the opening in the windpipe remains long open, and becomes fistulous,
the larynx contracts, and the voice is in a great measure lost, the
patient breathes almost entirely by the unnatural opening, and all the
respiratory functions are conducted imperfectly. But even this state
of parts may admit of remedy, as is exemplified by the following case:
Elizabeth Oswald, aged twenty-seven, attempted suicide in 1826, and
wounded the larynx through the crico-thyroid ligament. She was under
treatment for several months; but was at length abandoned with loss of
voice, breathing entirely through a silver tube placed in the original
wound. On her applying to me, I found the larynx had contracted; an
exceedingly minute aperture, not capable of admitting a common dressing
probe, extended from the wound towards the glottis, constituting
all that remained of the upper part of the natural air-passage at
this point. Small bougies were introduced from the wound into this
diminutive canal; and by gradually increasing their size, the passage
was brought to its natural diameter in less than three months. Part of
the trachea below the wound had also contracted considerably, and was
dilated by similar means.
A long œsophagus tube was introduced by the wound into the mouth, there
laid hold of and drawn upwards, and then pushed down into the trachea,
so that it extended from the mouth to some inches below the wound of
the trachea. Its introduction was followed by a severe fit of coughing,
which lasted about half an hour. The tube, nine inches long, and equal
in diameter to the largest œsophagus tube, was retained in the windpipe
for fifteen days, during which it caused great salivation; the teeth
loosened, and the strength was extremely reduced.
The callous edges of the wound were removed by incision, and the
opening closed by suture. The tube was removed on the tenth day
thereafter, and the patient breathed well. Within a few hours, however,
respiration became difficult, and tracheotomy (below the isthmus of the
thyroid) was performed. A silver tube was introduced into this recent
longitudinal opening, and retained for five days, when it was replaced
by a smaller one. After twenty days, this tube was also removed, and
in a short time afterwards the wound closed completely. The patient
continued to breathe with ease through the larynx, and slowly recovered
her voice. When agitated, or after sudden and violent exertion, her
inspirations are a little longer than natural, but in other respects
the cure is complete. She was in very good health some years after the
restoration of the air-tube.
_Laryngitis, cynanche trachealis_, most frequently occurs in children,
and in them it is termed _croup_; but it also, though rarely, attacks
adults. The voice is brazen, hoarse, and croaking; the cough is
barking, and the countenance suffused. Inspiration is long, painful,
effected with much difficulty, and attended with a wheezing or rattling
noise. Expiration, on the contrary, is easy.
Difficult inspiration is a symptom common to all affections of the
larynx, and admits of ready explanation. The membrane lining the
glottis is thickened, and covered also by a viscid mucus; the passage
is thus much contracted; the muscles, by the action of which the rima
is opened, participate in the inflammatory action, and are thereby
incapacitated for the full performance of their functions. While
inspiration is thus difficult, expiration is more easy, all the
powerful muscles of the chest combining to empty the lungs of the
little air which they receive.
In croup, there is confusion and pain of the head, the lips are of a
livid hue, and the veins of the neck are much distended. Respiration
is extremely laborious, the chest and nostrils heave, and all the
auxiliary muscles of respiration are called into play. Sleep is broken
and unrefreshing; the patient starts, much alarmed, from a feeling
of impending suffocation, and catches at the nearest object. The
circulation is accelerated, and becomes weak and irregular as the
disease advances.
A common cause of croup is exposure to cold and damp; but the
frequency of its occurrence in children is attributable to dentition.
Dentition induces a long catalogue of infantile diseases, and is
intimately connected with most cases of croup. Children are besides of
a peculiarly irritable system; and in them disorder of the digestive
organs may, in many instances, be considered as at least a predisposing
cause, and in all cases it is a constant attendant on the disease. It
may also be occasioned by inflammatory action extending to the larynx
and trachea from a neighbouring surface; from the fauces, for instance.
