continued. If it consisted in the administration of hydrargyrum, either
internally or externally, it must be continued. If its effect was not
sufficient to clear the larynx and to render the operation unnecessary,
it will or may be sufficient to complete its effect in the next day or
two, to prevent the process from descending or the membranes becoming
too many or too thick. No changes ought to be made in the treatment
unless there be changes in the symptoms. Not infrequently the first
symptoms of broncho-pneumonia come on within a few hours after the
operation, recognizable by frequent pulse, respiration frequent beyond
proportion, and physical symptoms. The stomach is not very reliable.
Quinine answers best hypodermically. From 6 to 10 grains may be
injected at once. The preparation which has served me best in the last
few years is a solution of the carbamid in five parts of water. If an
additional remedy is required, from 20 to 30 grains of sodium
salicylate may be given in the course of three or four hours, in hourly
doses, to reduce the temperature. Tincture of digitalis will prove
advisable at the same time when the heart appears to require it.
Strychniæ sulphas will act as a powerful nervine; 1/25 grain may be
given to a child two years of age every two hours, until four or five
doses shall have been taken. The rest of the treatment of the
complications depends on their nature and character. It is not the name
of the disease which has to be treated, here as in every case, but the
individual patient.
In regard to stimulants I have but little to say. I use alcohol in the
most pleasant shape, preferring brandy or whiskey. I use a great deal
of camphor, 10 to 40 grains daily, or in cases of urgency Siberian
musk, from 2 to 5 grains, every half hour or hour, until from 15 to 20
grains have been taken in cases of collapse or great prostration.
{109}
DISEASES OF THE LARYNX.
BY LOUIS ELSBERG, M.D.
Inflammation, Erosion, and Ulceration of the Epiglottis.
Of the diseases of particular portions of the larynx, those of the
epiglottis deserve especial attention in a work designed for general
practitioners, on account of the comparative ease of recognizing and
treating them if understood, and the promptness their management
requires. They occur more frequently than is generally supposed, their
symptoms are often erroneously ascribed to other affections, and they
may lead to extensive disease in the respiratory apparatus, sometimes
of a very serious character. Adjacent portions of the root of the
tongue and pharynx or of the larynx are apt to be coaffected. In
diseases which commence in the pharynx, usually the lingual surface,
and in such as spread upward from the larynx only the laryngeal
surface, of the epiglottis is involved mainly or exclusively.
Before describing the affections of the epiglottis a few words must be
said of the manner of using the tongue-spatula. Physicians almost
without an exception press the tongue from above downward and from
before backward; but in order to bring the epiglottis into view in the
majority of instances the proper method is just the opposite of
this--viz. from below upward and from behind forward. Place the spatula
far back, lift up the base of the tongue, and draw it forward. The
usual manner of depressing the tongue--no matter how good or bad an
instrument may be used, and an ordinary spoon-handle serves the purpose
better than most of the so-called tongue-depressors--pulls upon and
irritates the pharyngo-glossal fold, and often hides the epiglottis
instead of bringing it into view, besides producing intolerance and
intractability. The blade of the tongue-spatula should be long (at
least four, still better five, inches), slightly curved downward, not
more than from half an inch to one inch wide, and joined to the handle
at an obtuse angle.
1. Acute inflammation of the epiglottis is usually caused by taking
cold, exposure to draughts, wet, sudden changes of temperature, etc.
The symptoms are local pain and difficulty of swallowing; in severe
cases also some dyspnoea and dysphonia. Only occasionally there is a
hemming cough, and that a peculiar one, induced (usually voluntarily)
by a feeling of a foreign body at the root of the tongue. The diagnosis
is made by means of the tongue-spatula and laryngeal mirror, the
epiglottis being seen to be inflamed and swollen. When the lower
portion, the so-called cushion of the epiglottis, is affected, the
mirror is required for diagnosis. In this case suppuration is apt to
occur. The prognosis is good with attention; neglected epiglottitis may
cause great discomfort, and even death. Treatment must be
antiphlogistic and supporting. For mild cases systemic and dietetic
regulation suffices, with externally either hot fomentations or cold
applications as the patient can best bear. Severer cases require in
addition leeches and ice to the part; and cases of threatened
suppuration, medicated and unmedicated steam inhalation, and, when
necessary, lancing of the abscess through the {110} mouth under
guidance of the mirror. After the acute inflammation has subsided,
local treatment may become necessary to hasten or produce complete
restoration, as will be noticed in Chronic Epiglottitis.
