amenable to treatment. They are generally organic and progressive. The
exception to this statement, or at least the most notable exception, is
syphilis. The influence of this disorder in the production of paralysis
of central origin must be admitted, but it seems to have been by many
authorities overstated. The coincidence of paralysis with an earlier
infection does not by any means justify the inference that the one
disease has been produced by the other. When, however, there is reason
to think that this relation may exist, antisyphilitics should be
administered. In a few cases this treatment has been followed by marked
improvement of the laryngeal disease.
Cases dependent upon malignant growths within the cranium are
absolutely beyond the reach of treatment. Paralysis dependent upon bony
tumors, even though they are benign in character, are also for the most
part beyond the reach of surgical interference. If the paralysis is
complete--that is, if all the muscles are involved--there are no
indications for any operative procedure. If, however, only the nerves
that supply the posterior crico-arytenoids are involved, as
occasionally happens, tracheotomy should be resorted to even though the
dyspnoea is not urgent. This operation places the patient in a
condition of temporary safety, and gives time to resort to other means
if the indications for their use can be found.
The second group of cases includes all those in which the cause of the
paralysis is due to the presence of disease of the nerve-trunks, or to
pressure upon the nerves between their emergence from the cranium and
their terminations in the muscles of the larynx. Malignant growths and
benign tumors situated along the tract of the nerves, and pinching
them, are readily recognized, and when not contraindicated by other
facts they should be removed. Enlargement of the thyroid gland may in
some cases press upon the nerve and cause paralysis. This is
occasionally relieved by appropriate treatment directed to it. Among
those means which have occasionally been found efficacious for this
purpose iodine or some of its compounds, and especially electricity in
the form of galvanism, seem to be entitled to the most confidence. For
paralysis dependent upon cicatricial pinching of the recurrent
nerve-trunks relief may possibly be obtained by dissecting out the
bands by which the nerves are compressed. This is hardly indicated for
the partial derangements which do not endanger life, as in unilateral
paralysis of the recurrent. Where the trunk of the nerve is entirely
obliterated nothing can be done, and in many cases of injuries along
the trunk of the recurrent it will be impossible to know that the nerve
has not been destroyed in the mechanical lesion.
Paralysis caused by pressure upon the intra-thoracic portion of nerve
is beyond the reach of surgical interference. When this is aneurism,
disease of the apex of the lung, or pleuritis, as may possibly happen,
the paralysis or paresis must of course have a history coeval with the
thoracic disease. The causes themselves are unfortunately persistent
and tend to terminate in death; the paralyses are therefore persistent
and beyond the reach of medical or surgical relief. In cases where the
posterior crico-arytenoids are especially involved, tracheotomy, as in
the same condition from intra-cranial disease, should be performed. It
is certainly true that there may be a morbid {90} condition of one or
both of the pneumogastrics or recurrent nerves without macroscopic
changes in their structure; in such cases the use of the faradic
current together with general tonics is indicated.
The third group is made up of those cases in which there is disease of
the nerves or muscles of the larynx itself. It seems to be true that in
most of these patients there is a derangement of the general nutrition;
but this is not all: there is also a special morbid condition of these
special structures. For degeneration of the muscles of the larynx there
is probably no remedy; for atrophy there may be something done by
different methods of exercising the muscles. The use of electricity
when the muscles are still responsive to the current should be
attempted. Regular applications by which they are thrown into action
may result in the improvement of their nutrition. The use of them so
far as they are phonators, without carrying it to the extent of
producing fatigue, is also indicated. In addition to these local
measures, tonics for the purpose of improving the general condition may
be administered. Strychnia, with the purpose of stimulating the
centres, will also be found in some cases useful. When the disease is
partial, as in the case of the posterior crico-arytenoids, such
operative measures as have been already indicated must be resorted to.
The purpose is to prolong life, even though we cannot cure the disease.
