowness of the infant larynx and the looseness of its mucous membrane afford full play to injurious influences, such as dust, cold and moist air, changing temperatures, hot vapors and beverages. Colds, though their nature and effects can hardly be said to be understood, are certainly amongst the main causes. Perspiring surfaces afford frequent opportunities. One of the principal causes is insufficient clothing--more amongst the well-to-do than amongst the poor. The latter have this blessing in their misfortune, that they are protected uniformly if at all, and have their skins hardened by exposure. The bare necks and chests, the exposed knees, the low stockings and thin shoes of the children of the rich, old and young, are just as many inlets of laryngeal catarrh, inflammatory disease, and phthisis. Persons suffering from nasal catarrh or pharyngeal catarrh are liable to have laryngitis. Thus, not only rachitis, with its influence on lymphatic glands and the neighboring mucous membranes, but also acute infectious diseases, such as whooping cough, measles, influenza, erysipelas, hay fever, tuberculosis, syphilis, typhoid fever, and variola, are as many causes of laryngitis. That over-exertion of the voice should produce laryngitis seems probable, but experience does not teach that those babies who cry most are most subject to laryngeal catarrh.

SYMPTOMS.--Acute laryngitis is a frequent disease, and has always been. Still, in 1769, Millar mistook it for a sensitive neurosis, considering it as identical with spasm of the glottis, and recommended antispasmodic treatment. Guersant understood its nature better. He first (1829) used the names false croup and stridulous laryngitis. Acute laryngitis is attended with but little fever in the adult, but with a high elevation of temperature in {94} the young. In all, it yields a number of symptoms, part of which are uncomfortable only; others are liable to become dangerous.

Seldom without any catarrhal premonitory symptoms of other parts of the respiratory tract, sometimes, however, without any, there is a burning, tickling, irritating sensation in the larynx--a sense of soreness in it and the lower portion of the pharynx. Sometimes these sensations amount to actual pain, to difficulty of deglutition, and to the sensation of the presence of a foreign body. Speaking, coughing, cold air, increase the discomfort and pain. Hoarseness, sometimes increasing into aphonia, follows soon after, is seldom simultaneous with, the first appearance of cough, but lasts longer than the latter, which is, according to the severity of the case or the stage of the disease, changing between loose and dry, hoarse and barking. Inspiration is apt to become impeded, mainly in infants and children. In these it is often sibilant. It is followed by a reflex paroxysm of cough, with interrupted and brief expirations, during which the forcible compression of the thorax may result in cyanosis. The principal attacks are met with at night amongst children. Quite suddenly they wake up with a dry, barking cough, interrupted by considerable dyspnoea, which is great enough sometimes to give rise to much anxiety. They toss about or cling to a solid body, raise themselves on their knees, breathe with great difficulty, exhibit cyanosis in its different hues, perspire very freely, and yield all the symptoms of the strangulating attacks of membranous croup, its over-exertion of the sterno-cleido-mastoid muscles and supraclavicular and diaphragmatic recessions not excepted. These attacks occur but rarely during the day; on the contrary, well-marked remissions are quite common in the morning. Their occurrence during the night is best explained by the facility with which mucus will enter the larynx from above during the reclining posture, the increasing dryness of the pharynx during sleep, perhaps also the nervous influence depending upon the relative diminution of oxygen and increase of carbonic acid in the respiratory centre, leading to spasmodic contractions.

Some of these grave attacks of sudden dyspnoea are explained by the participation of the submucous tissue in the morbid process. When that occurs, adults also, who as a rule do not suffer from dyspnoea in laryngeal catarrh, are badly affected. The symptoms are rigor, high temperature, pain, hoarseness or aphonia, a barking cough, labored expectoration--which is sometimes bloody--dyspnoea, orthopnoea, cyanosis. In some cases, to which the name of laryngitis gravis or acutissima has been given, the symptoms grow urgent to such a degree that tracheotomy alone is capable of saving life.