Inflammatory oedema of the epiglottis will be considered under the head
of Laryngeal Oedema.
Chronic inflammation of the epiglottis is usually the result of uncured
acute epiglottitis or of laryngitis. The main symptom is dysphagia. The
epiglottis is found swollen and more or less discolored. Not only
tongue-spatula and laryngeal mirror, but also the finger carefully
introduced into the mouth, may ensure the diagnosis, especially if the
upper portion be affected: then the thickened epiglottis is seen and
felt as a peculiar rounded tumor at the base of the tongue. Oedema is
distinguishable from chronic inflammation by both sight and touch. As
to prognosis, it must be observed that the process of restoration is
slow and that there is always danger of acute exacerbation. The
treatment consists in attention to the general health and habits and in
local applications. The latter are indispensable, and should be made by
means of an instrument (Elsberg's applicator or the like) carrying a
little wad of cotton or sponge. Some prefer a brush: to such individual
preference no objection need be made, but powders and sprays are not
advisable. The remedies to be applied should be in liquid form, and
belong pharmacologically to the class of alteratives. Iodine, iodoform,
and silver nitrate in solution are most useful. In subacute
inflammation (see above) potassium bromide and chlorate, respectively,
in saturated aqueous solution, may be applied once a day, or a
saturated solution of iodoform in sulphuric ether, or ten grains of
crystallized silver nitrate dissolved in an ounce of water, every other
day. In chronic epiglottitis the tincture or compound solution of
iodine, the ethereal solution of iodoform, and the watery solution of
silver nitrate, in degrees of concentration varying according to the
severity of the case and the individuality of the patient (the choice
of either of the three agents, the repetition of the same, or the
change from one to the other depending upon the effect produced),
should be accurately applied to the part affected by means of the
laryngeal mirror or the tongue-spatula.
2. The most frequent, and at the same time the most neglected, morbid
condition of the larynx is erosion of the free edge of the epiglottis.
Louis has called attention to the epiglottic erosions in connection
with tubercular phthisis: he found them present in about one-sixth of
the patients who died of that disease, and they are caused, in his
opinion, by the constant passage of pus over the part. Horace Green was
the first who pointed out that they are also frequently met with
independently of tubercular disease. According to him, "These
instances, for the most part, have been found occurring in those cases
in which a persistent, teasing cough, following chronic follicular
disease or common catarrhal inflammation, has obstinately resisted all
the ordinary measures for its arrestment. On depressing the tongue in
such cases by means of the ordinary bent spatula or tongue-depressor,
so as to bring the epiglottis into view, this cartilage has been found
frequently inflamed, vascular, and its superior border marked at one or
more points by distinct erosions. In much the largest proportion of
cases these erosions make their first appearance on the left superior
edge of the epiglottis. Next in frequency they will be found occupying
its centre, and occasionally, but very rarely in comparison with the
two preceding locations, they have been observed upon its right border.
These erosions are not readily detected, at first, by the inattentive
observer, as they are quite small, are only slightly depressed, with a
pallid base, sometimes a little reddened, and with whitish, linear
edges. The surrounding mucous membrane is generally inflamed, its
delicate network of superficial vessels is red and injected, and the
epiglottis itself more or less thickened." Sometimes epiglottic
erosions exist without {111} much cough, and certainly a cough can
exist without erosions; but the two seem frequently to act
interchangeably as cause and effect; and certain it is that a cough,
from whatever cause, once firmly established, when such erosions have
supervened rarely if ever yields so long as the erosions continue, and
often stops when they are cured. According to my experience, the left
and right sides of the upper border are affected with about the same
frequency, and oftener than the centre. The erosions are catarrhal in
their nature, even in tubercular subjects; in non-specific cases they
degenerate exceedingly rarely into ulcers--_i.e._ they may exist for
years without involving any tissue below the epithelium unless the
patient is or becomes syphilitic or phthisical. They often produce
symptomatically, especially in the beginning, more hemming than cough.
The diagnosis is easy on thorough inspection of the epiglottis.
