Chapter VII: Part 7

The laryngoscope would be a great aid in diagnosis if it could be used during the distress of a membranous laryngitis. Still, it has been employed by Ziemssen, Rauchfuss, and others. But the opportunities are rare.

TREATMENT.--The objects of treatment differ with the various stages of the disease. The inflammatory symptoms of the commencement, the completed exudation, the maceration and disintegration, and also the expectoration of the pseudo-membranes, and, finally, the asphyctic stage, have each their own indications. If there is anything which must not be recommended, it is depletion. Fortunately, there are but few practitioners left who still apply leeches or employ more general depletion, but these few are still doing too much harm by their practice and teaching. The application of ice, however, in bags over and near the larynx, and of iced cloths frequently changed, combined with the swallowing of small pieces of ice from time to time, is apt to be beneficial in well-nourished, hearty children. Such as have been anæmic, with thin muscles and pale mucous membranes, do not bear it so well.

The most powerful and reliable preventive and solvent, thus far, is hydrargyrum. It is true that many voices have been raised against it, but from Bard, Bretonneau, and Billard to Rauchfuss, Ch. West, Lynn, Pepper, and others, the remedy has had its admirers. Large single doses of calomel have been given by some, amounting to 15-30 grains (gramme 1.0-2.0), but that treatment has not found many friends. In small and frequent doses it has been of good service to me both in fibrinous laryngitis and bronchitis, {105} particularly in the latter; gr. ¼-½ may be given every half hour or every hour. Tartar emetic is liable to develop so many unfavorable effects that even doses--in combination with calomel--of 1/100 of a grain require great caution. The most reliable mercurial preparation, in my experience, and the least hurtful, is the corrosive chloride. In the stomach it combines with the chloride of sodium, is absorbed without being changed, and transmuted into an albuminate during its circulation in the blood. Babies of tender age bear one-half of a grain and more, daily, many days in succession. Salivation and stomatitis are exceedingly rare after its use. Gastro-intestinal disturbances are not at all frequent; diarrhoea, if observed at all, is very moderate, and can be avoided or removed by the administration of mucilaginous and farinaceous food or a mild dose of an opiate. But the administration of the bichloride requires care in regard to its solution. A fiftieth of a grain may be safely given to a baby a year old every hour, but it must be dissolved in one-half of a tablespoonful or a whole tablespoonful of water. The solution of a grain in a pint of water is about correct. In those very rare cases in which no preparation of mercury is borne internally the inunction of sufficient and frequent doses of the oleate of mercury may take the place of the internal administration or alternate or be combined with it. The blue ointment is not so effective as the oleate. The subcutaneous injection of the corrosive chloride may be added to the modes of administration if no time must be lost in introducing as much as possible of the drug into the system. Now and then, however, the subcutaneous tissue of the child does not tolerate it well in that form, though the solution may be not larger than 2 per cent.[3] The cyanide of mercury, in doses of a hundredth of a grain every hour, has been warmly praised by A. Erichsen and C. G. Rothe.

[Footnote 3: _The Medical Record_, May 24, 1884.]

The large mortality in croup and the inefficiency of remedial treatment have been the reasons why the recommendations of remedies have been very numerous. Alkalies were held in great favor during different periods of our literature, mainly the carbonate and bicarbonate of potassium (and sodium), in daily doses, to a child, of ½ drachm or 1 drachm or more; also the chlorate of potassium or sodium. As an adjuvant it may be useful; as an antidiphtheritic or antimembranous remedy it must not be regarded. What it can do is to heal or prevent a catarrhal stomatitis and pharyngitis. The best and most reliable is probably the iodide, in larger doses than are usually given. One or two drachms daily (grammes 4.0-8.0) are well tolerated when sufficiently diluted. Benzoate of sodium was recently recommended for its supposed antifermentative and antibacteric effect; its practical utility is but very limited; not even its antifebrile effect is anything but reliable. Lime-water has not fulfilled in my hands the promises made by others--neither its internal use nor spray nor inhalation. The most certain mode of introducing lime particles into the larynx is, after all, the inhalation of slaked lime, which allows a quantity sufficient to be somewhat effective to enter the respiratory organs. Its comparative inefficiency has been acknowledged by those who add 1 per cent. of the liquor of caustic potassium or sodium to the lime-water.

Quinia, in doses of 15 or 30 grains (grammes 1.0-2.0) daily, has been recommended by Monti for the same indications, mainly in the commencement of febrile cases. It has been claimed that cold applications, to be changed every hour or two according to the Priessnitz or hydropathic plan, had a great power in macerating and disintegrating mucous membrane. Many of the successful cases of these, as of all other specialists, are undoubtedly the result of the convenient substitution of a grave diagnosis for a milder one. The effect of such applications in laryngeal catarrh, like that of warm applications, is undoubted. Vesicatories applied to the neck over the larynx are never {106} useful--frequently injurious by the sore surface becoming the seat of a pseudo-membrane.

Inhalations of warm vapor are decidedly beneficial, but atomized water is not of equal value. Thus, Richardson's atomizer is not so useful as Siegle's inhaler or other apparatuses working on the same plan.

Lactic acid, in solutions of 1:10 or 25 (Monti's solution of 1:200 is certainly too weak), has been applied by means of a sponge, inhaled, or thrown in from an atomizer for the same purpose. Good results have been reported, failures also; and still, recoveries are rushed into print much more readily than failures. The same may be said of the local applications of glycerin, boric acid, carbolic acid in solutions of 1 or 2 per cent., salicylic acid, iodoform, and hypermanganate of potassium; also of bromine (bromine and potas. bromid. _aa_) 1:water 500, or a stronger solution.

Tannin, dry or with glycerin, is rather more injurious than it can be useful. It is apt to coagulate the mucus contained in the pharynx and the upper part of the larynx, and to render the dyspnoea graver than before. Such an aggravation of symptoms must be carefully avoided, though it be but temporary. The same must be said of alum, which has been used solid, in finely-powdered condition, down to a 3 per cent. solution in water.

