Opening

A SYSTEM OF PRACTICAL MEDICINE.

BY AMERICAN AUTHORS.

EDITED BY WILLIAM PEPPER, M.D., LL.D.,

PROVOST AND PROFESSOR OF THE THEORY AND PRACTICE OF MEDICINE AND OF CLINICAL MEDICINE IN THE UNIVERSITY OF PENNSYLVANIA.

ASSISTED BY LOUIS STARR, M.D.,

CLINICAL PROFESSOR OF DISEASES OF CHILDREN IN THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA.

VOLUME III.

DISEASES OF THE RESPIRATORY, CIRCULATORY, AND HÆMATOPOIETIC SYSTEMS.

PHILADELPHIA: LEA BROTHERS & CO. 1885.

Entered according to Act of Congress, in the year 1885, by

LEA BROTHERS & CO.,

WESTCOTT & THOMSON, Stereotypers and Electrotypers, Philada.

WILLIAM J. DORNAN, Printer, Philada.

CONTENTS OF VOLUME III.

DISEASES OF THE RESPIRATORY SYSTEM. PAGE LARYNGOSCOPY AND RHINOSCOPY. By CARL SEILER, M.D. . . . . . . . . 19

DISEASES OF THE NASAL PASSAGES. By HARRISON ALLEN, M.D. . . . . . 41

NEUROSES OF THE LARYNX. By HOSMER A. JOHNSON, M.D., LL.D. . . . . 59

ACUTE CATARRHAL LARYNGITIS (FALSE OR SPASMODIC CROUP). By ABRAHAM JACOBI, M.D. . . . . . . . . . . . . . . . . . . . . 92

PSEUDO-MEMBRANOUS LARYNGITIS. By ABRAHAM JACOBI, M.D. . . . . . . 100

DISEASES OF THE LARYNX. By LOUIS ELSBERG, A.M., M.D. . . . . . . 109

DISEASES OF THE TRACHEA. By LOUIS ELSBERG, A.M., M.D. . . . . . . 133

TRACHEOTOMY. By GEORGE M. LEFFERTS, A.M., M.D. . . . . . . . . . 145

DISEASES OF THE BRONCHI. By N. S. DAVIS, M.D., LL.D. . . . . . . 164

BRONCHIAL ASTHMA. By W. H. GEDDINGS, M.D. . . . . . . . . . . . . 184

HAY ASTHMA. By W. H. GEDDINGS, M.D. . . . . . . . . . . . . . . . 210

DILATATION OF THE BRONCHIAL TUBES, CIRCUMSCRIBED AND DIFFUSED. By SAMUEL C. CHEW, M.D. . . . . . . . . . . . . . . . . . . . . 227

EMPHYSEMA. By SAMUEL C. CHEW, M.D. . . . . . . . . . . . . . . . 232

COLLAPSE OF THE LUNG (ATELECTASIS). By SAMUEL C. CHEW, M.D. . . . 250

CONGESTION AND OEDEMA OF THE LUNGS (HYPOSTATIC PNEUMONIA). By SAMUEL C. CHEW, M.D. . . . . . . . . . . . . . . . . . . . . 258

HÆMOPTYSIS. By WILLIAM CARSON, M.D. . . . . . . . . . . . . . . . 266

PULMONARY APOPLEXY. By WILLIAM CARSON, M.D. . . . . . . . . . . . 293

ABSCESS OF THE LUNG. By WILLIAM CARSON, M.D. . . . . . . . . . . 296

GANGRENE OF THE LUNG. By WILLIAM CARSON, M.D. . . . . . . . . . . 301

CROUPOUS PNEUMONIA. By ALFRED L. LOOMIS, M.D., LL.D. . . . . . . 307

CATARRHAL PNEUMONIA. By WILLIAM PEPPER, M.D., LL.D. . . . . . . . 353

PULMONARY EMBOLISM. By BEVERLEY ROBINSON, M.D. . . . . . . . . . 373

PULMONARY PHTHISIS (FIBROID PHTHISIS OR CHRONIC INTERSTITIAL PNEUMONIA). By AUSTIN FLINT, M.D. . . . . . . . . . . . . . . . 391