Otherwise, the severity of the symptoms does not go parallel with the local lesions. Particularly in children, hoarseness, cough, and dyspnoea are liable to be grave, while the local hyperæmia is not intense at all. A pharyngeal catarrh is very apt to increase the suffering. Complications with tracheitis or bronchitis are liable to prolong the course of the disease and to render respiration--which is not accelerated in laryngeal catarrh--more frequent. Otherwise, the disease runs a favorable course. Remissions of the severe attacks which may occur in several successive nights take place in the morning. Expectoration, which in the beginning was either absent or scanty, becomes soon more copious and mucous; the hard, barking, loud cough grows looser with increasing secretion. In most cases the violence of the affection is broken in from three to five days, and the disease runs its full course in a week or two. But hoarseness may remain behind for some time; in rare cases aphonia has become permanent and relapses are frequent. Not infrequently children are presented who are reported to have had croup five or ten or more times. In some families all the children are subject to laryngeal catarrh, and hereditary influence cannot be doubted.

The very worst complication of laryngitis is oedema of the glottis. It {95} affects both the mucous membrane and the submucous tissue of the larynx. It is met with on the inferior (posterior) surface of the epiglottis, in the ary-epiglottic folds, and on the false (inferior) vocal cords, the submucous tissue of which is of a very loose structure normally. Amongst its causes--which may be various (foreign bodies in the larynx, injuries, mechanical and chemical irritants of any kinds; typhoid, tubercular, variolous, syphilitic ulcerations; erysipelas of the neighborhood, inflammations of the parotids or tonsils, suppuration in the pharynx, thyroid body, and cellular tissue of the neck)--both catarrhal and croupous laryngitis are not at all uncommon. This is particularly so when they are complicated with cardiac and renal anomalies, pulmonary emphysema, and compression of the veins of the neck by glandular swellings; also with changes in the structure of the walls of the blood-vessels. The last-named pathological conditions are alone capable of giving rise to chronic oedema of the larynx, which is by no means so fatal, but still dangerous.

In glottic oedema the dyspnoea is both very great and very sudden. First, it is inspiratory only, but soon becomes both inspiratory and expiratory. The swelling is felt distinctly by the examining finger; the laryngoscope is neither required nor advisable.

DIAGNOSIS.--It is by no means easy in all cases. When laryngeal diphtheria (membranous croup) happens to be frequent, the most experienced diagnostician will meet with occasional difficulties. The sound of the barking, explosive, tickling cough locates its origin in the larynx, but the affection may be very mild or very severe. Expectoration in small children is not pathognomonic; even when it is copious it is not brought up, but swallowed. Fibrinous expectoration would settle the diagnosis of a croupous process. Depressing the tongue with a spoon or spatula and producing the movements of vomiturition often reveals the presence of a tough, viscid mucus rising from the larynx. It renders the catarrhal nature of the laryngitis positively clear. The frequency or volume of the pulse is of no account in diagnosis; it is too variable. Of more importance is the temperature, at least in children. Uncomplicated sporadic croup has no increase, or very little; catarrhal laryngitis is mostly attended with high fever. In very many cases this symptom has guided me safely, in spite of the statements of the books. The stenosis of catarrhal laryngitis comes on very suddenly, in diphtheritic laryngitis mostly slowly. In the former it is not of long duration; remission sets in soon, and is more complete than in membranous croup. An attack of stenosis occurs mostly in the night, and is apt to return with the same vehemence after a fair remission after twenty-four hours. The frequency of relapses in catarrhal laryngitis in children who have been affected before must, however, not prejudice in favor of the catarrhal nature of an individual case, for not infrequently will those who have had many attacks be taken with membranous croup some other time. In the latter the main symptoms--viz. stenosis, hoarseness (or aphonia), and cough--will mostly develop simultaneously and in equal proportion; the unproportionality of these symptoms--for instance, much stenosis and cough, but little hoarseness, or barking cough and hoarseness with little stenosis--would speak for catarrh. The laryngoscope, when it can be used--viz. in the adult and very docile children--reveals redness of the mucous membrane of the pharynx and all or part of the larynx; also tumefaction of the epiglottis or fossæ Morgagni or ary-epiglottic folds. Sometimes the inferior part of the larynx only is affected; Ziemssen has described a severe form under the name of hypoglottic laryngitis. The vocal cords can be watched easily. Their proportionate and parallel contraction is often interfered with.

Tubercular laryngitis, particularly when there is no pulmonary tuberculosis, is not easily diagnosticated by the local changes only. The long duration of {96} hoarseness and fever, increasing emaciation, and the knowledge of the presence of tuberculosis in the family are more conclusive than local examinations can be.