The fourth group, the paralyses of reflex origin, are generally within
the reach of treatment; at least, they usually recover. They depend for
the most part, as will be remembered, upon some disorder of distant
organs. There is primarily no disease of the larynx, and not
necessarily even a secondary disorder of its structures. It is true
that long inaction may result in atrophy of the muscular structure, but
this is, I am convinced, a rare exception to the rule that in
hysterical paralysis there is maintained a complete integrity of the
muscles of the organ, even though the parts have been for years in a
state of inaction. For some reason, the nutrition is maintained much
better than in paralysis from other cases. The trophic nerves are
evidently not involved. The treatment should be both local and general.
It should be directed to the larynx and to the distant part upon which
the motor disorder of the larynx depends. So far as the larynx is
concerned, we know of nothing better than electricity. The faradic
current, by which the muscles are stimulated and the nervous energies
awakened, seems to be most useful. The method of applying electricity
to the larynx may be varied according to the nature of the case and the
age of the patient. In young children the current should be directed
through the walls of the larynx from side to side or from before
backward. It should be repeated every day if possible. In adults the
current may with advantage be passed through the larynx from within
outward or from one side to the other. This may be accomplished by the
use of Mackenzie's laryngeal electrode. The instrument is either single
or double. Armed with a sponge and bent to the proper curve, one pole
is introduced into the larynx, the other placed upon the neck, and then
by pressing a spring the circuit is closed, permitting the current to
pass through the parts from one pole to the other. In using the
instrument with two electrodes, as in paralysis of the arytenoids and
constrictors, the instrument with two branches, each armed with a
sponge, and to which the two poles are attached, is introduced with one
branch in one of the depressions in one side of the larynx, and the
other on the opposite side in the corresponding depression. The circuit
is now closed as before, with the muscles between the two poles as part
of the circuit. The electrodes may be carried down into the organ and
the stimulus applied directly to the vocal bands. In some cases the
first shock is followed by distinct phonation; in others repeated
applications are necessary; while in still others all efforts of this
kind fail entirely. Both the galvanic and the faradic current may be
used. When the object {91} is to stimulate the dormant energies of the
nerves or muscles, the faradic is probably the more useful; if it is
desired to modify the nutrition of the parts, the galvanic is
preferable. The strength of the current should be carefully tried upon
the surface of the hand of the operator before introducing it into the
larynx. The shock to the nervous system from the dread of the operation
has sometimes resulted in the recovery of the voice before anything has
been done. The morbid spell is broken and the patient speaks. This is
true in spasm even, as shown in a case reported by Lefferts, where it
was thought that tracheotomy was necessary for the purpose of saving
life. The patient, frightened at the thought of the operation,
recovered, and respiration became easy. There was no reason to think
that the case was one of simulation.
For the general condition, which is usually one of asthenia,
nerve-stimulants are indicated, and the bitter tonics, with iron and
strychnia, good generous diet, outdoor exercise, change of
surroundings, travel, moral impressions, in short everything that tends
to promote general good health,--these are among the most important
requirements. If there is local uterine trouble, this of course
requires attention, or if there is any other derangement which serves
as the point of departure for the morbid phenomena, this will also
demand consideration. In fact, no organ suffers alone. There is a
community of function and there is a community of suffering. This
subject has been perhaps sufficiently discussed in the consideration of
the treatment of hysterical disorders of sensation and of spasm, to
which the reader is referred.
The fifth group comprises paralyses toxic in their origin. When the
cause is typhoid fever or diphtheria, we may confidently expect the
paralysis to disappear with the other manifestations of adynamia. Time
and tonics, with attention to diet, and in the more protracted cases
electricity, will generally be all that is required. Cases depending
upon the toxic effects of lead or arsenic demand the treatment
appropriate for the other manifestations of these forms of paralyses.
