Volume 3 — DISEASES OF THE RESPIRATORY SYSTEM. (continued 4)

Chronic cases require all the preventive measures enumerated above and 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.

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 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).

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.

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 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 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 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.

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, 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.

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 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 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

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 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.

DISEASES OF THE LARYNX.

BY LOUIS ELSBERG, A.M., 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 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 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 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. ¹/8–½ 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 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.

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 larynx² 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.

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. 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 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.

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

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.

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 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), 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, 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 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.

In the course of the necrotic stage of the disease the laryngeal framework may cave in, and a stenosis be produced which may quickly put an end to the patient's life unless tubage—as explained under the head Oedema—or tracheotomy be performed. A loose piece of dead cartilage getting into the rima can produce the same fatal effect. Smaller or larger pieces of necrosed cartilage, sometimes partially or wholly ossified, have been expectorated, or, post-mortem, found lying in the respiratory passage, looking dirty-yellowish or blackish. Fistulous openings may take place in the larynx, pharynx, and in the skin covering these parts. Gaucher has reported an extraordinary case in which a perichondritic abscess of the thyroid cartilage had opened into the vertebral canal, as well as externally by the side of the sterno-cleido-mastoid muscle. If the perichondritis has followed deep-going ulcerative destruction of the mucous membrane, the perichondritic abscess bursts more easily, and less burrowing of the pus usually takes place.

In the rare termination of healing of the necrotic stage of perichondritis the loss of cartilage-substance is supplied by connective-tissue granulation emanating from the perichondrium. Cohen has reported a case in which there was apparently a reproduction of the whole cricoid cartilage, the necrosed original one remaining in the interior of the larynx as a foreign body.

Just as laryngeal stenosis is the grave danger during the continuance of the disease before the perichondritic abscess has opened from its protrusion into the laryngeal cavity, together with the accompanying oedema, and from the undermining of soft parts by burrowing pus, and after the abscess has opened from exfoliated pieces of cartilage blocking the interior, or, when eliminated, from caving in of the laryngeal framework, so laryngeal stenosis is the grave consequence of the disease from remaining deformity, cicatricial contraction, ankylosis of the crico-arytenoid articulation, etc. An open perichondritic abscess may also lead to extensive gangrenous destruction, and occasionally to subcutaneous emphysema.

Under the microscope the first stage of perichondritis is marked by the appearance in the fibrous basis-substance of the perichondrium of more or less coarsely granular corpuscles, the so-called inflammatory corpuscles. As to their origin, it is well known that Virchow taught that they are produced by the enlargement, division, and subdivision of the connective-tissue corpuscles, while Cohnheim claimed that they are nothing but emigrated colorless blood-corpuscles: in point of fact, most of them arise from the liberation of the living matter contained in the basis-substance, by the liquefaction or melting out of the non-living ingredient, and the increase and division of this matter into medullary or inflammatory corpuscles which constitute the so-called inflammatory infiltration. So long as the corpuscles remain connected by filaments of living matter, the inflammatory process may terminate by a new formation of basis-substance in hyperplasia—i.e. in the new formation of connective tissue. When, on the contrary, the inflammatory corpuscles are torn apart and become suspended in a liquid exudate, they constitute pus, and then the termination of the inflammatory process is in suppuration; that is to say, usually in an abscess.

The perichondrium and cartilage are normally so closely connected that the one tissue passes gradually into the other without definite boundary-line, and the cartilage participates in the inflammatory process by a liquefaction of its basis-substance, reappearance of the living matter therein contained, and the formation of more inflammatory corpuscles. So long as the inflamed perichondrium remains in living connection with the cartilage, both tissues may participate in the new formation of a dense connective tissue, and hyperplasia be the result of the perichondritis and chondritis. Should, on account of suppuration at the boundary of the cartilage, the vascularized portion of the perichondrium become detached, the cartilage, being itself devoid of blood-vessels, will become dead. Its corpuscles will shrivel, and together with the lifeless basis-substance become disintegrated. Pieces of necrotic cartilage may be found lying in the surrounding pus, and, though usually chondritis has preceded the necrosis, the latter may ensue without previous change of the cartilage tissue, especially if the perichondritis runs its course to suppuration rapidly; but in every case suppurative perichondritis precedes necrosis of the cartilage.