Prognosis is generally favorable, except in phthisical cases; in
others, although they sometimes prove exceedingly obstinate, they
usually yield with surprising promptness to topical treatment. In
specific cases, and even in chronic naso-laryngeal catarrh, they are
apt to recur, however. A cotton wad dipped in a strong solution (gr.
xxx-drachm j ad ounce j water) of either silver nitrate or gold
chloride must be brought accurately into contact with the eroded spots
once in twenty-four or forty-eight hours; ordinarily only a fortnight's
treatment is necessary, except for the frequently accompanying (or
underlying) catarrhal condition of a more or less large extent of the
upper respiratory mucous membrane. In very severe cases a few
applications at longer intervals of a still stronger solution (drachm
j-drachm ij), or even of the solid silver or gold preparation, may be
required.
3. Epiglottic ulcerations differ from erosions in the fact that the
latter are confined to the epithelium, while the former involve also
deeper structures. It has been asserted by some observers that an
erosion is always the first stage of an ulceration, and by others that
the one never passes into the other. I believe that both of these
extreme assertions are incorrect; but if it were possible to
distinguish, clinically or pathologically, every case of superficial
ulceration from erosion, I might incline to agree with the latter.
Histologically, epiglottic ulceration affects the mucous membrane,
glands, or cartilage. Most frequently it seems to originate in the
follicles. As Horace Green has long ago pointed out, "At first an
enlarged or pimple-like follicle appears on the border of the
epiglottis, surrounded by an inflamed and highly-injected portion of
mucous membrane. Soon the follicle softens, and degenerates into an
ulcer with irregular edges and an inflamed and reddened circumference.
In many instances these ulcers remain for some time superficial,
destroying only the mucous membrane; in others they penetrate deep into
the fibro-cartilage, and occasionally they result in the total
destruction of the epiglottis." Sometimes the ulcer seems to originate
in the superficial layer of the mucous membrane, the molecular death
proceeding from the surface downward; these are the cases which in the
beginning cannot be distinguished from erosions. Both these kinds of
ulceration of the epiglottis occur without, and with, grave
constitutional affections, but the cartilaginous tissue usually, though
not invariably, remains intact except in phthisis, syphilis, and
cancer. Lupus, lepra, and glanders also give rise to ulceration, and
sometimes to much accompanying thickening of the epiglottis. The seat
of the ulcers is, as a rule, on the upper border and laryngeal surface
of the epiglottis, only exceptionally on the lingual. Together with
ulcers on the laryngeal face those on the lingual face are found, but
not vice versâ. Ulcers of the epiglottis are usually small, but
numerous, worm-eaten in appearance, and frequently pass to other
laryngeal structures. Though occasionally resulting from tuberculosis,
syphilis, and other constitutional affections, they also occur as
primary disease due to catarrh and local injury, but may become the
antecedents, and in many instances the exciting cause, of other grave
maladies. Indeed, I quite agree {112} with Horace Green that they are
often "not only among the earliest manifestations of thoracic diseases,
but are themselves in many instances the true exciting cause of these
affections; and furthermore, this postulate once established, that we
have it in our power, by timely topical medication, to arrest,
positively, cases of disease which otherwise would, and in many
instances which do, terminate fatally."
The symptoms vary with the seat and extent of ulceration. Cough and the
sense of irritation in the throat are usually present. "In several
instances all the prominent rational signs, with some of the earlier
physical manifestations, of pulmonary disease have been observed to
follow long-continued ulceration of the epiglottis; all of which
symptoms have been seen to disappear after these lesions have been
healed." When the upper border is extensively affected, and still more
when either surface, especially the lower portion of the laryngeal
surface, be involved, there is difficulty of swallowing; the pain is
due often as much to surrounding inflammation as to the epiglottic
lesion. In some cases the voice also is affected.
The diagnosis of the existence of an ulcer is easily made when the
epiglottis can be seen not only with the spatula, but also with the
laryngeal mirror. Its origin and nature are, however, not always easily
recognized, and the patient's general condition and history, as well as
the appearance of the ulcer, must be taken into account. The diagnosis
of catarrhal epiglottic ulceration must be made only after other
underlying conditions, as phthisis, syphilis, malignant disease, lupus,
lepra, and glanders (see the articles on those subjects), have been
excluded. The prognosis is good, except in cases of phthisis, syphilis,
etc., or in which already a great deal of the cartilage has been
destroyed; and even in these cases appropriate treatment will often
give the patient much comfort. Appropriate constitutional treatment
must be instituted in all cases in which the constitution is affected.