The iodide of potassium internally, with attention to the general
health, and especially to the functions of the excreting organs,
constitute the most important measures. In addition, strychnia may be
administered, and the faradic current applied through the larynx. It is
certainly possible that laryngeal paralysis may be produced by arsenic,
as shown in the case reported by Mackenzie, and probably also by copper
or mercury. Such cases, however, must be exceedingly rare. The
potassium iodide, as suggested for lead-paralysis, may be resorted to
in case mercury is supposed to be the cause. For arsenic- and
copper-poisoning the reader is referred to articles upon these subjects
elsewhere. Cases in which there is evidence of a local lesion due to
syphilitic intoxication should receive both local and general
treatment.
{92}
ACUTE CATARRHAL LARYNGITIS (FALSE OR SPASMODIC CROUP).
BY A. JACOBI, M.D.
PATHOLOGY.--Catarrhal inflammations of the mucous membrane and the
submucous tissue of the larynx are of frequent occurrence. They are
either general or local; that is, confined to the epiglottis or the
vocal cords, etc. The affected parts are red (only less so where the
elastic fibres are developed to an unusual degree and capable of
compressing the dilating capillaries) and more or less tumefied.
Sometimes small hemorrhages occur. The secretion is either changed in
character or in quantity. It is either mucous or purulent, or (mainly
in passive congestions produced by interrupted venous circulation)
serous. The epithelium is either thrown off or accumulated in some
spots, particularly on the vocal cords, so as to form whitish
conglomerates which may become the abode of schizomycetæ. The
muciparous follicles are enlarged and dilated; to this condition is due
the granular form of laryngitis, with the nodulated condition of the
epiglottis or the fossæ Morgagni or the inferior vocal cords.[1]
[Footnote 1: Ziegler, _Pathol. Anat._]
When the catarrhal process is of longer duration, the capillaries and
small veins become permanently enlarged; round cells are deposited
between the epithelium and cellular tissue; the cellular tissue becomes
hypertrophied; papillary elevations are formed on the vocal cords. The
disintegration of the epithelium and the bursting of the tumefied
muciparous glands lead to the formation of erosions and ulcerations;
the chronic swelling and hypernutrition of the muciparous follicles to
their destruction by cicatrization or simple induration; and to atrophy
of the mucous membrane.
Many of the specific causes of inflammation of the larynx exhibit no
peculiar alterations of their own. Scarlatina, measles, and
exanthematic typhus are complicated with either a catarrhal (in most
cases) or a diphtheritic laryngitis. Variola, however, has a peculiar
form of its own, with red, pointed, whitish stains or nodules,
consisting of a cellular infiltration or of a deposit upon or into the
upper layers of the mucous membrane, composed of necrotic epithelia and
pus-corpuscles or of coherent membrane. Hemorrhages or abscesses are
but rare, and chondritis seldom results from it. Even syphilis has not
always changes which are characteristic. The laryngitis accompanying it
is often but catarrhal, without anything pathognomonic about it. But
whitish papules consisting of granulation-tissue (plaques muqueuses),
gummata often changing into sinuous ulcerations, particularly on the
epiglottis and posterior wall of the larynx, also perichondritis with
loss of cartilage and deep cicatrization, such as are not found in
either carcinosis or tuberculosis of the larynx, are frequently met
with. Typhoid fever shows different forms of laryngitis, from the
catarrhal to the ulcerous. Epithelium is thrown off at an early period
of the disease; erosions and ecchymoses follow; rhagades on {93}
the margins of the epiglottis, and a deposit on the anterior wall of
the larynx and the vocal cords, consisting of epithelium and round
cells, are frequent. That they should be mixed with micrococci and
bacteria is self-understood. Not so that these bacteria are to be
considered as the cause of the disintegration which is taking place,
the less so as no specific typhoid bacterium has been demonstrated, and
several varieties of them are found both in the mouth and in these
ulcerations. These changes are apt to terminate in ulceration of the
epiglottis and false vocal cords; these will extend in different
directions, and to the deeper tissue down to the cartilage.