After the elimination of necrosed portions cartilage is as a rule replaced by newly-formed dense fibrous connective tissue. Some clinically-observed cases, aside from the remarkable case of Cohen already mentioned, indicate, however, that, exceptionally, new formation of cartilage may occur from hyperplastic perichondrium, in the same manner as new bone is sometimes formed from hyperplastic periosteum after osseous necrosis.

DIAGNOSIS.—The inflammatory stage may be suspected, rather than positively recognized, from the peculiar pain if the laryngoscope (or, in the rare case of thyroid perichondritis, palpation) reveals enlargement of a part of the cartilaginous structure without much injection of the mucous membrane. The presence of other symptoms mentioned, and in the case of cricoid perichondritis the localized pharyngeal reddening, make the diagnosis more probable. During the suppurating and necrotic stages the diagnosis becomes certain from the symptoms I have described, especially expectoration of fragments of necrosed cartilage, together with direct examination. The laryngoscope may show the abscess; sometimes the finger or a probe can detect fluctuation, and frequently through an opening the probe detects the necrosis. The movement of one or both vocal bands may be affected either mechanically from purulent accumulation, or from articular ankylosis, or from interference with muscular attachments or action, or with innervation. In my hand, and in that of others, a probe introduced through an external fistula has been seen in the larynx; others have been able to inject colored fluid and find it in the interior.

PROGNOSIS.—Except in slight cases death is more apt to take place than recovery. If tracheotomy has saved the patient from impending death, ultimate prognosis is still unfavorable in severe cases. In idiopathic, traumatic, and syphilitic cases the prognosis is of course better than in others in which we have to face grave dangers of the underlying disease as well. The remaining laryngeal stenosis after recovery makes the prognosis bad as to the doing away with the tracheotomy-tube, although it is far more favorable at the present day than it was previous to Schrötter's success with dilating measures.

TREATMENT.—Throughout the disease the patient's general health and strength must be carefully attended to, tonics and stimulants used according to circumstances, and the underlying condition of secondary perichondritis, such as syphilis, etc., treated secundum artem. Locally, the treatment during the first stage must be antiphlogistic, by leeches, ice, etc., and soothing, especially by inhalations. Afterward, abscesses must, if accessible by means of the laryngoscope, be opened. Artificial feeding, through either an oesophageal or a rectal tube, may become necessary. Schrötter's hard-rubber tubes may be inserted to conduct air to the lungs, but tracheotomy, not laryngotomy, must be performed if, in spite of this tubage, suffocation threatens.

The methodical dilatation of post-perichondritic laryngeal stenosis requires special bougies, catheters, hard-rubber tubes, pewter plugs, and dilators which are not to be found in the ordinary armamentarium of a medical practitioner; but the proper and frequently successful use of these can be acquired with patience and perseverance when a case of the kind presents itself for treatment.

Chronic Laryngitis.

DEFINITION, SYNONYMS, AND CLASSIFICATION.—Under the name chronic laryngitis are brought together a number of different diseases of the larynx which have the character in common that they are more or less inflammatory and chronic in their course. The various conditions of chronic inflammation of the mucous membrane (chronic laryngeal catarrh) prominently belong to this category, but the chronic inflammation of every other constituent tissue of the larynx, except cartilage and perichondrium, is included.

The synonyms refer mostly to individual etiological and other factors not applicable to all cases, as clergymen's laryngitis, phthisical laryngitis, and many of the designations of different classes.