Spirits of turpentine are inhaled either from an inhaling apparatus or by saturating the air of the room. Water is kept boiling constantly on a stove, oven, or alcohol lamp (not on gas, which consumes a larger quantity of oxygen), and a tablespoonful of the spirits of turpentine is poured hourly or in shorter intervals upon the boiling surface.

Hydrochlorate of ammonia can be used in the same manner as described in the article on Catarrhal Laryngitis.

Hydrochlorate of pilocarpine was introduced into the treatment of diphtheria and pseudo-membranous croup some years ago, and recommended as no less than a specific. It increases, physiologically, the secretion of the skin, the mucous membranes, the lachrymal and muciparous glands, the kidneys. It also depresses the heart's action. In all cases in which the latter effect is to be feared the drug is contraindicated; thus in septic diphtheria, in pseudo-membranous croup with great asthenia, in general debility and anæmia. By increasing the secretion of the mucous membranes it is expected to macerate the pseudo-membrane and raise it from its bed. This can be accomplished wherever the membrane is deposited upon the mucous membrane--that is, whenever the number of muciparous follicles is large and the epithelium is cylindrical. This is not so on the vocal cords, and thus the floating effect of pilocarpine cannot be obtained exactly where it is most needed--that is, on the vocal cords, where the pseudo-membrane is more intimately imbedded into the tissue than, for instance, on the posterior wall of the fauces or the trachea and bronchi. Still, pilocarpine may be tried, in combination with other modes of treatment, as long as the heart's action is competent and the general condition satisfactory. It is dissolved in water; its dose, for a child a year old, 1/30 grain (2 milligrammes = 0.002) every hour. A subcutaneous injection every four or six hours of 1/60 grain (three drops of a 2 per cent. solution) will prove very effective for good and evil. I believe it has rendered me good service in some well-marked but mild cases of pseudo-membranous laryngitis, which it either aided in healing or prevented from getting worse.

Emetics have their distinct indication. It is irrational to expect any relief from them when the larynx is narrowed by firmly-adhering pseudo-membranes. Their indication depends on the possibility of removing something which acts as a foreign body. This something can be either mucus or loose or partially loose membrane. The peculiar flapping sound produced by the latter admits of or requires the administration of an emetic. Above I have stated which {107} of them ought to be selected. Turpeth mineral in a dose of from 3 to 5 grains, repeated in six or eight minutes, acts quite well. Hypodermic injections of apomorphine may be required in urgent cases.

The introduction of catheters into the larynx, according to the methods of Horace Green, is a dangerous proceeding and ought not to be indulged in. It gave the idea to Loiseau and Bouchut to force a tube into and through the larynx, full of pseudo-membrane, for permanent use until the pseudo-membrane would have disappeared. This tubage was rendered ridiculous at once by the assertion of Bouchut (1858) that children suffering from croup who were supplied with this laryngeal tube were not only relieved at once, but expressed their gratitude in audible oratory. Still, there are some cases on record of more recent date in which tubage is reported to have been attended with success. It is not very probable, however, that a larynx which admits of no air, because of its being clogged with firm pseudo-membrane, should be willing to admit and endure the presence of a tube.

Massage of the larynx has been recommended by Bela Weiss. It consists in systematical gentle pressing and kneading of the larynx by the physician while sitting behind the patient. He asserts its satisfactory influence not only in catarrhal but also in diphtheritic (croupous) laryngitis.

The inhalation of oxygen has proved rather advantageous in my hands in a few instances. The most memorable case of the kind I have mentioned elsewhere. It was that of a child on whom tracheotomy had been performed. The pseudo-membranous process, however, invaded the bronchi, with the result of producing dyspnoea, cyanosis, and convulsions. Whenever a current of oxygen was introduced into the lungs through the canula both cyanosis and convulsions would cease, and returned when its supply was stopped.

But if no medication will have proved successful, the symptoms of stenosis, dyspnoea, cyanosis, and the supra- and intraclavicular and epigastric recension increase steadily to an alarming extent. When the pulse becomes frequent and intermitting, even without the presence of asphyxia and anæsthesia, air ought to be introduced into the lungs by tracheotomy. No positive rules can be laid down as to the length of time one ought to wait before performing it. No subdivision of the disease into several stages is of any benefit in selecting the exact period in which the trachea must or may be opened. No alleged contraindication to the performance of tracheotomy, whether the tender age of the patient or a complication with either an inflammatory or an infectious disease, must be considered valid. The one strict indication for the performance of tracheotomy is when the diagnosis of pseudo-membranous laryngitis is undoubted, the increasing dyspnoea, cyanosis, and approaching asphyxia, with the certainty that a well-directed and sufficient medicinal treatment has been, and in all probability will be, useless. Even under these circumstances there is no mathematical certainty. The matured experience of a well-informed and thoughtful physician will commit but few errors. If there be the slightest doubt, the operation ought to be preferred to suffocation.

The operative procedure and the surgical treatment after the performance of tracheotomy will form the subject of a special article in this work. In this place a few remarks upon the medicinal and dietetic treatment in that period of the disease must suffice.[4]

[Footnote 4: Cf. _The Med. Rec._, May 24, 1884.]

The nutrition of the patient has generally suffered much. Before the operation but little food was taken, still less was digested, and the operation itself and the anæsthetic have added to the previous weakness or exhaustion. Moderate feeding and stimulation are therefore to be commenced soon. Vomiting after chloroform I have seldom seen to last long or to be embarrassing under these circumstances. Feeding and stimulation are the more necessary {108} the more the hungry lymph-vessels are liable to absorb injurious material when not supplied with healthy food.