In tuberculosis, laryngitis is a frequent occurrence. In most cases it
is secondary to the pulmonary affection, and due to the direct
influence of the contagious sputum--according to Heinze, however, not
to contagion, but to the influence of the infected blood. In other
cases it appears to develop spontaneously, before any pulmonary
affection is diagnosticated, and may then be due to some poison
circulating in either blood or lymph. Tubercular laryngitis, according
to Rindfleisch, commences in the excretory ducts of the muciparous
glands. That this is so in a great many cases is undoubted. The first
changes visible are small cellular subepithelial infiltrations or real
subepithelial tubercles, which, while growing, undergo gaseous
degenerations and ulcerate. These ulcerations are either flat and small
or deeper with an infiltrated edge, and are apt to terminate in
secondary nodulated infiltrations and abscesses. Large tumors are not
met with, but oedema and phlegmonous inflammations are by no means
rare.
ETIOLOGY.--The predisposition varies according to individuals, ages,
and seasons. Some mucous membranes appear to be more sensitive than
others. The hereditary transmission of peculiarities of structure of
all or some tissues or organs is apparent, in the case of laryngitis,
in the fact that many children in the same family or the children of
parents who were sufferers themselves are affected. Children are more
liable than adults, infants more than children: 20 per cent. of all the
cases are met with under a year, 25 from the first to the second, 15
from the second to the third. Not many occur after the twelfth year.
The narrowness of the infant larynx and the looseness of its mucous
membrane afford full play to injurious influences, such as dust, cold
and moist air, changing temperatures, hot vapors and beverages. Colds,
though their nature and effects can hardly be said to be understood,
are certainly amongst the main causes. Perspiring surfaces afford
frequent opportunities. One of the principal causes is insufficient
clothing--more amongst the well-to-do than amongst the poor. The latter
have this blessing in their misfortune, that they are protected
uniformly if at all, and have their skins hardened by exposure. The
bare necks and chests, the exposed knees, the low stockings and thin
shoes of the children of the rich, old and young, are just as many
inlets of laryngeal catarrh, inflammatory disease, and phthisis.
Persons suffering from nasal catarrh or pharyngeal catarrh are liable
to have laryngitis. Thus, not only rachitis, with its influence on
lymphatic glands and the neighboring mucous membranes, but also acute
infectious diseases, such as whooping cough, measles, influenza,
erysipelas, hay fever, tuberculosis, syphilis, typhoid fever, and
variola, are as many causes of laryngitis. That over-exertion of the
voice should produce laryngitis seems probable, but experience does not
teach that those babies who cry most are most subject to laryngeal
catarrh.
SYMPTOMS.--Acute laryngitis is a frequent disease, and has always been.
Still, in 1769, Millar mistook it for a sensitive neurosis, considering
it as identical with spasm of the glottis, and recommended
antispasmodic treatment. Guersant understood its nature better. He
first (1829) used the names false croup and stridulous laryngitis.
Acute laryngitis is attended with but little fever in the adult, but
with a high elevation of temperature in {94} the young. In all, it
yields a number of symptoms, part of which are uncomfortable only;
others are liable to become dangerous.
Seldom without any catarrhal premonitory symptoms of other parts of the
respiratory tract, sometimes, however, without any, there is a burning,
tickling, irritating sensation in the larynx--a sense of soreness in it
and the lower portion of the pharynx. Sometimes these sensations amount
to actual pain, to difficulty of deglutition, and to the sensation of
the presence of a foreign body. Speaking, coughing, cold air, increase
the discomfort and pain. Hoarseness, sometimes increasing into aphonia,
follows soon after, is seldom simultaneous with, the first appearance
of cough, but lasts longer than the latter, which is, according to the
severity of the case or the stage of the disease, changing between
loose and dry, hoarse and barking. Inspiration is apt to become
impeded, mainly in infants and children. In these it is often sibilant.