PROGNOSIS.--The termination of catarrhal laryngitis in the adult is almost always favorable. Still, relapses are frequent, and it may become chronic, with permanent tickling of the mucous membrane and submucous tissue. In children it is mostly favorable; still, it is doubtful, because of the frequency of complication with, or transmutation into, bronchitis, pneumonia, or glottic oedema, and because of the facility with which in a prevailing epidemic the catarrhal laryngitis becomes diphtheritic. The elevation of temperature is not a very significant symptom in regard to prognosis. The danger does not increase with the temperature at all. On the contrary, those cases which set in with a high temperature will, as a rule, terminate soon and favorably. When, however, the temperature rises again after having gone down to the normal or nearly normal standard, complications or extension of the catarrhal or inflammatory process must be expected. Catarrhal secretion from the nasal mucous membrane, which was dry in the beginning, is a favorable symptom; so is the looser and moister character of the cough.

TREATMENT.--Whatever plays an important part in the etiology of the disease ought to be carefully avoided. The feet must be kept warm under all circumstances, nothing being more injurious to health in general, and to that of the respiratory organs in particular, than cold and moist feet. Shoes and stockings must be kept dry, the latter changed when wet, and of slowly-conducting material. No part of the body must be kept uncovered, and the dresses of children made the particular object of care on the part of the family physician. Linen must not be in immediate contact with the skin, cotton--or, still better in all seasons, wool--being required for the undergarment. At the same time, the hygiene of the skin requires attention. Regular washing or bathing need not be mentioned as a requisite, as it is self-understood. What, however, cannot be insisted upon too much is this, that the skin must get accustomed to cold water. The whole body must be exposed once a day to cold water--washing or bathing--and well rubbed off afterward with a thick towel. Young infants and those who are very susceptible to colds begin with tepid water, the temperature being lowered from day to day. Even children of three or four years enjoy, finally, a morning bath at sixty or sixty-five degrees F. in winter. Such as do not get easily warmed up under the succeeding friction may mix alcohol with the water they use for washing and sponging purposes, in the proportion of 1:5-8. Sea-bathing also makes the skin more enduring, to such an extent that exposure to cold air has no longer any damaging influence. In fact, cold air without wind is easily tolerated even by those who have a tendency to respiratory disorders, while wind and draught must be avoided. From this point of view the change of climate sometimes required for such as suffer from catarrhal laryngitis must be instituted. It is not always necessary to select a very warm climate; undoubtedly, many of the winter resorts are badly selected, for the very reason that they are too warm. On the other hand, great elevations are not advisable. The sudden atmospheric changes and fogs of high mountains are injurious.

Patients suffering from catarrhal laryngitis or a tendency in that direction must avoid all irritation of the pharynx and larynx. They must not smoke, or talk too much or too loud. Those few clergymen who suffer from clergymen's sore throat in consequence of speaking only will remember that they can speak just as forcibly when speaking less vehemently. The use of alcoholic beverages, unless greatly diluted, is prohibited. Catarrh of the nares and pharynx must get cured. The former will get well in most cases under the use of salt water. A tepid solution of 1 or ½ per cent. of table-salt {97} in water, snuffed up copiously (a tumblerful) from the hand of an adult patient, or a similar solution in a small quantity injected through each nostril of a child, twice or three times a day for weeks and months in succession, will often remove a laryngeal as well as a pharyngeal catarrh. Care must be taken that the fluid passes the whole length of the nasal canal. It must be applied in the fauces, and will then be ejected through the mouth or a small portion of it swallowed. Many a severe nasal catarrh requires no other treatment. Some chronic ones require the use of a spray of nitrate of silver in a solution of ½-1 per cent. every other day, or of a 2 per cent. solution of alum daily. Where both the pharyngeal and nasal catarrh are complicated with, or kept up by, enlarged or ulcerated tonsils, these organs must be resected. The combination of these two measures, exsection of the tonsils and nasal injections, has proved very beneficial in a great many cases.

The treatment of an acute case requires great care. Avoid injurious influences. The patient must keep silent and quiet in bed. The temperature of the room is to be about 70° F., the air moistened by vapor, which must not be allowed to get cold before it reaches the patient.