Is internal treatment required? The general treatment must be continued. If it consisted in the administration of hydrargyrum, either internally or externally, it must be continued. If its effect was not sufficient to clear the larynx and to render the operation unnecessary, it will or may be sufficient to complete its effect in the next day or two, to prevent the process from descending or the membranes becoming too many or too thick. No changes ought to be made in the treatment unless there be changes in the symptoms. Not infrequently the first symptoms of broncho-pneumonia come on within a few hours after the operation, recognizable by frequent pulse, respiration frequent beyond proportion, and physical symptoms. The stomach is not very reliable. Quinine answers best hypodermically. From 6 to 10 grains may be injected at once. The preparation which has served me best in the last few years is a solution of the carbamid in five parts of water. If an additional remedy is required, from 20 to 30 grains of sodium salicylate may be given in the course of three or four hours, in hourly doses, to reduce the temperature. Tincture of digitalis will prove advisable at the same time when the heart appears to require it. Strychniæ sulphas will act as a powerful nervine; 1/25 grain may be given to a child two years of age every two hours, until four or five doses shall have been taken. The rest of the treatment of the complications depends on their nature and character. It is not the name of the disease which has to be treated, here as in every case, but the individual patient.

In regard to stimulants I have but little to say. I use alcohol in the most pleasant shape, preferring brandy or whiskey. I use a great deal of camphor, 10 to 40 grains daily, or in cases of urgency Siberian musk, from 2 to 5 grains, every half hour or hour, until from 15 to 20 grains have been taken in cases of collapse or great prostration.

{109}

DISEASES OF THE LARYNX.

BY LOUIS ELSBERG, M.D.

Inflammation, Erosion, and Ulceration of the Epiglottis.

Of the diseases of particular portions of the larynx, those of the epiglottis deserve especial attention in a work designed for general practitioners, on account of the comparative ease of recognizing and treating them if understood, and the promptness their management requires. They occur more frequently than is generally supposed, their symptoms are often erroneously ascribed to other affections, and they may lead to extensive disease in the respiratory apparatus, sometimes of a very serious character. Adjacent portions of the root of the tongue and pharynx or of the larynx are apt to be coaffected. In diseases which commence in the pharynx, usually the lingual surface, and in such as spread upward from the larynx only the laryngeal surface, of the epiglottis is involved mainly or exclusively.

Before describing the affections of the epiglottis a few words must be said of the manner of using the tongue-spatula. Physicians almost without an exception press the tongue from above downward and from before backward; but in order to bring the epiglottis into view in the majority of instances the proper method is just the opposite of this--viz. from below upward and from behind forward. Place the spatula far back, lift up the base of the tongue, and draw it forward. The usual manner of depressing the tongue--no matter how good or bad an instrument may be used, and an ordinary spoon-handle serves the purpose better than most of the so-called tongue-depressors--pulls upon and irritates the pharyngo-glossal fold, and often hides the epiglottis instead of bringing it into view, besides producing intolerance and intractability. The blade of the tongue-spatula should be long (at least four, still better five, inches), slightly curved downward, not more than from half an inch to one inch wide, and joined to the handle at an obtuse angle.

1. Acute inflammation of the epiglottis is usually caused by taking cold, exposure to draughts, wet, sudden changes of temperature, etc. The symptoms are local pain and difficulty of swallowing; in severe cases also some dyspnoea and dysphonia. Only occasionally there is a hemming cough, and that a peculiar one, induced (usually voluntarily) by a feeling of a foreign body at the root of the tongue. The diagnosis is made by means of the tongue-spatula and laryngeal mirror, the epiglottis being seen to be inflamed and swollen. When the lower portion, the so-called cushion of the epiglottis, is affected, the mirror is required for diagnosis. In this case suppuration is apt to occur. The prognosis is good with attention; neglected epiglottitis may cause great discomfort, and even death. Treatment must be antiphlogistic and supporting. For mild cases systemic and dietetic regulation suffices, with externally either hot fomentations or cold applications as the patient can best bear. Severer cases require in addition leeches and ice to the part; and cases of threatened suppuration, medicated and unmedicated steam inhalation, and, when necessary, lancing of the abscess through the {110} mouth under guidance of the mirror. After the acute inflammation has subsided, local treatment may become necessary to hasten or produce complete restoration, as will be noticed in Chronic Epiglottitis.

Inflammatory oedema of the epiglottis will be considered under the head of Laryngeal Oedema.

Chronic inflammation of the epiglottis is usually the result of uncured acute epiglottitis or of laryngitis. The main symptom is dysphagia. The epiglottis is found swollen and more or less discolored. Not only tongue-spatula and laryngeal mirror, but also the finger carefully introduced into the mouth, may ensure the diagnosis, especially if the upper portion be affected: then the thickened epiglottis is seen and felt as a peculiar rounded tumor at the base of the tongue. Oedema is distinguishable from chronic inflammation by both sight and touch. As to prognosis, it must be observed that the process of restoration is slow and that there is always danger of acute exacerbation. The treatment consists in attention to the general health and habits and in local applications. The latter are indispensable, and should be made by means of an instrument (Elsberg's applicator or the like) carrying a little wad of cotton or sponge. Some prefer a brush: to such individual preference no objection need be made, but powders and sprays are not advisable. The remedies to be applied should be in liquid form, and belong pharmacologically to the class of alteratives. Iodine, iodoform, and silver nitrate in solution are most useful. In subacute inflammation (see above) potassium bromide and chlorate, respectively, in saturated aqueous solution, may be applied once a day, or a saturated solution of iodoform in sulphuric ether, or ten grains of crystallized silver nitrate dissolved in an ounce of water, every other day. In chronic epiglottitis the tincture or compound solution of iodine, the ethereal solution of iodoform, and the watery solution of silver nitrate, in degrees of concentration varying according to the severity of the case and the individuality of the patient (the choice of either of the three agents, the repetition of the same, or the change from one to the other depending upon the effect produced), should be accurately applied to the part affected by means of the laryngeal mirror or the tongue-spatula.