Chronic laryngitis frequently involves more than one tissue, but usually one prominently. Histologically, the following kinds of chronic laryngitis have been distinguished: viz. catarrhal, when simply or principally the mucous membrane is affected; granulous or glandular, when the muciparous glands; submucous or parenchymatous, when the connective tissues underneath the mucous membrane are prominently implicated; and muscular, when there is chronic inflammation of the muscular tissue. According to the seat, there will be supraglottic, glottic, and infraglottic chronic laryngitis. There have also been described atrophic, hypertrophic, and polypoid chronic laryngitis; dry and blenorrhoeic or hypersecreting chronic laryngitis; simple, fetid or ozænic, and ulcerative; phlebectasis laryngea, trachoma, etc.

ETIOLOGY.—Chronic laryngitis is caused in many ways. Frequently it follows uncured or neglected acute laryngitis. It is apt to occur in persons whose avocations or habits lead them to strain or otherwise abuse their vocal organ, to work in an impure or irritating atmosphere, or to use tobacco or alcohol excessively; and it may depend upon or be an extension of chronic inflammation of either the naso-pharyngeal or tracheo-bronchial mucous membrane. Secondarily, it accompanies all long-continued laryngeal affections, such as phthisis, syphilis, lupus, etc. Males suffer more often than females, and middle-aged persons more often than either children or the very old. Boys at the time of puberty are liable to become affected.

SYMPTOMATOLOGY.—The diseases comprised under the collective name of chronic laryngitis give rise to various symptoms, of which the chief are morbid sensations in the region of the larynx and alteration of the voice. Unless ulceration have occurred, the morbid sensations hardly amount to pain, except on acute exacerbation from catching cold or after long-continued use of the voice. They consist in a sense of dryness or of pressure, in a tickling or in an unnatural feeling that cannot be definitely described in words. Though not acute, they are sufficient to make the patient constantly conscious of their existence and to induce fruitless efforts at clearing the throat, etc. The alteration of the voice varies from occasional unsteadiness or veiling, or a loss of power or purity of tone, to different degrees of hoarseness, dysphonia, and even aphonia. In singers and public speakers the disease interferes sometimes with professional vocal efforts only, ordinary conversation not being affected. The voice is best, sometimes worst, after a night's rest, and in either instance changes after moderate use for worse or better as the case may be; but long-continued exercise is always harmful. The voice is comparatively easily fatigued, and then the vocal organ becomes positively painful.

In addition to the two chief and constant symptoms there are others that may or may not be present, and which sometimes assume even greater prominence than the modification of the voice. Thus, secretion, which in most cases is very slight, glassy grayish, and viscid, is occasionally very abundant, yellowish, or darkish, or more rarely still mixed with streaks of blood and in clumps, though not sticky or dried into scabs, and is sometimes so fetid that the patient's breath is exceedingly malodorous. Cough, which in most cases is either absent or comparatively trifling, barking, or hacking, occasionally is the most troublesome of all the symptoms. Dysphagia is sometimes present even in simple or mild cases. In severer cases, in the later stages, especially in syphilitic and phthisical chronic laryngitis, swallowing becomes painful and difficult, or even impossible. Dyspnoea occurs only from accumulations of phlegm in the larynx, and is then lessened after expectoration, or it may depend upon the diminished lumen of the laryngeal cavity on account of thickening of the walls, as it is especially apt to do in subglottic chronic laryngitis, or on account of so-called polypoid hypertrophies in simple cases, gummata or cicatricial tissue in specific cases, etc. Dyspnoea may become so urgent as to require tracheotomy.