Topical treatment consists in the application of alteratives,
astringents, stimulants, or sedatives, as the case may call for. Some
cases may require once or more times touching with solid silver
nitrate; watery solution of this remedy, varying in strength from gr. x
to drachm ij to the ounce; solution of gold chloride of similar
strength; of iron pernitrate and perchloride drachm ss-drachm j to the
ounce; of zinc chloride (gr. x-drachm ss to the ounce); a solution of
iodine in olive oil (gr. x-xxv ad ounce j with a few grains of
potassium iodide), or of iodoform in sulphuric ether (drachm i-drachm
ij ad ounce j); carbolic acid in glycerin (gr. v ad ounce j) or
Magendie's solution of morphine, or a mixture of morphine and syrup of
tolu (gr. 1/8-1/2 to a few drops),--have most frequently been
beneficial in my hands. In many cases in which the pain on swallowing
has been so great as to make deglutition almost impossible, I have
succeeded in temporarily anæsthetizing the parts before a meal by
applying, after cleansing them, a watery solution of cocaine
hydrochloride (gr. xx ad ounce j). If, in spite of all, the difficulty
of swallowing threatens the patient with starvation, feeding with the
oesophageal tube must be resorted to.
Laryngeal Oedema.
DEFINITION.--Infiltration of a fluid or semi-fluid into the submucous
connective tissue of the larynx.
SYNONYMS.--Oedema of the glottis (often incorrectly so called, as will
presently be seen), Oedematous laryngitis, Phlegmonous laryngitis,
Submucous laryngitis, Dropsy of the larynx, Angina laryngis infiltrata,
Angina laryngea oedematosa, Angine infiltro-laryngée, etc.
CLASSIFICATION.--Cases of laryngeal oedema are classified as to their
occurrence into acute and chronic, corresponding generally to
inflammatory {113} and non-inflammatory; as to the nature of the
infiltration, into serous, purulent, sanguineous, sero-purulent,
sero-sanguineous, etc.; as to the extent of the infiltration, into
diffuse and circumscribed (the latter often leading to
abscess-formation, and then called laryngeal abscess rather than
laryngeal oedema, differing, however, from perichondric abscess); and
as to the seat, into epiglottic, supraglottic, infraglottic, and
glottic. When epiglottic, it implicates, besides the upper border,
often the glossal, hardly ever the laryngeal, surface; in supraglottic,
the ary-epiglottic folds, arytenoid region, ventricular folds, or
ventricles are involved; in glottic, the interfibrillar connective
tissue of the thyro-arytenoid muscle is infiltrated, very
exceptionally, if ever, the submucous tissue of the vocal bands
themselves;[1] and in infraglottic, the submucous connective tissue
down to the first ring of the trachea. Glottic oedema occurs extremely
seldom, but the designation oedema glottidis is often used, no matter
what portion of the larynx is affected. Laryngeal oedema usually
affects both sides; occasionally one side more than the other, still
more rarely one side exclusively.
[Footnote 1: Such a case has been positively reported, or I would deny
the possibility of its occurrence.]
ETIOLOGY.--Laryngeal oedema is seldom, if ever, idiopathic. Usually it
accompanies or follows either some disease or injury of the larynx[2]
or neighboring structures or a constitutional affection. Acute oedema
may be caused by catarrhal or diphtherial pharyngo-laryngitis;
irritation from scalds, burns, caustics, foreign bodies (especially
sharp ones), or other trauma; laryngeal ulcers, especially syphilitic
and tuberculous; laryngeal perichondritis, tonsillitis, parotitis, or
inflammation of cervical tissues on the one hand, and pyæmia and
septicæmia, endocarditis, erysipelas, small-pox, scarlatina, measles,
typhoid fever, typhus, or acute Bright's disease of the kidneys on the
other. "It has ensued upon deglutition of very cold water and upon
prolonged vocal efforts" (Cohen). Perichondritis and chondritis,
tuberculous, syphilitic, carcinomatous, or typhoid ulcerations of the
larynx, especially when deep-seated or extensive, are sometimes
attended with acute, but more often with chronic, oedema.