2. The most frequent, and at the same time the most neglected, morbid condition of the larynx is erosion of the free edge of the epiglottis. Louis has called attention to the epiglottic erosions in connection with tubercular phthisis: he found them present in about one-sixth of the patients who died of that disease, and they are caused, in his opinion, by the constant passage of pus over the part. Horace Green was the first who pointed out that they are also frequently met with independently of tubercular disease. According to him, "These instances, for the most part, have been found occurring in those cases in which a persistent, teasing cough, following chronic follicular disease or common catarrhal inflammation, has obstinately resisted all the ordinary measures for its arrestment. On depressing the tongue in such cases by means of the ordinary bent spatula or tongue-depressor, so as to bring the epiglottis into view, this cartilage has been found frequently inflamed, vascular, and its superior border marked at one or more points by distinct erosions. In much the largest proportion of cases these erosions make their first appearance on the left superior edge of the epiglottis. Next in frequency they will be found occupying its centre, and occasionally, but very rarely in comparison with the two preceding locations, they have been observed upon its right border. These erosions are not readily detected, at first, by the inattentive observer, as they are quite small, are only slightly depressed, with a pallid base, sometimes a little reddened, and with whitish, linear edges. The surrounding mucous membrane is generally inflamed, its delicate network of superficial vessels is red and injected, and the epiglottis itself more or less thickened." Sometimes epiglottic erosions exist without {111} much cough, and certainly a cough can exist without erosions; but the two seem frequently to act interchangeably as cause and effect; and certain it is that a cough, from whatever cause, once firmly established, when such erosions have supervened rarely if ever yields so long as the erosions continue, and often stops when they are cured. According to my experience, the left and right sides of the upper border are affected with about the same frequency, and oftener than the centre. The erosions are catarrhal in their nature, even in tubercular subjects; in non-specific cases they degenerate exceedingly rarely into ulcers--_i.e._ they may exist for years without involving any tissue below the epithelium unless the patient is or becomes syphilitic or phthisical. They often produce symptomatically, especially in the beginning, more hemming than cough. The diagnosis is easy on thorough inspection of the epiglottis. Prognosis is generally favorable, except in phthisical cases; in others, although they sometimes prove exceedingly obstinate, they usually yield with surprising promptness to topical treatment. In specific cases, and even in chronic naso-laryngeal catarrh, they are apt to recur, however. A cotton wad dipped in a strong solution (gr. xxx-drachm j ad ounce j water) of either silver nitrate or gold chloride must be brought accurately into contact with the eroded spots once in twenty-four or forty-eight hours; ordinarily only a fortnight's treatment is necessary, except for the frequently accompanying (or underlying) catarrhal condition of a more or less large extent of the upper respiratory mucous membrane. In very severe cases a few applications at longer intervals of a still stronger solution (drachm j-drachm ij), or even of the solid silver or gold preparation, may be required.

3. Epiglottic ulcerations differ from erosions in the fact that the latter are confined to the epithelium, while the former involve also deeper structures. It has been asserted by some observers that an erosion is always the first stage of an ulceration, and by others that the one never passes into the other. I believe that both of these extreme assertions are incorrect; but if it were possible to distinguish, clinically or pathologically, every case of superficial ulceration from erosion, I might incline to agree with the latter. Histologically, epiglottic ulceration affects the mucous membrane, glands, or cartilage. Most frequently it seems to originate in the follicles. As Horace Green has long ago pointed out, "At first an enlarged or pimple-like follicle appears on the border of the epiglottis, surrounded by an inflamed and highly-injected portion of mucous membrane. Soon the follicle softens, and degenerates into an ulcer with irregular edges and an inflamed and reddened circumference. In many instances these ulcers remain for some time superficial, destroying only the mucous membrane; in others they penetrate deep into the fibro-cartilage, and occasionally they result in the total destruction of the epiglottis." Sometimes the ulcer seems to originate in the superficial layer of the mucous membrane, the molecular death proceeding from the surface downward; these are the cases which in the beginning cannot be distinguished from erosions. Both these kinds of ulceration of the epiglottis occur without, and with, grave constitutional affections, but the cartilaginous tissue usually, though not invariably, remains intact except in phthisis, syphilis, and cancer. Lupus, lepra, and glanders also give rise to ulceration, and sometimes to much accompanying thickening of the epiglottis. The seat of the ulcers is, as a rule, on the upper border and laryngeal surface of the epiglottis, only exceptionally on the lingual. Together with ulcers on the laryngeal face those on the lingual face are found, but not vice versâ. Ulcers of the epiglottis are usually small, but numerous, worm-eaten in appearance, and frequently pass to other laryngeal structures. Though occasionally resulting from tuberculosis, syphilis, and other constitutional affections, they also occur as primary disease due to catarrh and local injury, but may become the antecedents, and in many instances the exciting cause, of other grave maladies. Indeed, I quite agree {112} with Horace Green that they are often "not only among the earliest manifestations of thoracic diseases, but are themselves in many instances the true exciting cause of these affections; and furthermore, this postulate once established, that we have it in our power, by timely topical medication, to arrest, positively, cases of disease which otherwise would, and in many instances which do, terminate fatally."

The symptoms vary with the seat and extent of ulceration. Cough and the sense of irritation in the throat are usually present. "In several instances all the prominent rational signs, with some of the earlier physical manifestations, of pulmonary disease have been observed to follow long-continued ulceration of the epiglottis; all of which symptoms have been seen to disappear after these lesions have been healed." When the upper border is extensively affected, and still more when either surface, especially the lower portion of the laryngeal surface, be involved, there is difficulty of swallowing; the pain is due often as much to surrounding inflammation as to the epiglottic lesion. In some cases the voice also is affected.