When swelling and dyspnoea are considerable, particularly in those grave cases attended with swelling of the submucous tissue, the application of an ice-bladder or ice-cloths will be found beneficial and agreeable. But the cases in which these applications are indispensable are but few. In most of them the necessity of subduing intense inflammation is less urgent than the advisability of increasing the secretion of the congested larynx. For that purpose warm poultices, but of light weight, act very favorably. Inhalation of warm vapors either constantly or at short intervals, or of muriate of ammonium or spirits of turpentine, will prove beneficial. The latter is evaporated from the surface of boiling water, on which a small quantity, from a teaspoonful to a tablespoonful, may be poured every one or two hours. The hydrochlorate of ammonium is evaporated, 10 or 20 grains (1.0 gramme), every one or two hours by heating it on a hot stove or otherwise. The white cloud penetrates the air of the whole room, and, while not uncomfortable to the well, serves a good purpose in liquefying the viscid and tough secretion of the mucous membrane. The internal administration of liquefying and resolvent remedies may properly accompany the external applications and inhalations. Amongst them I count the alkalies, mainly bicarbonate and chlorate of potassium or sodium and the hydrochlorate of ammonium. A child of two years will take daily a scruple (gramme 1.0-1.5). The iodide of potassium will also have a good effect and counteract many a predisposition to chronicity. A child may take from 8 to 15 grains a day (gramme 0.5-1.0). Hydrochlorate of apomorphine, gr. 1/50-1/30 (0.001-0.002), dissolved in water, a dose to be given every two hours or every hour, is quite sufficient to act as a fair expectorant without being enough to produce emesis. Antimonii et potassii tartras has been used more extensively in former times than at present. An adult would take gr. 1/20-1/15 every two hours. Children ought to be spared the drug, as it is depressing, produces unnecessary vomiting now and then, even in small doses, and, what is still worse, diarrhoea. The other antimonial preparations, such as kermes mineral and the oxysulphuret of antimony, are less depressing and less purging, but also less effective; and there are but few cases where a good substitute could not be found. For the purpose of increasing secretion the hydrochlorate of pilocarpine has been recommended. It certainly has that effect, but its indications become doubtful in many cases where the saving of strength is of paramount importance. I shall return to this subject in my remarks on the therapeutics of membranous laryngitis.

Derivation is of great service when well directed. Local depletion must be avoided. A purgative in the beginning is beneficial--a dose of calomel {98} as good as, or mostly better than, anything else. Diaphoretics and diuretics act quite well; the best of them all are warm beverages of any kind. They need not come from the apothecary's nor be very unpleasant to take--water not too cold, Apollinaris, Selters, or Vichy, hot milk, tepid lemonade in large quantities and very often. Sinapisms have a good effect. When not kept on longer than a few minutes--long enough to give the surface a pink hue--they may be applied every hour or two.

Some urgent symptoms may require symptomatic treatment. When secretion is copious, but too tough, and expectoration insufficient because of both the character of the mucus and the incompetency of the respiratory muscles, ipecac in small doses or camphor is indicated. A child's dose of the latter would be gr. ¼-½(gramme 0.015-0.03) every one or two hours. In these cases the hydrochlorate of ammonium may be combined with the carbonate (ammon. chlorid. drachm ss. (2.0); ammon. carbonat. scruple j (1.25); extr. glycyrrh. pur. scruple ij (2.5); aq. pur. fluidounce iij (grammes 100.0)--teaspoonful every hour). When the difficulty of expectoration is excessive an emetic may be resorted to. It is true that infants and children vomit with less straining and difficulty than adults, but, still, the practice of flinging emetics around is too common. The unpleasantness of getting up in the night because of a pseudo-croup in a distant patient's baby is not a correct indication for encouraging the indiscriminate use of emetics. When they are required, antimonials ought to be excluded from the list. Ipecac, sulphate of zinc, sulphate of copper, turpeth mineral are preferable.

In urgent cases the hydrochlorate of apomorphia may be used hypodermically (six or ten drops of a 1 per cent. solution in water). Cases of such urgency, and so excessive dyspnoea coupled with cyanosis, as to necessitate tracheotomy are but very rare. But once in thirty years and in many more than four hundred tracheotomies have I been compelled to operate for a case of catarrhal laryngitis. Still, a few such cases are on record. The best-known amongst them is that of Scoutetten, who operated successfully on his own daughter six weeks old.