PATHOLOGY AND MORBID ANATOMY.—In catarrhal chronic laryngitis there is congestion of the mucous membrane, dilatation of the blood-vessels, and altered secretion. The mucous membrane becomes, as a rule, hypertrophied, tougher, and more firmly connected with the subjacent tissues. Laryngeal venous congestion (so-called phlebectasis laryngea) is occasionally, though rather rarely, met with; and still more rare is a hemorrhage from the surcharged vessels in chronic cases. In granular or glandular chronic laryngitis—i.e. when the muciparous glands are prominently involved in the inflammatory process—they form elevations, making the surface uneven, and the tissues become tenser and more compact. When the submucous connective tissue takes much part in the process the hypertrophy is still greater, and not only may the lumen of the laryngeal cavity become greatly diminished, but projections of various lengths (the so-called cellular polypi and papillary excrescences) are apt to occur. The objective term tuberosa is sometimes added to laryngitis or to the designation for inflammation of a portion of the larynx; as, for example, that of the vocal bands—viz. chorditis tuberosa, when small whitish, tumor-like elevations occur. These, especially on the vocal bands, where they have been described by Tuerck, Elsberg, Cohen, and others, are also called trachomata. In cases to which the name muscular chronic laryngitis is given the muscular tissue has been found prominently hypertrophied. Moura Bourillou has recorded a case in which the striated fibres of the posterior crico-arytenoid muscle were converted into fibrous tissue. In many of the common cases of catarrhal chronic laryngitis the alteration of the voice depends upon paralysis of the muscles—especially the thyroid arytenoid and the arytenoid—directly caused by the transmitted inflammation and by thickening of the overlying mucous membrane. In fetid chronic laryngitis there is usually found excoriation of the mucous membrane, and atrophy. That erosions—i.e. superficial ulcerations extending no deeper than the epithelial layer—frequently occur in the course of catarrh is admitted by everybody, but much unnecessary discussion has been indulged in concerning the question whether deeper ulcerations of the mucous membrane can ever take place under these circumstances. It has been insisted upon that catarrhal ulcerations never occur. This is a mistake, but it is true that catarrhal ulceration is rare unless the patient is greatly debilitated or cachectic. Ulcerative chronic laryngitis in the majority of cases depends upon some cachexia—i.e. tuberculosis, syphilis, lupus, lepra, etc.

Tuberculous chronic laryngitis—laryngeal phthisis proper—frequently accompanies pulmonary consumption. Usually it follows, but occasionally precedes, the latter. Unquestionably, it also occurs, though rarely, without any disease in the lungs. Anæmia of the laryngeal mucous membrane is present from the first, and usually persists throughout. There is a low form of inflammation, swelling of the tissue, and then ulceration, the ulcers being at first small, and afterward coalescing to form larger ones. Much destruction may take place, and more or less oedema is always present. Paralysis of some of the interior laryngeal muscles may also occur, depending alike upon anæmia and oedematous infiltration of the muscular substance, or upon compression of the nerve-tracts by enlarged lymphatic glands (most frequently on the right side) or upon involvement of the nerves—pleuritic adhesions, tuberculous deposits, etc.

Syphilitic chronic laryngitis is a local manifestation occasionally of hereditary, but usually of acquired, syphilis. It may vary from a slight erythematous condition of the mucous membrane to intense inflammatory thickening or destructive ulceration, may be accompanied by laryngeal oedema and pericarditis, and may lead to dangerous adhesions, cicatrizations, and stenosis. The chronic laryngitis occurring in lupus and lepra and in malignant diseases of the larynx partakes of the character of these processes, and is accompanied by their peculiar thickenings, tuberosities, granulations, and ulcerations.

DIAGNOSIS.—Chronic alteration of voice, local morbid sensation, and other symptoms mentioned may lead us to suspect the presence of chronic laryngitis, but are insufficient for diagnosis without mirror examination. The diagnosis can be positively made only by means of the laryngoscope, and even by this means requires care. It is of the utmost importance that the physician make himself perfectly familiar with the appearance of the healthy larynx by the particular illumination he uses for examining patients.

A very able laryngoscopist, Carl Michel of Cologne, confesses⁶ that he has many times diagnosed chronic laryngitis when none existed, and explains that with inadequate illumination the contours of the small vessels run into one another and make the whole surface which they traverse appear red. In simple chronic laryngitis the redness has a somewhat livid look; in syphilitic chronic laryngitis it is darker and more angry-looking; in phthisical cases it is duller, even though the mucous membrane be congested, while usually it is pale. In both the latter diseases the swelling is greater, the natural contour of the parts more changed, and destruction more imminent than in the simple chronic laryngitis. When oedema is present there is a peculiar transparent or translucent appearance. In subglottic chronic laryngitis, especially when much hypertrophy has already taken place, the color is often quite light grayish instead of red.