The diagnosis of the existence of an ulcer is easily made when the epiglottis can be seen not only with the spatula, but also with the laryngeal mirror. Its origin and nature are, however, not always easily recognized, and the patient's general condition and history, as well as the appearance of the ulcer, must be taken into account. The diagnosis of catarrhal epiglottic ulceration must be made only after other underlying conditions, as phthisis, syphilis, malignant disease, lupus, lepra, and glanders (see the articles on those subjects), have been excluded. The prognosis is good, except in cases of phthisis, syphilis, etc., or in which already a great deal of the cartilage has been destroyed; and even in these cases appropriate treatment will often give the patient much comfort. Appropriate constitutional treatment must be instituted in all cases in which the constitution is affected.

Topical treatment consists in the application of alteratives, astringents, stimulants, or sedatives, as the case may call for. Some cases may require once or more times touching with solid silver nitrate; watery solution of this remedy, varying in strength from gr. x to drachm ij to the ounce; solution of gold chloride of similar strength; of iron pernitrate and perchloride drachm ss-drachm j to the ounce; of zinc chloride (gr. x-drachm ss to the ounce); a solution of iodine in olive oil (gr. x-xxv ad ounce j with a few grains of potassium iodide), or of iodoform in sulphuric ether (drachm i-drachm ij ad ounce j); carbolic acid in glycerin (gr. v ad ounce j) or Magendie's solution of morphine, or a mixture of morphine and syrup of tolu (gr. 1/8-1/2 to a few drops),--have most frequently been beneficial in my hands. In many cases in which the pain on swallowing has been so great as to make deglutition almost impossible, I have succeeded in temporarily anæsthetizing the parts before a meal by applying, after cleansing them, a watery solution of cocaine hydrochloride (gr. xx ad ounce j). If, in spite of all, the difficulty of swallowing threatens the patient with starvation, feeding with the oesophageal tube must be resorted to.

Laryngeal Oedema.

DEFINITION.--Infiltration of a fluid or semi-fluid into the submucous connective tissue of the larynx.

SYNONYMS.--Oedema of the glottis (often incorrectly so called, as will presently be seen), Oedematous laryngitis, Phlegmonous laryngitis, Submucous laryngitis, Dropsy of the larynx, Angina laryngis infiltrata, Angina laryngea oedematosa, Angine infiltro-laryngée, etc.

CLASSIFICATION.--Cases of laryngeal oedema are classified as to their occurrence into acute and chronic, corresponding generally to inflammatory {113} and non-inflammatory; as to the nature of the infiltration, into serous, purulent, sanguineous, sero-purulent, sero-sanguineous, etc.; as to the extent of the infiltration, into diffuse and circumscribed (the latter often leading to abscess-formation, and then called laryngeal abscess rather than laryngeal oedema, differing, however, from perichondric abscess); and as to the seat, into epiglottic, supraglottic, infraglottic, and glottic. When epiglottic, it implicates, besides the upper border, often the glossal, hardly ever the laryngeal, surface; in supraglottic, the ary-epiglottic folds, arytenoid region, ventricular folds, or ventricles are involved; in glottic, the interfibrillar connective tissue of the thyro-arytenoid muscle is infiltrated, very exceptionally, if ever, the submucous tissue of the vocal bands themselves;[1] and in infraglottic, the submucous connective tissue down to the first ring of the trachea. Glottic oedema occurs extremely seldom, but the designation oedema glottidis is often used, no matter what portion of the larynx is affected. Laryngeal oedema usually affects both sides; occasionally one side more than the other, still more rarely one side exclusively.

[Footnote 1: Such a case has been positively reported, or I would deny the possibility of its occurrence.]

ETIOLOGY.--Laryngeal oedema is seldom, if ever, idiopathic. Usually it accompanies or follows either some disease or injury of the larynx[2] or neighboring structures or a constitutional affection. Acute oedema may be caused by catarrhal or diphtherial pharyngo-laryngitis; irritation from scalds, burns, caustics, foreign bodies (especially sharp ones), or other trauma; laryngeal ulcers, especially syphilitic and tuberculous; laryngeal perichondritis, tonsillitis, parotitis, or inflammation of cervical tissues on the one hand, and pyæmia and septicæmia, endocarditis, erysipelas, small-pox, scarlatina, measles, typhoid fever, typhus, or acute Bright's disease of the kidneys on the other. "It has ensued upon deglutition of very cold water and upon prolonged vocal efforts" (Cohen). Perichondritis and chondritis, tuberculous, syphilitic, carcinomatous, or typhoid ulcerations of the larynx, especially when deep-seated or extensive, are sometimes attended with acute, but more often with chronic, oedema. Non-inflammatory or chronic laryngeal oedema is sometimes part and parcel of general dropsy in consequence of heart, kidney, or lung disease: Horace Green has reported a case occurring in a man who had hydræmia from great losses of blood from hemorrhoidal tumors; and it is sometimes due to some impediment to free venous circulation in the laryngeal tissues, from paralysis of the walls of the vessels, mechanical obstruction, tumors of the thyroid body or in the mediastinum, etc. compressing the jugular veins, compression of the superior vena cava, etc.

[Footnote 2: According to Sestier, who has written (in 1852) the most elaborate treatise extant on the subject, four-fifths of all cases occur in other laryngeal affections.]

Cohen mentions cases to show that acute iodism and mercurialization may cause laryngeal oedema. He also says that although occurring in individuals in good general health, it is more apt to take place in those of impaired constitution or recently convalescent from acute diseases; and in some instances there would appear to be some peculiar predisposition toward its occurrence the nature of which is not understood, for examples are on record of more than one attack in the same individual. Under all these circumstances the immediate exciting cause, when apparent, seems to be exposure to cold and moisture.

Laryngeal oedema is not a disease of childhood; exceptional under five years, it is very rare until after ten. Most cases occur between eighteen and thirty-five. After the sixtieth year it is again rare; and it occurs more rarely in women than in men.