Narcotics prove quite beneficial, particularly in complications with pharyngeal catarrh. A dose of gr. j-jss of Dover's powder (gramme 0.05-0.1) at night will secure rest for several or many hours to a child of two or three years; an adult is welcome to a dose of 10 or 12 grains (0.6-0.75). When the irritation is great during the day, it is advisable to add a narcotic (acid. hydrocyan. dil., min. j; vin opii, min. viij-xij; codeine gr. 1/3-1/2, or extr. hyoscyam. gr. ij-iij--daily) to whatever medicine was given. I am partial to the latter, giving it up to gr. viij-x (0.5-0.6) to adults daily in their mixture, retaining the single dose of opium or morphine to be taken for the night. At that time a single larger dose is rather better than several small ones. Narcotics cannot be dispensed with in all those cases in which--as, for instance, in tubercular laryngitis--deglutition is very painful because of the catarrhal and ulcerous pharyngitis. Bromide of potassium has a fair effect, but frequently fails, and the administration of morphia before each meal is sometimes an absolute necessity.

That complications, such as bronchitis, have their own indications is self-understood. The general rules controlling the treatment of laryngitis are not interfered with by them. Oedema of the glottis, however, when occurring during an attack of laryngitis, has its own indications, and very urgent ones indeed in all acute cases. In chronic cases a causal treatment is required according to the etiology of the affection as specified above. In acute cases it is not permitted because of want of time. The danger of immediate strangulation is often averted only by a deep scarification or the performance of tracheotomy.

Chronic cases require all the preventive measures enumerated above and {99} the internal use of iodide of potassium or sodium (scruple j-scruple iiss = gramme 1.25-3.0 daily, for adults), and tincture of pimpinella saxifraga three or four teaspoonfuls daily. When it is given it ought to have an opportunity to develop its local effect on the pharynx also by giving it but little diluted, and not washing it down afterward (tinct. pimpinella saxif., glycerin. _aa_, teaspoonful every two hours). In these cases, while the local salt-water treatment recommended above is indispensable, the nitrate-of-silver spray mentioned in that connection is here again referred to as very beneficial indeed. But the solution of 1 per cent. is the highest degree of concentration allowable. Conducted through the nose, it will reach the larynx better than through the mouth. When both accesses are rather difficult the application must be made directly to the larynx.

{100}

PSEUDO-MEMBRANOUS LARYNGITIS.

BY A. JACOBI, M.D.

PATHOLOGY.--Pseudo-membranous laryngitis is characterized by the presence, on and in the mucous membrane, of a pseudo-membrane of a whitish-gray color, various consistency, and different degrees of attachment. It has been called croupous when it was lying on the mucous membrane without changing much or at all the subjacent epithelium and could be removed without any difficulty. It has been called diphtheritic when it was imbedded into the mucous membrane and was difficult to remove. This difference exists, but it does not justify a difference of names except for the purpose of clinical discrimination; for the histological elements of the two varieties are the same, and the difference in their removability is explained by the anatomical conditions of the territory in which they make their appearance. The membrane consists of a net of fibrin studded with and covering conglomerates of round cells, mixed with mucus-corpuscles, epithelial cells more or less changed, and a few blood-cells. The fibrinous deposit is either quite superficial or lies just over the basal membrane or on layers of round cells originating from the basal membrane. It is continued into the open ducts of the muciparous follicles, filling them entirely in the worst cases, or meeting the normal secretion of mucus in the interior of the duct. The principal seat of the pseudo-membrane is that mucous membrane which is covered with pavement epithelium; thus it is that the tonsils are the first, usually, to exhibit symptoms of diphtheria. But cylindrical epithelium is by no means excluded. However, while pavement epithelium is generally destroyed by the diphtheritic process, the cylindrical epithelium is frequently found unchanged, or but little changed, on top of the mucous membrane under the pseudo-membrane.