In some instances inflammatory swelling has been produced by the direct
application of stimuli to the membrane; as by the patient inadvertently
swallowing boiling water, and a portion of the hot fluid, or rather
of the steam, being drawn into the windpipe. It is supposed that
certain slight degrees of this affection are to be ascribed to spasm;
in nervous and hysterical females, paroxysms of slight difficulty in
breathing are not of unfrequent occurrence, and in them it may be
ascribed, with much probability, to a spasmodic action. The expiration
may be then performed with difficulty, and occasionally there is almost
complete aphonia. In children, dyspnœa, apparently dependent on spasm,
is produced by some affection of the base of the brain.
The most desirable termination of the disease is of course
resolution—the cough, pain, and uneasiness subsiding, and the
constitution gradually attaining its former state of composure. Too
frequently, however, the inflammatory action proceeds unabated, and
terminates in effusion of lymph, which is generally of great extent,
adhering to the surface of the mucous lining, and forming what is
termed a false or adventitious tubular membrane. On the occurrence
of lymphatic formation, dyspnœa is much aggravated; and the second
stage of the disease is then said to have commenced. Occasionally the
patient sinks before effusion has taken place. The extent to which the
pseudo-membranous deposit occurs is extremely various; in some cases
it is confined to the larynx, or to the upper part of it; in others
it lines the whole of the windpipe, and often is prolonged, either in
flakes or tubes, into the ramifications of the bronchi. In general,
it is not at every point adherent to the mucous membrane, but more or
less detached, particularly at its inferior extremity, by a quantity
of vitiated mucus which intervenes between it and the mucous surface,
and is intimately adherent to the latter. The mucous membrane is also
slightly elevated by effusion into the subjacent cellular tissue.
By the formation of false membrane, the symptoms may be so much
increased as to cause speedy dissolution; but in many cases the
patient’s strength is not altogether exhausted, and the extraneous
substance by its irritation causes frequent and violent attempts
to expectorate, by which the lymph is not unfrequently expelled
either entire or in irregular portions; the relief thereby afforded,
though considerable, is in general temporary, for lymph is speedily
redeposited, or there is a profuse muco-purulent expectoration, and
the patient succumbs. It has been already stated that a portion of the
false membrane is usually detached from the lining membrane of the
canal, and from this the existence of the membrane is in general easily
recognised; for on its being moved by the passage of air in the canal,
a peculiar sound is frequently audible, and has been compared to that
made by the movement of the valve or clapper of a pump. When perceived
during inspiration, it indicates that the membrane is detached at
its superior extremity; when in expiration, that the separation has
occurred inferiorly. A fatal termination may suddenly take place, in
consequence of the detached extremity being so displaced by the passage
of the air as to form a complete valve, obstructing respiration, and
causing death by suffocation.
When the inflammation extends into the bronchi and substance of the
lungs, laborious breathing and the mucous rattle occur. The bronchi are
obstructed by vitiated mucus, or by lymph, and serum is effused at the
base of the brain; and from either or both of these circumstances the
patient soon perishes. In children the gums should be looked to, and if
swollen or tender, they must be freely scarified; this always affords
relief, and often forms the most important part of the treatment. The
bowels must be completely freed from the fetid dark-coloured matter
which they contain; and if this be effected at an early period, it
will generally be sufficient to arrest the progress of the disease.
Calomel is the medicine usually preferred, not only from its excellent
qualities as correcting and purging out the vitiated secretions,
but also on account of its supposed effect of preventing lymphatic
effusion. To the procuring of copious evacuations from the stomach and
bowels, the attention of the practitioner ought to be chiefly directed
at the commencement. With the same view, emetics are of much service.
The warm bath will be of use in promoting the cutaneous discharge,
and assisting to allay irritation. When the inflammatory symptoms are
violent, bleeding, both local and general, is indispensable, and must
be had recourse to early; for during the commencement only of the
disease can it be of service. The first, or acute, inflammatory stage
is of but short continuance, speedily terminating in effusion; and
when this has occurred, the symptoms all denote debility of the system,
and will be irreparably aggravated by depletion. The most effectual
mode of abstracting blood, is by opening the external jugular vein,
and this may be followed by the application of leeches to the forepart
of the neck; in the second stage of the disease, their place is to be
supplied by blisters, and other counter-irritants. Much benefit will
be derived from the continued use of nauseating doses of the tartrite
of antimony; in the first stage the vascular action will be thereby
subdued, and in the second the medicine acts as a powerful expectorant,
determines to the surface, and promotes the evacuations from the
bowels. Often, however, the disease defies all sanative measures, and
advances unsubdued to a fatal termination.