SYMPTOMATOLOGY.--The symptoms of laryngeal oedema vary with the seat and degree--that is, according to the class to which the case belongs. {114} Increasing interference with breathing is the most prominent symptom. Interference with swallowing, though not always present, is the next prominent. Sometimes the occurrence is so sudden, insidious, or overwhelming that the patient dies before aid can be procured. Such was Boerhaave's case of a man who during dinner suddenly spoke with a changed voice, which his companions took as a joke, and in a few minutes fell dead; Rühle's case of a servant-girl, who, a trifle hoarse, went out lightly clad on a cold morning and suffocated while going up stairs on her return; and the case of a patient of mine with subacute catarrhal laryngitis, who rode out behind a fast horse on a cold afternoon, and died, within ten minutes after entering his own house, from serous infiltration of the upper aperture of the larynx. A number of similar cases have been reported, but usually the disease runs its course less rapidly. When the ary-epiglottic folds are the seat of the oedema, the patient experiences either suddenly or gradually a difficulty of inspiration, while the expiration may be at first unimpaired, and with increasing sensation of constriction of the throat or of the presence of a foreign body, hoarseness, and stridor, but often without dysphagia, the most threatening paroxysms of suffocation supervene. When the epiglottis is the main seat, while respiration is also more or less impeded, swallowing is rendered painful, difficult, and sometimes impossible without choking and regurgitation through the nares, and the voice roughened and sometimes extinguished. When the arytenoid region is also affected, respiration and deglutition are still worse, aphonia is complete, the sense of irritation at the upper aperture of the larynx often amounting to pain, and the patient with great effort expectorates slightly. In oedema of the ventricular folds there is early aphonia and gradually increasing dyspnoea, which affects both expiration and inspiration, sometimes the former even worse than the latter. This makes the sufferer's efforts to breathe most frightful to witness, the feeble inspiration being accompanied by a slow whistling sound, and the expiration, despite most violent exertion, almost entirely shut off. Glottic oedema is, as before said, exceptional; when it occurs to any great extent apnoea ends the case unless operative relief is immediately afforded. In infraglottic oedema, which is exceedingly rare and chronic in nature, there is steadily increasing dyspnoea, wheezing, cough, and abundant expectoration.

In acute cases of supraglottic and epiglottic oedema the suffocative paroxysms may last several minutes, and recur at irregular intervals of a few hours with increased intensity. If not relieved, patients become wildly excited or terror-stricken; they may throw the chest forward, open the mouth, grasp the throat outside or thrust their hands into it, and make convulsive movements in their struggles for breath; with protruding eyes and flushed face they become cyanotic, the extremities cold, the pulse small and frequent; coma supervenes, and death. In chronic cases the symptoms are not so violent, though they may steadily progress to impending strangulation, but for a long time the dysphagia gives the patient much more distress than the dyspnoea.

In circumscribed acute cases leading to the formation of an abscess there is usually pain in a particular spot, and often general feverishness, in addition to all the symptoms before mentioned, according to the seat of the oedema. Sometimes the suffering in laryngeal abscess at its height is very intense. Perforation into the pharynx, oesophagus, or even externally, may take place, but usually the pus points into the larynx. When the pus is evacuated either spontaneously or by incision, violent choking, coughing, and hawking may occur, but after it is evacuated all dangerous symptoms usually rapidly subside.

In sanguineous infiltration the symptoms do not differ from serous or purulent oedema under the same circumstances. Hemorrhagic infusion is usually {115} sudden, and the resulting stenosis often fatal. Muscular spasm or paralysis sometimes coexists with laryngeal oedema, and greatly adds to the interference with respiration.

PATHOLOGY AND MORBID ANATOMY.--The seat of the morbid process being the connective tissue, those localities of the larynx in which this tissue is most abundantly interposed between the mucous membrane and the cartilage are most liable to infiltration. I must say from my own experience that the epiglottis--particularly the glosso-epiglottic region--is most frequently affected,[3] next the ary-epiglottic folds, then the arytenoid region, and then the ventricular folds. The ventricles and the vocal bands are very rarely involved. Infraglottic oedema is still more rare, and is never an extension of the supraglottic. The disease is never a primary one, and, though seated in the submucous connective tissue, it may have started with inflammation of either the overlying mucous membrane or the underlying perichondrium. Effusion of blood is generally limited to traumatic cases, but has ensued from mercurialization, small-pox, and typhus; purulent infiltration and abscess formation is the result of phlegmonous inflammation and breaking down of the tissue, occurring especially in the cushion of the epiglottis and in the ventricular and ary-epiglottic folds; but as a rule the effusion in laryngeal oedema is of a serous or sero-purulent character.[4] In infraglottic oedema it is said to be fibrinous.

[Footnote 3: According to Sestier, the ary-epiglottic folds are affected in nearly every case, either alone or together with other parts.]

[Footnote 4: In 90 cases Sestier found the infiltration serous 60 times, sero-gelatinous 6, sero-purulent 9, sero-purulent with plastic lymph 4, purulent 8 times, sero-sanguineous twice, and sanguineous once.]

The mucous membrane covering the oedematous structures is tense and discolored; except in very inflammatory conditions it is yellowish, shimmering, and pallid. On cutting into the diseased parts often but little exudation takes place, and sometimes even squeezing between the fingers does not suffice to cause disgorgement.[5] After the fluid is evacuated the parts collapse and the mucous membrane is left wrinkled and folded.

[Footnote 5: In 23 autopsies Sestier found that incisions into the oedematous structures made the liquid run out either without any or with slight pressure 10 times; with repeated pressure, with difficulty and only in small quantity, 6 times; and not at all, in spite of repeated incisions and pressure, 7 times.]