The nature and consistency of the pseudo-membrane in the larynx is best studied by the light of the study of its anatomy. There is a great deal of elastic tissue in both epiglottis and larynx; the mucous membrane of the latter is thin, and sometimes folded on the vocal cords. The epithelium of the epiglottis is pavement; only at its insertion it is cylindrical. In the larynx it is also pavement on the true vocal cords and in the ary-epiglottic folds, and fimbriated toward the fossæ Morgagni and trachea. Lymph-vessels are but scanty on the epiglottis, still more so in the larynx. Of acinous muciparous glands there are none on the epiglottis, none on the true vocal cords; they are more frequent in and round the fossæ Morgagni, with cylindrical epithelium in the glandular ducts. The trachea and bronchi contain a good many elastic fibres, less connective tissue, fimbriated epithelium, some lymph-vessels, but no lymph-glands, and acinous muciparous glands in large numbers. Wherever the pavement epithelium membrane is abundant the membrane is firmly adherent and imbedded into the mucous membrane. Where it is cylindrical and plenty of acinous glands secrete their mucus, they are loosely spread over the mucous membrane, from which {101} they can be easily removed; while the histological condition of both the imbedded and the loose membrane is exactly the same.

Before the membranous deposit takes place the surface is in a condition of catarrh. Round the membrane the mucous membrane is red and slightly swollen. Not always, however, is that so. Particularly, the epiglottis may be covered on its inferior surface with a solid membrane or be studded with tufts of membrane, without much or any hyperæmia. The same can be said of the larynx, which is supplied with but a scanty distribution of blood-vessels and a sufficient network of elastic fibres to counteract the dilatation of blood-vessels peculiar to the catarrhal and inflammatory processes.

In uncomplicated cases of membranous laryngitis the membrane is confined to the larynx. Dozens of years ago--viz. before 1858, when diphtheria began to settle amongst us, never, it appears, to give up its conquest again--that took place in most cases. But since that period we meet with few such simple cases. As a rule, the membrane makes its appearance in the pharynx first, from there to descend into the larynx, and not infrequently into the trachea and bronchi. In other--fortunately, but few--cases the membrane is formed in the bronchi and trachea first, and invades the larynx from below.

Other organs suffer but consecutively and from the results of impeded circulation only. Thus, in post-mortem examination hyperæmia of the brain, liver, and kidneys, and bronchitis, broncho-pneumonia, or pulmonary oedema, are met with. Only those cases of membranous laryngitis which are complicated with general diphtheria yield the additional changes of the latter.

ETIOLOGY.--Intense irritants will produce an irritation on mucous membranes. In the larynx the product is, according to the severity of the irritation, either a catarrhal or a phlegmonous or a croupous laryngitis. The irritating substances may be mechanical, chemical, or thermical. Heubner produced diphtheria of the bladder by cutting off, temporarily, the supply of circulation. Traumatic injury of the throat and larynx will soon show a croupous deposit. Caustic potassium, sulphuric acid, caustic ammonium, corrosive sublimate, arsenic, chlorine, or oxygen, applied to the trachea or larynx, produce croupous deposits.[1] Inhalations of heat, smoke, and chlorine have the same effect. These, however, are not the usual causes of croup. Cold and moist air is a more common cause, mainly during a prevailing epidemic of diphtheria. In former times, which are unknown to the younger generation of physicians, when no such epidemics existed, the only form of diphtheria occurring now and then was the local laryngeal diphtheria called pseudo-membranous croup. It was then a rare disease, while at the present time it is of but too frequent occurrence. In my _Treatise_ I have explained at some length the relations of the two (p. 128).

[Footnote 1: A. Jacobi, _Treatise on Diphtheria_, p. 111.]

Age has some influence in its development. The disease is not frequent in the first year of life; between the second and seventh years almost all the cases are met with. There are families with what appears to be a general tendency to croupous laryngitis. It may return. Even tracheotomy has been performed twice on the same individual.[2] It is contagious. In the same family, from a case of croup, either another case of laryngeal croup may originate or another form of diphtheria will develop in other members of the household. It is not so contagious, it is true, as generalized diphtheria must be, for the infecting surface is but small in uncomplicated membranous croup, and the membrane not so apt to macerate and be communicated. Boys appear to be affected more frequently than girls. But the previous constitution makes no difference.

[Footnote 2: _Treatise_, p. 27.]