Non-inflammatory or chronic laryngeal oedema is sometimes part and
parcel of general dropsy in consequence of heart, kidney, or lung
disease: Horace Green has reported a case occurring in a man who had
hydræmia from great losses of blood from hemorrhoidal tumors; and it is
sometimes due to some impediment to free venous circulation in the
laryngeal tissues, from paralysis of the walls of the vessels,
mechanical obstruction, tumors of the thyroid body or in the
mediastinum, etc. compressing the jugular veins, compression of the
superior vena cava, etc.
[Footnote 2: According to Sestier, who has written (in 1852) the most
elaborate treatise extant on the subject, four-fifths of all cases
occur in other laryngeal affections.]
Cohen mentions cases to show that acute iodism and mercurialization may
cause laryngeal oedema. He also says that although occurring in
individuals in good general health, it is more apt to take place in
those of impaired constitution or recently convalescent from acute
diseases; and in some instances there would appear to be some peculiar
predisposition toward its occurrence the nature of which is not
understood, for examples are on record of more than one attack in the
same individual. Under all these circumstances the immediate exciting
cause, when apparent, seems to be exposure to cold and moisture.
Laryngeal oedema is not a disease of childhood; exceptional under five
years, it is very rare until after ten. Most cases occur between
eighteen and thirty-five. After the sixtieth year it is again rare; and
it occurs more rarely in women than in men.
SYMPTOMATOLOGY.--The symptoms of laryngeal oedema vary with the seat
and degree--that is, according to the class to which the case belongs.
{114} Increasing interference with breathing is the most prominent
symptom. Interference with swallowing, though not always present, is
the next prominent. Sometimes the occurrence is so sudden, insidious,
or overwhelming that the patient dies before aid can be procured. Such
was Boerhaave's case of a man who during dinner suddenly spoke with a
changed voice, which his companions took as a joke, and in a few
minutes fell dead; Rühle's case of a servant-girl, who, a trifle
hoarse, went out lightly clad on a cold morning and suffocated while
going up stairs on her return; and the case of a patient of mine with
subacute catarrhal laryngitis, who rode out behind a fast horse on a
cold afternoon, and died, within ten minutes after entering his own
house, from serous infiltration of the upper aperture of the larynx. A
number of similar cases have been reported, but usually the disease
runs its course less rapidly. When the ary-epiglottic folds are the
seat of the oedema, the patient experiences either suddenly or
gradually a difficulty of inspiration, while the expiration may be at
first unimpaired, and with increasing sensation of constriction of the
throat or of the presence of a foreign body, hoarseness, and stridor,
but often without dysphagia, the most threatening paroxysms of
suffocation supervene. When the epiglottis is the main seat, while
respiration is also more or less impeded, swallowing is rendered
painful, difficult, and sometimes impossible without choking and
regurgitation through the nares, and the voice roughened and sometimes
extinguished. When the arytenoid region is also affected, respiration
and deglutition are still worse, aphonia is complete, the sense of
irritation at the upper aperture of the larynx often amounting to pain,
and the patient with great effort expectorates slightly. In oedema of
the ventricular folds there is early aphonia and gradually increasing
dyspnoea, which affects both expiration and inspiration, sometimes the
former even worse than the latter. This makes the sufferer's efforts to
breathe most frightful to witness, the feeble inspiration being
accompanied by a slow whistling sound, and the expiration, despite most
violent exertion, almost entirely shut off. Glottic oedema is, as
before said, exceptional; when it occurs to any great extent apnoea
ends the case unless operative relief is immediately afforded. In
infraglottic oedema, which is exceedingly rare and chronic in nature,
there is steadily increasing dyspnoea, wheezing, cough, and abundant
expectoration.
In acute cases of supraglottic and epiglottic oedema the suffocative
paroxysms may last several minutes, and recur at irregular intervals of
a few hours with increased intensity. If not relieved, patients become
wildly excited or terror-stricken; they may throw the chest forward,
open the mouth, grasp the throat outside or thrust their hands into it,
and make convulsive movements in their struggles for breath; with
protruding eyes and flushed face they become cyanotic, the extremities
cold, the pulse small and frequent; coma supervenes, and death. In
chronic cases the symptoms are not so violent, though they may steadily
progress to impending strangulation, but for a long time the dysphagia
gives the patient much more distress than the dyspnoea.