DIAGNOSIS.--With the laryngoscope, the spatula, and the finger the seat, the degree, and often the nature of the infiltration can be determined. A successful laryngoscopical examination may sometimes require in such cases more than ordinary skill, and there is often so much tumefaction that the parts are not easily recognizable. The epiglottis may appear as a thick roundish tumor, or be of a more or less indistinct horse-shoe shape, overhanging the laryngeal aperture; the ary-epiglottic folds may be converted into large lateral cushions pressing against the arytenoid bodies, or be merged with the latter into huge, irregularly pear-shaped, oval, or globular masses; and the ventricular folds may be immensely tumefied, or else, by means of the swelling and the being pushed into a horizontal position of the whole lateral lining of the upper laryngeal cavity, may be obliterated altogether. Glottic oedema never occurs except with supraglottic, and the upper surface of the vocal bands may look elevated, arched, and bladder-like, even if only the thyro-arytenoid muscles are infiltrated. In infraglottic oedema there is usually neither epiglottic nor supraglottic oedema; pads are seen underneath the vocal bands, either ring-shaped or projecting from side to side toward the middle line, and fill up to a greater or less degree the rima glottidis. The oedematous parts have sometimes a pinkish, but usually a yellowish, translucent or semi-translucent aspect. Accumulation of pus lessens the translucency and sometimes makes the yellow more marked. Sanguineous {116} infiltration shows a bluish-red or livid discoloration. In chronic oedema the color is lighter, sometimes a dirty gray.

I have already explained the proper method of using the spatula. It reveals in all cases, sometimes best during retching, the epiglottis, and in many cases the ary-epiglottic folds. With the finger these parts can be touched, and all the more easily when they are swollen; but great care must be exercised to avoid provoking by digital examination a suffocative paroxysm. When felt by the finger the peculiar elasticity or fluctuation present is unmistakable.

PROGNOSIS.--Laryngeal oedema is always a very dangerous condition--in a chronic case less so than in an acute one. The prognosis depends largely upon the causative or accompanying disease. The more local the oedema and the more promptly medical, and in most instances surgical, aid can be had, the more favorable is the prognosis, though uncertain even then. Sometimes a rapidly fatal attack supervenes in a mild, chronic, or apparently convalescing case. In abscess formation it is generally favorable unless the underlying disease makes it the reverse.

TREATMENT.--Antiphlogistic treatment of every sort has been recommended against this dread disease. Its frequently rapid course usually necessitates primarily topical measures. Even fifty years ago, when bleeding and tartar emetic were in vogue, Ryland entirely discountenanced these, and said: "Our chief reliance must be placed on the local detraction of blood by means of a large number of leeches applied in the vicinity of the larynx; on the use of blisters, which should never be put on the front of the neck, as their operation will interfere with the subsequent performance of tracheotomy should such a step be necessary, but on the back of the neck or the upper part of the chest; and on the internal administration of large doses of calomel, which, either by their purgative effect or by their specific action on the general system, tend to check the inflammation in the glottis and to promote the absorption of the effused fluids. These remedies can only be of use during the early stages of the disease, and experience shows but too plainly that even then we have far more reason to anticipate failure than success."

Many years ago it was proposed to catheterize the trachea for the purpose of allowing air to reach the lungs in this and other diseases in which the larynx is obstructed; and more recently Hack has shown the great benefit of using, under sight by means of the laryngoscopic mirror, Schrötter's dilating hard-rubber tubes in acute as well as chronic laryngeal oedema. According to him, they do good not only symptomatically, but also curatively.

Furthermore, we can employ, under the guidance of the mirror or of the finger, scarifications of the infiltrated structures by means of the laryngeal lancet, or in its absence of a long bent, sharp-pointed bistoury covered, except for a quarter of an inch or so from its point, with adhesive plaster. (For the epiglottis the ordinary gum lancet will often do.) An abscess is opened in the same way. When the bleeding following scarification is excessive we use ice internally or externally, or both; when bleeding is insufficient, steam inhalation, hot fomentations, etc. To promote absorption we make topical applications, either before or certainly after the scarification, of a saturated solution of iodoform in sulphuric ether (drachm ij ad ounce j), or of a strong watery solution of silver nitrate (scruple ij-drachm j ad ounce j). Astringents, especially tannin and alum, applied in the form of spray to parts that cannot otherwise be reached, are advisable; and antispasmodics and narcotics (potassium bromide and morphine) should not be omitted in cases complicated with muscular spasm, etc. The internal administration of fluid extract of jaborandi in drachm doses or the hypodermic injection of pilocarpine is highly lauded as promoting absorption; also diaphoretics, purgatives (salines and croton oil), {117} etc. From the beginning the patient's general functions must be regulated and his strength supported by tonics and nutritives, and any underlying disease amenable to treatment must of course be attended to. The slow swallowing of pieces of ice is often of great benefit. In every case that does not visibly improve by the vigorous carrying out of the treatment hitherto detailed, especially the catheterization by means of Schrötter's tubular dilators, the ultima ratio--viz. tracheotomy, particularly inter-crico-thyroid laryngotomy--must be resorted to without waiting until the patient has lost much ground by the impediment to respiration. One of the lessons taught us by pathological investigation is that epiglottic, supraglottic, and glottic oedema does not extend beyond the upper surface of the vocal bands: therefore, while in infraglottic oedema, and when the two conditions supraglottic oedema and infraglottic coexist, tracheotomy should be performed, in the other cases the air-passage should be opened by introducing a tube through the inter-crico-thyroid membrane. This operation is, especially for the general medical practitioner, much easier, safer, and quicker of performance, and answers in those cases all purposes. This important lesson is not heeded by any of the recent authors on the subject. Indeed, Cohen expressly says: "The trachea is to be opened in preference to the larynx, as being at a greater distance from the seat of the disease and less liable to involvement, as well as for the reason that the disease occasioning the oedema may be extending low down in the larynx, and therefore exist at the very point usually selected for laryngotomy." Supraglottic oedema does not extend to the region of the inter-thyro-cricoid membrane, and the tube may therefore safely be there introduced.

Perichondritis and Chondritis of the Larynx.

DEFINITION.--Inflammation of the laryngeal perichondrium and cartilage.

SYNONYMS.--Phthisis laryngea of the older authors, Laryngitis affecting the cartilages, Deep-seated ulcerative laryngitis, Caries cartilaginum laryngis, Vomica laryngis, Perichondric laryngeal abscess, Necrosis laryngis. (Some of these names refer to the product or terminal stage of the disease.)