Tracheotomy has been both proposed and performed in this disease.
Recourse to it is not warrantable till the later period of the
affection, and then it will be found unavailing. If performed early,
there is found no obstruction to respiration that can be removed;
it can therefore be of no service, and is not required. If it be
undertaken at a more advanced period, lymph will most probably be found
to extend below the incision; the bronchial tubes and the substance of
the lungs are then the principal seat of the disease, and consequently
the operation is futile, at least in children. When first I entered on
practice I was several times prevailed on to perform tracheotomy on
children labouring under croup; the results were unsuccessful, and from
my own experience I cannot recommend the practice.
The fauces and larynx of children are occasionally injured, as
stated above, by the attempt to swallow by mistake boiling water,
and inhaling the steam. The alarming symptoms follow in a very few
hours, in consequence of the formation of numerous minute vesicles,
with swelling, from effusion of serum into the submucous tissue.
Great pain is generally experienced at the moment, but after crying
violently the child may fall asleep and awaken croupy, and with
threatened suffocation. By this time inflammatory action has been
fairly established, the submucous effusion has begun to take place,
and it is this that gives rise to the danger. The excited action is to
be combated by leeching and exhibition of calomel in small doses, with
or without opium frequently repeated, so as to arrest the lymphatic
effusion, which is apt to supervene. When these means fail, tracheotomy
must be resorted to without delay. The fauces and upper part of the
larynx are only involved at first; this practice is sound, and good
success may be expected from the operation. The breathing has been
suddenly suspended in children by the attempt to swallow acrid fluids,
such as alkaline solutions, or concentrated acids.
Cynanche laryngea, in adults, is of comparatively rare occurrence; at
least that kind of inflammation of the windpipe, which in children
is so rapid in its progress, and so prone to terminate in effusion
of lymph, is not often met with in persons of an advanced age.
Inflammatory affections of the larynx and trachea are, however, by no
means unfrequent in adults; but are of a very different character, as
to symptoms, progress, and termination, from that affection which is
strictly denominated croup. Pain is felt in the region of the windpipe,
and is aggravated by pressure on the forepart of the neck, by speaking,
and by deglutition; expectoration is increased, and ultimately
assumes a muco-purulent character. The voice is altered in tone and
in strength, and occasionally there is complete aphonia. Frequently
these symptoms, after having continued for a short time, gradually
subside; if not, the mucous membrane, particularly in the upper part
of the larynx, becomes thickened and considerably softened in texture,
with effusion of serous fluid in the subjacent cellular tissue, and
apparently in the substance of the membrane itself. In consequence
of such effusion, the difficulty of breathing is much increased.
Occasionally lymph is effused on the surface of the membrane; but this
is seldom met with, and when it does take place, is generally confined
to the upper part of the larynx. The larynx and trachea of an old lady
of seventy years is here shown, with very extensive false membranes
blocking up the bronchi; a large portion besides was coughed up. The
specimen, a rare one, is in my collection.