⁶ Practische Beiträge zur Behandlung der Krankheiten des Mundrachenhöhle und des Kehlkoffes (Leipzig, 1880).

Phlegm found in the larynx may have come from the bronchial tubes or the trachea; when it is cleared away by cough or otherwise, the larynx may prove to be unaffected. In all cases of suspected secondary chronic laryngitis, phthisical, syphilitic, etc., the state of the lungs and whole respiratory tract, as well as the general health in every respect, hereditary tendencies, and past diseases, must be carefully inquired into.

PROGNOSIS.—The prognosis of chronic laryngitis is good as to life except in broken-down constitutions, neglected exacerbations, and grave underlying affections; but, even with these exceptions, it can be said to be favorable as to cure only with expert local treatment and if no severer tissue-alterations, usually hypertrophic, have as yet taken place. If the latter have taken place—especially if the submucous tissues are prominently involved—the organ can seldom be restored to perfect integrity. For persons in ordinary vocations and situations in life the recovery that can generally be secured may be entirely satisfactory, but more exacting demands on the speaking and singing voice require special measures, including hygienic precautions, to be carried out carefully, and sometimes to be long continued.

BY J. SOLIS COHEN, M.D.

TREATMENT.—Whatever the grade or stage of a chronic laryngitis, the constitutional condition or proclivity of the patient always requires suitable hygienic, dietetic, and therapeutic management. The repair of regional or local morbid conditions may often be confidently entrusted to such constitutional measures; and it is only when these morbid conditions resist the influence of systemic treatment, or are of some special character obviously insusceptible to such influence, that topical medication or actual surgical procedure becomes requisite in addition. The accessibility of the interior of the larynx to instrumental manipulation under laryngoscopic guidance offers great temptations for topical interference. The result is, that the diseased larynx is sometimes submitted to unnecessary, and even injurious, direct attack at the hands of a dexterous manipulator untrained in general practice, and consequently ignorant of the beneficial influence of purely constitutional measures upon many local morbid conditions. While it is highly proper, therefore, to utter a few words of caution, it is equally proper to assert that many local conditions are entirely beyond the control of systemic measures, and require topical treatment.

Constitutional Treatment.—Simple or catarrhal chronic laryngitis, unassociated with special diathesis, is often admirably influenced by the prolonged administration of some preparation of cubeb; the oleoresin being preferred by the writer in doses of from fifteen to twenty-five minims for the adult, three times a day on crushed sugar. This drug being eliminated in part by the bronchial tract, it seems especially adapted to exert upon chronic inflammatory conditions of the aërial mucous membrane that healing process which it is known to exert on mucous membrane elsewhere. Among other useful constitutional remedies from which similar service can be expected may be enumerated compound tincture of benzoin in doses of from thirty to sixty minims for the adult, three or more times daily; fermented infusion of tar or tar beer, several ounces daily; and petroleum mass, one to two grains for the adult, three or four times daily, with pulverized extract of glycyrrhiza in pill or capsule. In cases with deficient secretion ammonium chloride is indicated. In cases associated with impaired digestion, with excess of acidity, the prolonged use of alkaline mineral waters is advisable; preferably, if convenient, at their sources. In cases associated with chronic diarrhoea the mineral acids are indicated. Cod-liver oil, hydrated chloride of calcium, and preparations of iodine and of arsenic are useful in patients of the scrofulous diathesis. Iodoform, one grain for the adult, rubbed up with glucose or some other excipient, in pill or capsule, three times a day, is often useful in patients with the tuberculous diathesis. Specific remedies are required for syphilis. In like manner, any constitutional abnormality is to be systematically attacked.

The functions of skin, kidneys, and intestine are to be maintained as nearly normal as may be, or even a little in excessive action from time to time for derivative purposes. Abstinence is to be enjoined from all exposures or indulgences deleterious to the parts diseased; with as sparing a use of the voice as is compatible with ordinary domestic or social demands, and absolute rest for prolonged periods of days at a time whenever unusual demands have resulted in exacerbating the malady. Under such treatment many cases of simple catarrhal or glandular chronic laryngitis may get well, as has been intimated, without any special local measures.