It is followed by a reflex paroxysm of cough, with interrupted and
brief expirations, during which the forcible compression of the thorax
may result in cyanosis. The principal attacks are met with at night
amongst children. Quite suddenly they wake up with a dry, barking
cough, interrupted by considerable dyspnoea, which is great enough
sometimes to give rise to much anxiety. They toss about or cling to a
solid body, raise themselves on their knees, breathe with great
difficulty, exhibit cyanosis in its different hues, perspire very
freely, and yield all the symptoms of the strangulating attacks of
membranous croup, its over-exertion of the sterno-cleido-mastoid
muscles and supraclavicular and diaphragmatic recessions not excepted.
These attacks occur but rarely during the day; on the contrary,
well-marked remissions are quite common in the morning. Their
occurrence during the night is best explained by the facility with
which mucus will enter the larynx from above during the reclining
posture, the increasing dryness of the pharynx during sleep, perhaps
also the nervous influence depending upon the relative diminution of
oxygen and increase of carbonic acid in the respiratory centre, leading
to spasmodic contractions.
Some of these grave attacks of sudden dyspnoea are explained by the
participation of the submucous tissue in the morbid process. When that
occurs, adults also, who as a rule do not suffer from dyspnoea in
laryngeal catarrh, are badly affected. The symptoms are rigor, high
temperature, pain, hoarseness or aphonia, a barking cough, labored
expectoration--which is sometimes bloody--dyspnoea, orthopnoea,
cyanosis. In some cases, to which the name of laryngitis gravis or
acutissima has been given, the symptoms grow urgent to such a degree
that tracheotomy alone is capable of saving life.
Otherwise, the severity of the symptoms does not go parallel with the
local lesions. Particularly in children, hoarseness, cough, and
dyspnoea are liable to be grave, while the local hyperæmia is not
intense at all. A pharyngeal catarrh is very apt to increase the
suffering. Complications with tracheitis or bronchitis are liable to
prolong the course of the disease and to render respiration--which is
not accelerated in laryngeal catarrh--more frequent. Otherwise, the
disease runs a favorable course. Remissions of the severe attacks which
may occur in several successive nights take place in the morning.
Expectoration, which in the beginning was either absent or scanty,
becomes soon more copious and mucous; the hard, barking, loud cough
grows looser with increasing secretion. In most cases the violence of
the affection is broken in from three to five days, and the disease
runs its full course in a week or two. But hoarseness may remain behind
for some time; in rare cases aphonia has become permanent and relapses
are frequent. Not infrequently children are presented who are reported
to have had croup five or ten or more times. In some families all the
children are subject to laryngeal catarrh, and hereditary influence
cannot be doubted.
The very worst complication of laryngitis is oedema of the glottis. It
{95} affects both the mucous membrane and the submucous tissue of the
larynx. It is met with on the inferior (posterior) surface of the
epiglottis, in the ary-epiglottic folds, and on the false (inferior)
vocal cords, the submucous tissue of which is of a very loose structure
normally. Amongst its causes--which may be various (foreign bodies in
the larynx, injuries, mechanical and chemical irritants of any kinds;
typhoid, tubercular, variolous, syphilitic ulcerations; erysipelas of
the neighborhood, inflammations of the parotids or tonsils, suppuration
in the pharynx, thyroid body, and cellular tissue of the neck)--both
catarrhal and croupous laryngitis are not at all uncommon. This is
particularly so when they are complicated with cardiac and renal
anomalies, pulmonary emphysema, and compression of the veins of the
neck by glandular swellings; also with changes in the structure of the
walls of the blood-vessels. The last-named pathological conditions are
alone capable of giving rise to chronic oedema of the larynx, which is
by no means so fatal, but still dangerous.
In glottic oedema the dyspnoea is both very great and very sudden.
First, it is inspiratory only, but soon becomes both inspiratory and
expiratory. The swelling is felt distinctly by the examining finger;
the laryngoscope is neither required nor advisable.