SYMPTOMS.--Membranous laryngitis begins sometimes with but slight symptoms of catarrh, sometimes without them. Nasal, pharyngeal, and laryngeal catarrh may precede it a few hours or a week, with or without fever and with {102} a certain sensation of pain or uneasiness in the throat and a moderate amount of cough and hoarseness. This condition has been called the prodromal stage of membranous laryngitis, though it is just as natural to presume that the changes in the mucous membrane merely facilitated the deposit of false membrane. The latter is more apt to develop on a morbid than on a healthy mucous membrane. The membranous laryngitis proper dates from the time at which, with or without an elevation of temperature, a paroxysmal cough makes its appearance--first in long, afterward in shorter intervals--which is increased by a reclining posture, mental emotions, or deglutition. At an early period this cough, which is very labored and gives rise to dilatation of the veins about the neck and head, is complicated with hoarseness, which gradually increases into more or less complete aphonia. Respiration becomes audible, sibilant, with the character of increasing stenosis. Inspiration becomes long and drawn; expiration is loud; head thrown back; the scaleni, sterno-cleido-mastoid, and serrati muscles are over-exerted; above and below the clavicles and about the ensiform process deep recessions take place in the direction of the lungs, which are expanded with air, but incompletely; dyspnoea becomes the prominent symptom, and occasional attacks of suffocation render the situation very dangerous and exciting indeed. These sudden attacks of suffocation are due--besides the permanent narrowing of the larynx by the membranes, which gradually increase in thickness--to occasional deposits of mucus upon the abnormal surface of the larynx and vocal cords, by partly-loosened false membrane, which now and then become audible, yielding a flapping sound, by oedema in the neighborhood, and by secondary spasmodic contractions. They are mostly met with in the evening and night; there is often a slight remission in the morning, which rouses new hopes, which soon, however, prove unfounded. Meanwhile, the pulse becomes more frequent in proportion with the increase of dyspnoea, and finally irregular; the temperature rises but little, and usually only when the throat or other organs, which are in more intimate connection with the lymph circulation than the larynx, are participating in the exudative process; and the laryngeal sounds become so loud as to render the auscultation of the lungs impossible. The glands of the neck are not swollen when the process is confined to the larynx. Now and then small or larger, rarely cylindrical, pieces of false membranes are expectorated, with or without any amelioration of the condition. In this condition the patient may remain a few hours or a few days.

Then the dyspnoea will rise into orthopnoea; the anxious expression and bearing of the little patient--for the vast majority of the sufferers are children--becomes appalling to behold; cyanosis increases; the head is thrown back; the larynx makes violent excursions upward and downward; the abdominal muscles work in rivalry with those of the thorax and neck; the surface is bathed in perspiration; still, consciousness is retained by the unhappy little creature tossing about and fighting for breath, and in complete consciousness he is strangled to death. Now and then the carbonic-acid poisoning renders the pitiful sight a little less appalling to the powerless looker-on by giving rise to convulsions or anæsthesia and sopor, which finally terminate the most fearful sight, the like of which the most hardened man, the most experienced medical attendant, prays never to behold again.

Besides the brain symptoms just mentioned, but few other organs give rise to abnormal function. In the kidneys the stagnant circulation results in albuminuria--in the bronchi and lungs, in hyperæmia, inflammation, and oedema.

The symptoms described above are the same both in those cases which are strictly localized and those which descend from the pharynx. In the latter there is fever only when the pharyngeal diphtheria was attended with it. The process descending into the trachea and bronchi changes the symptoms {103} but little, as far as the laryngeal stenosis is concerned, for it is the latter which destroys by suffocation. Only when tracheotomy has been performed, and the immediate danger of suffocation has been removed, the further progress in a downward direction gives rise to a new series of symptoms. After the temporary relief procured by the operation dyspnoea will set in anew, not always, however, of that intense degree of the laryngeal stenosis; respiration will become dry and loud again, and a little more frequent than in the uncomplicated laryngeal cases. Death will finally also result, either from suffocation or from the symptoms I enumerated above.