ETIOLOGY.--Laryngeal perichondritis and chondritis occur either as idiopathic or as symptomatic or secondary affections. Even the former, caused by so-called catching cold or exposure to cold and wet while the system is in a state of lowered vitality, may have a septicæmic basis; it is much more rare than the secondary. Rühle has remarked that arytenoid perichondritis may probably sometimes start in the crico-arytenoid articulation, and in an instance which has come under my observation this certainly seemed to have been the case. Authors state that occasionally the inflammation commences in the cartilaginous tissue itself, instead of in its investment; this is hardly conceivable. Perichondritis must always precede chondritis, but it always causes the cartilage to become involved in the morbid process. Quite often perichondritis and chondritis constitute an extension of a particular ulcerative disease of the mucous and elastic membranes. In the great majority of cases the causes are tuberculosis, syphilis, diphtheria, cancer, lupus, typhus and typhoid fever, small-pox, or else traumatic occurrences, especially suicidal throat-cutting, decubitus or other pressure upon the part--as, for instance, the frequent introduction in an aged subject of the oesophageal sound observed by Ziemssen, and overstrain of the voice alleged by Flormann. At least three cases are reported (viz. by Porter, Lawrence, and Eppinger) in which the disease has been ascribed to the administration of mercury, and Graves and Stokes remark that in broken-down constitutions, {118} where large quantities of mercury have been used, chronic laryngitis is very apt to terminate in ulceration of the cartilages.

The disease occurs oftener in men than in women, and oftener between the twentieth and fortieth years than at any other age.

SYMPTOMATOLOGY.--I distinguish three stages of laryngeal perichondritis and chondritis--viz. the inflammatory, suppurative, and necrotic. The symptoms of the first stage are obscure: the main one is pain, usually of a boring, burning character, localized according to the precise cartilage affected, which is increased by functional or other movement of the part and by pressure from the outside. To the pain there are gradually added--also depending somewhat upon the precise seat of the inflammation--cough, dysphonia, and dysphagia. In cricoid perichondritis--especially when, as is generally the case, the posterior surface of the plate of the cricoid cartilage is affected--there is sometimes inflammatory reddening of the pharyngeal mucous membrane which may extend upward to the palate. Inflammatory swelling of some part of the cartilaginous framework may be recognizable in the first stage of the disease by means of the laryngoscope.

The suppurative stage is attended with more swelling of the part affected, due to accumulation of pus and to collateral oedema. Pain, dysphagia, or dysphonia, and sometimes irritative, harsh cough may be much augmented; but, above all, dyspnoea now appears, which sometimes so rapidly increases that the patient dies asphyxiated unless tracheotomy is performed.

During the necrotic stage the symptoms of laryngeal stenosis sometimes persist, and sometimes cease with the expectoration of quantities of pus containing possibly a part, and occasionally the altered whole, of the affected cartilage: with continued purulent expectoration the patient's strength fails, the breath becomes very fetid, and hectic fever and death may supervene.

Swelling of cervical lymphatic glands, though by no means always present, has been observed in the early and sometimes only in the later stages of the disease.

The course of the disease, whether idiopathic or secondary, is either acute or chronic. It tends either toward abscess-formation, which predominates, or toward new growth of tissue; for a time sometimes the one, sometimes the other occurs, and, as a rule, during the former the process is more acute, and during the latter more chronic: the proliferated tissue, after being produced, may break down and increase the amount of pus. When acute, the three stages of the disease follow each other rapidly, if, indeed, the third be not cut off by the death of the patient. When chronic, the pus collected is very apt to burrow and to make fistulous passages and openings internally and externally. At various points also perichondric hypertrophies, ecchondroses, and exostoses are apt to occur.

The inflammatory stage can terminate by more or less complete resolution, though usually some enlargement of the cartilages permanently remains; recovery can also take place in the later stages, and leave deformities and produce cicatricial contractions.

PATHOLOGY AND MORBID ANATOMY.--The perichondrium of the larynx is diseased comparatively oftener than that of any other region of the body; which, aside from other causes, is partly due to the fact that the laryngeal cartilages become with increasing age normally vascular and ossified. The morbid process never affects at one time the whole of the cartilaginous framework of the larynx, and usually only one cartilage, or even only a limited portion of one cartilage, except in the case of the cricoid and arytenoid, which are sometimes together implicated. Perichondritis does not spread easily. The cricoid is most frequently affected, next the arytenoid, far less often the thyroid, and exceedingly rarely the epiglottis.

As already remarked, the inflammation of cartilage and perichondrium {119} has a great tendency to suppuration--occasionally, though rarely, proliferation and hypertrophy; or, on the other hand, and more frequently if the inflammation is a slowly progressing one, the processes leading to ossification take place. The suppurative stage follows the inflammatory quickly unless the latter has been comparatively very slight. A great abundance of pus collects between the cartilage and its investing membrane. As the former is thereby denuded and separated from its nutritive vessels, it must become necrotic. Exfoliated pieces of cartilage are generally found in the abscess. Caries of adjacent tissues is apt to take place, and oedema of the surrounding connective tissue, and sometimes far-reaching destruction, before the perichondrium bursts or becomes destroyed over a large extent. In cricoid perichondritis, the plate mainly being affected, the abscess projects mostly toward the oesophagus and the trachea, or it points outwardly when the narrow portion is involved; the opening when the abscess has burst is frequently large, and shows a portion of the necrosed cartilage; sometimes there are a number of perforations. In arytenoid perichondritis the abscess bulges either into the interior of the larynx or into the adjacent pyriform sinus; bursting usually occurs at the posterior portions of the ventricular folds or near the posterior vocal process, and the undermined edges may disclose the dead cartilage. In thyroid perichondritis either the interior of the larynx, the pyriform sinus, or the outside of the neck is encroached upon.