[Illustration]
The effusion of serum is often abundant, causing protrusion of the
mucous membrane, and narrowing of the canal; and when it is limited
to the upper part of the larynx, as frequently happens, the disease
is termed _Œdema Glottidis_. In this affection, the majority of
the symptoms, which have been already enumerated as attendant on
laryngitis, are all present, and in an aggravated form. Inspiration
is extremely difficult and sibilant, and occasionally the patient
experiences a sensation, as if a foreign body were lodged in the
passage, and had changed its position on the muscles of the part being
put in motion. The symptoms of œdema come on gradually in some cases,
in others with alarming rapidity. They often follow ulcerations of the
soft palate, and of the root of the tongue, as shown in treating of
diseases of that organ, occurring on the patient being exposed to cold
or moisture, or supervening rapidly when discharge from the ulcerations
is by any accident suddenly suppressed. The difficult breathing, with
cough and violent attempts at expectoration, takes place in paroxysms,
and often to so alarming a degree as to threaten immediate suffocation,
especially during the night. The patient, if he has fallen asleep,
often starts up suddenly, and catches at the nearest object, having
dreamed probably of drowning or strangulation. Deglutition is seriously
impeded, the strength is exhausted, the body is emaciated, the features
become contracted, and evince great anxiety. As already stated, the
serous effusion is chiefly situated in the upper part of the larynx,
particularly on the lips of the glottis, and on the inferior surface of
the epiglottis; and on introducing the finger, a soft swelling can be
felt beneath this cartilage. Perhaps the following sketch exhibits the
most complete instance of œdematous swelling of the rima glottidis to
be found in collections of morbid anatomy. The patient was brought to
the Royal Infirmary labouring under all the symptoms of the disease in
a very aggravated form. Tracheotomy was performed without delay, and
with instant relief. The patient fell into a quiet and profound sleep,
which lasted for six or seven hours. He started up suddenly and fell
down dead; probably the end of the tube had become obstructed by mucus.
It is scarcely to be supposed that the patient could have breathed at
all with such a state of parts at the top of the air-tube, as here
represented. Could any of the swelling have come on in the interval
betwixt the performance of the operation and his sudden death? In some
instances, the disease rapidly proceeds to a fatal termination, the
glottis being speedily and entirely shut by the swelling; in others,
the patient lingers for weeks, or even months.
[Illustration]
Depletion, local and general, especially the former, if employed on
the first appearance of the inflammatory symptoms, will often arrest
their progress; but if practised at a more advanced period, it can
be productive of no benefit, and if any advantage does follow, it
is merely temporary. Sometimes considerable benefit will be derived
from the use of blisters, or from the unguentum tartritis antimonii
being rubbed on the sides of the neck and over the larynx, so as to
produce an eruption of numerous pustules. When all hopes of procuring
resolution have passed, and when the urgent symptoms occasionally
threatening suffocation supervene, tracheotomy should be performed
without delay; and it ought to be borne in mind, that the more early
this operation is resorted to, the greater is the chance of success.
It has been repeatedly stated, that the disease is confined to the
larynx, and, in most instances, to the upper part of it; so that,
by making an opening in the windpipe below the thyroid gland, the
disease is situated above the incision, the patient breathes through
a canal which is in its healthy state, the affected parts are set at
rest, and from their remaining comparatively motionless the disease
often subsides spontaneously; if not, the various applications to the
parts can be employed much more successfully than before; for when
the parts remain subject to constant irritation from the movements
necessary for respiration and nutrition, all medicines and all topical
applications are generally productive of little or no benefit. But if
the incision be made into the crico-thyroid membrane, we shall, in
most instances, cut into the very middle of the disease; at any rate,
the affected parts can be at no great distance from the incision,
and the irritation of the tube will be a sufficient cause to excite
inflammatory action in parts contiguous to the original disease, and
already disposed to assume a similar action; thus the disease may be
extended. I have performed tracheotomy on a very considerable number of
patients afflicted with œdema glottidis, and I may say, with almost
uniform success. The disease was speedily subdued, and in most of them
there was no great difficulty in closing the artificial aperture, and
restoring natural respiration. The relief afforded by the operation is
almost instantaneous; the performance of it, if skilful, is attended
with no danger; and want of success will generally be found to proceed
from its having been too long delayed.