Lastly, when membranous laryngitis is but the terminating development of extensive membranous bronchitis, the symptoms differ from those described above in this, that the laryngeal symptoms last but a short time. For days or weeks no symptoms but those of an ordinary bronchial and tracheal catarrh were observed: all at once the process reaches the larynx; in a few hours the very last stage of croupous stenosis is reached; even tracheotomy does not relieve the symptoms. Or the fibrinous bronchitis was extensive enough to give rise to a sufficient number of symptoms before the larynx was reached. Amongst them is, foremost, frequency of respiration, because of its insufficiency; diminution of respiratory murmur over the area supplied with the affected bronchi; sometimes localized absence of respiratory murmur, while the percussion sound is sonorous. Another complication is emphysema, either subpleural or pulmonary. It is not frequent, except in combination with fibrinous bronchitis. The increase of respiratory movements is quite sudden, percussion sound tympanitic, and auscultation negative. Pulmonary oedema is quite frequent; it is the result of the rarefaction of air in the bronchi, the consecutive dilatation of the blood-vessels, and the effusion of serum by intravascular pressure. Every severe case is accompanied with it; in every tracheotomy it is met with coming up into the incision. Oedema of the glottis is less common, but it is met with in the same manner and with the same symptoms which characterize the glottic oedema of catarrhal laryngitis.

PROGNOSIS.--It is not favorable even in the simple and uncomplicated cases. Infants and children under two years almost invariably die. The percentage of average mortality rates very high--from 80 to 90 and more. It is probable that some recent therapeutical advances have reduced it, will reduce it, considerably. Tracheotomy is known to do so certainly, as from 20 to 45 out of 100 operations prove successful. The previous condition of the patient is of very little account in regard to the course and termination of the disease; no constitution protects or saves. The more the disease is local the better the prognosis. When fever makes its appearance, it means a complication, such as extending diphtheria or bronchitis or bronchi-pneumonia, and impairs the chances of recovery. The expectoration of membranous shreds or whole membranes does not improve the prognosis much, as the new formation of membranes may be very rapid indeed. I have seen new membranes rising to a formidable extent in from two to seven hours. The prognosis is improved when the cough becomes looser, expectoration more purulent, pulmonary respiration become audible again after having been covered by the laryngeal noises, rhonchi become moist, and portions of lungs which before were inaccessible to air by clogging membranes are reopened. Increasing debility, frequent and irregular pulse, are ominous symptoms. Even more so is the failure on the part of emetics to take effect.

DIAGNOSIS.--It may be quite difficult to diagnosticate croupous from catarrhal laryngitis, particularly in those cases where the former is not complicated with any visible exudative process in the fauces. In membranous laryngitis stenosis begins gently (except in those cases which ascend from the bronchi) and increases gradually; there are, it is true, remissions in the {104} morning (mostly), but they are but slight, and the subsequent evenings are worse than the previous ones. It increases from day to day until a slight cyanotic hue of the lips is followed with more general cyanosis. There is no fever or very little, except in the cases of generalized diphtheria. The character of the cough does not change; perhaps it becomes more dry and suppressed after a while. Hoarseness does not improve, but increases steadily into aphonia. Expectoration is but scanty; now and then a small portion of mucus from the lower portion of the respiratory tract, now and then shreds of membrane, are expelled.

In catarrhal laryngitis stenosis begins abruptly and suddenly, and is often at its height a few minutes after the commencement of the attack. Remission sets in soon, is more marked, sometimes complete, and a new attack, just as sudden as the first, may occur in the next night. Real cyanosis is but rarely developed; when it is, it changes soon into a more normal condition. Catarrhal laryngitis in the child is a febrile disease. In it the cough changes after a little time, some moisture mixes with the expectoration and changes both cough and articulation; also, the voice is not equally husky; now and then a clear note comes in. Close inspection of the throat exhibits sometimes a thick, viscid mucus floating up and down with the excursions of the larynx in catarrh. It never has any membranous expectoration.

Local oedematous swelling of the ary-epiglottic folds, with or without membranous deposits in some other parts of the larynx, yields all the symptoms of membranous croup with its dangers and death-rate. The effect of this oedema is partial paralysis of the vocal cords. Thus, inspiration is impeded, as in membranous obstruction; expiration, however, is free and the voice intact to a certain extent. This local oedema may be detected by palpation.

General oedema of the larynx (glottis) is fortunately rare. The attack is very sudden; there is no cold, no hoarseness, no choking cough, no membrane; there is only dyspnoea, gasping, asphyxia, sopor, and death, unless relief is given almost instantaneously.

The presence of a foreign body has been mistaken sometimes for membranous laryngitis. The history is a different one; there was no prodromal catarrh; the children were taken suddenly while playing or eating.