Topical Treatment.—The difficulty of impressing patients with the necessity of submitting to these hygienic measures and to dietetic restrictions, and for avoidance of occupations or habits which favor or maintain the condition of chronic inflammation, renders topical treatment necessary in many instances. Direct instrumental medication requires the personal attention of the medical attendant. Medication by inhalation or insufflation may be entrusted to the patient or the nurse in most instances. In instituting a course of topical treatment several things must be taken into consideration, such as the condition of hyperæsthesia, hypersecretion, insufficient secretion, congestion, hemorrhagic infiltration, hemorrhage, hypertrophy of tissue or tissue-elements, erosion, fissure, ulceration, and excessive granulation. The first three of these furnish the clue to the nature of the home-treatment, the remainder to that required at the hands of the physician. The home-treatment is to be directed to keeping the parts clean and comfortable; the manipulation of the physician is to be directed toward overcoming special pathological conditions.

Should secretion be defective, alkaline sprays inhaled at regular intervals, for a few minutes at a time, tend to augment secretion and to facilitate the detachment of adherent mucus. For the purpose choice may be made of the following drugs in the proportion of about five grains to the ounce for the adult, dissolved in distilled water or tar-water, with the addition of a sedative when the parts are hyperæsthetic, or an opiate when they are painful: ammonium chloride, sodium borate, sodium bicarbonate, sodium chloride, sodium chlorate, sodium iodide, potassium iodide, potassium chloride. The spray should be propelled by means of compressed air, with what is known as the hand-ball atomizer, in preference to steam, the effect of which is too relaxing in most instances. A few drops of some aromatic or balsamic product will render the spray more agreeable in many instances. Should these agents fail, pyrethrum or jaborandi may be found more serviceable, in the proportion of from one to five minims of the fluid extract to the ounce of water.

Should secretion be excessive, astringents are indicated; and choice may be made from alum, five grains to the ounce of rose-water; tannic acid, two or three grains; zinc sulphate or zinc sulphocarbolate, two grains; lead acetate, two grains; ferric chloride, one grain; and silver nitrate, half a grain to the ounce. Personal supervision of the initial inhalations is requisite to ensure proper use of the spray. Whether the medicament is to be propelled directly into the larynx by means of a tube with a vertical tip to be passed beyond the tongue, or to be inhaled by efforts of inspiration from spray projected horizontally, will depend upon the skill of the individual using it. Hard-rubber spray-producers are furnished with series of tips, so that either method may be employed. When the horizontal tip is used, the instrument should be held some distance from the mouth, so that the spray may be deflected into the larynx by the act of inspiration. When the tube is placed within the mouth most of the spray becomes condensed upon the pharynx, and very little can be drawn down into the larynx. As metallic tubes are liable to become reduced by certain remedies—ammonium chloride, for instance—tubes of glass or of hard rubber are to be preferred.

Should a steam apparatus be employed, the patient should remain housed for half an hour after inhalation, except in very warm weather. In cases of hyperæsthetic mucous membrane the home inhalation of volatile remedies daily is often useful. Compound tincture of benzoin, camphorated tincture of opium, oil of pine, oil of turpentine, terebene, eucalyptol, creasote, carbolic acid, may be inhaled from a bottle containing hot water or from a special inhaler, a few drops of chloroform being advantageously added when there is a good deal of irritative cough. A few drops of the more pungent volatile substances, such as terebene, eucalyptol, and creasote, may be dropped on the sponge supplied with the perforated zinc respirator of Yeo of London, and the apparatus be worn for an hour or longer continuously. In cases with excessive secretion and in syphilis, ethyl iodide is indicated as a remedy appropriately administered by this method. When the parts are very irritable, a respirator of this kind or some similar contrivance, or a fold or two of woollen or silk gauze worn in front of the mouth and nose while in the open air, will often protect the tissues from too cool an atmosphere, and enable the patient to bear exposure with comfort.