In consequence of laryngitis, or of long-continued irritation in the
neighbourhood, the mucous membrane becomes indurated, and subsequently
ulcerates; or ulceration may extend from the fauces. In some cases, the
ulcers of the larynx are few, and of slight extent; in others, they are
more numerous, and of considerable width and depth; and in some there
is extensive and uninterrupted destruction of the surface, surrounded
by thickened and elevated mucous membrane. This disease is termed
_Phthisis Laryngea_. It is characterised by constant tickling cough
with expectoration of purulent matter; by pain in the region of the
larynx increased on pressure; by great prostration of strength, with
general sinking of the vital powers, and frequently by hectic fever.
From extension of the ulceration, the vocal chords, the ventricles
of the larynx, and the mucous folds forming the rima glottidis,
are more or less injured, and frequently altogether obliterated;
partial or complete aphonia is the consequence. In phthisis laryngea,
especially when advanced, swelling from serous effusion, to a greater
or less degree, almost certainly supervenes, the œdema is found in
the upper surface of the epiglottis, beneath the mucous membrane,
upper and forepart of the pharynx, and occasionally also in the
lips of the glottis,—an effect of the contiguous ulceration,—in the
same way as œdema glottidis supervenes on ulceration of the lining
membrane of fauces and pharynx; the usual train of symptoms denoting
phthisis laryngea may thus be interrupted by those of œdema of the
glottis becoming (each paroxysm) more and more urgent, terminating in
suffocation or relieved by tracheotomy.
From the reasons which have been already stated, inspiration is
performed with difficulty, and accompanied with a wheezing and rattling
sound, resembling the passage of air through a narrow aperture lined
with viscid fluid. Deglutition is difficult; and, from the inactive
state of the muscles which naturally close the glottis during
swallowing, and from the greater or less destruction of the epiglottis,
a portion of the fluid taken by the mouth escapes into the windpipe,
produces violent coughing, and is ejected by the mouth or nostrils.
As the disease advances, the lungs become affected, the patient is
incapacitated for ordinary exertion by the dyspnœa which ensues, he
grows weak and languid, and seems, in fact, to labour under phthisis
pulmonalis. Not unfrequently the two diseases are combined; but, in the
majority of cases, the affection of the lungs supervenes on that of
the larynx. Ulcers with tubercular bases are very frequent about the
ventricles of the larynx in subjects dead of pulmonary phthisis. The
chordæ vocales are thus often exposed. The affection of the lungs is
perhaps attributable to frequent and harassing cough, occasioned by the
state of the larynx and ejection of profuse vitiated secretions.
When the ulceration extends deeply, portions of the cartilages
sometimes become diseased; the soft parts surrounding them are
destroyed, they become necrosed, and are expectorated along with
a quantity of highly fetid purulent fluid. In some instances, the
expectorated portions are osseous, of loose texture, irregular margins,
and dark colour, exhaling an odour intolerably fetid. It sometimes
happens that the ulcerations proceed still more deeply, perforating
the parietes of the canal, and establishing a communication betwixt
the windpipe and gullet; or, if the perforation is anteriorly, the
communication is with the cellular tissue on the forepart of the neck,
abscess forms which may attain a large size and be productive of much
inconvenience and danger.
The disease has been frequently produced by mercury, when the abuse of
that mineral was common; its abuse is still far from uncommon.
The symptoms may be mitigated by counter-irritation. The parts
covering the trachea should not be subjected to counter-irritation;
in consequence of repeated blistering, the application of irritating
ointments, effusion and thickening of the cellular tissue is
caused, and this may prove a serious obstacle in the performance of
tracheotomy, should that afterwards, as is too likely, be required.
Setons may be inserted on the sides of the neck, and applications made
over the box of the larynx. But tracheotomy affords the only hope of
permanent relief; and if performed at an early period, if the lungs are
not the seat of tubercular disease, as they too frequently are, there
is every reason to expect that it will prove successful. It is followed
by the beneficial results mentioned when speaking of the preceding
disease, and the nitrate of silver can be applied to the more external
ulcers, along with the internal use of sarsaparilla, &c. Ulcers, which
there is every reason to suppose had been both extensive and deep,
have healed even after the discharge of portions of dead, sometimes
ossified, cartilage. The symptoms abate; the patient recovers, though
in general with imperfect voice, as might be expected.