SYPHILITIC DISEASE OF THE LUNG. By EDWARD T. BRUEN, M.D. . . . . 447

PNEUMONOKONIOSIS. By EDWARD T. BRUEN, M.D. . . . . . . . . . . . 454

CANCER OF THE LUNGS. By EDWARD T. BRUEN, M.D. . . . . . . . . . . 460

PULMONARY HYDATIDS. By EDWARD T. BRUEN, M.D. . . . . . . . . . . 466

ACUTE MILIARY TUBERCULOSIS. By JOHN S. LYNCH, M.D. . . . . . . . 472

DISEASES OF THE PLEURA. By FRANK DONALDSON, M.D. . . . . . . . . 483

DISEASES OF THE CIRCULATORY SYSTEM.

DISEASES OF THE SUBSTANCE OF THE HEART. By WILLIAM OSLER, M.D. . 601

ENDOCARDITIS AND CARDIAC VALVULAR DISEASES. By ALFRED L. LOOMIS, M.D., LL.D. . . . . . . . . . . . . . . . 639

CYANOSIS AND CONGENITAL ANOMALIES OF THE HEART AND GREAT VESSELS. By MORRIS LONGSTRETH, M.D. . . . . . . . . . . . . . . . . . . 687

CARDIAC THROMBOSIS. By BEVERLEY ROBINSON, M.D. . . . . . . . . . 718

NEUROSES OF THE HEART. By AUSTIN FLINT, M.D. . . . . . . . . . . 747

DISEASES OF THE PERICARDIUM. By J. M. DACOSTA, M.D., LL.D. . . . 769

THE OPERATIVE TREATMENT OF PERICARDIAL EFFUSIONS. By JOHN B. ROBERTS, A.M., M.D. . . . . . . . . . . . . . . . . 794

DISEASES OF THE AORTA. By G. M. GARLAND, M.D. . . . . . . . . . . 800

DISEASES OF THE CORONARY, PULMONARY, SUPERIOR MESENTERIC, INFERIOR MESENTERIC, AND HEPATIC ARTERIES, AND OF THE COELIAC AXIS. By ELBRIDGE G. CUTLER, M.D. . . . . . . . . . . . . . . . 828

DISEASES OF THE VEINS. By ANDREW HEERMANCE SMITH, M.D. . . . . . 843

THE CAISSON DISEASE. By ANDREW HEERMANCE SMITH, M. D. . . . . . . 854

DISEASES OF THE MEDIASTINUM. By EDWARD T. BRUEN, M.D. . . . . . . 861

DISEASES OF THE BLOOD AND OF THE HÆMATOPOIETIC SYSTEM.

DISEASES OF THE BLOOD AND BLOOD-GLANDULAR SYSTEM. By WILLIAM OSLER, M.D. . . . . . . . . . . . . . . . . . . . . 882

DISEASES OF THE SPLEEN. By I. EDMONDSON ATKINSON, M.D. . . . . . 951

DISEASES OF THE THYROID GLAND. By D. HAYES AGNEW, M.D., LL.D. . . 974

SIMPLE LYMPHANGITIS. By SAMUEL C. BUSEY, M.D. . . . . . . . . . . 983

INDEX. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 993

CONTRIBUTORS TO VOLUME III.

AGNEW, D. HAYES, M.D., LL.D., Professor of Principles and Practice of Surgery in the University of Pennsylvania, Philadelphia.

ALLEN, HARRISON, M.D., Emeritus Professor of Physiology in the University of Pennsylvania, Philadelphia.

ATKINSON, I. EDMONDSON, M.D., Professor of Pathology and Clinical Medicine and Clinical Professor of Dermatology in the University of Maryland, Baltimore.

BRUEN, EDWARD T., M.D., Assistant Professor of Physical Diagnosis in the University of Pennsylvania; Physician to Philadelphia (Blockley) Hospital; Lecturer on Pathology in the Woman's Medical College, Philadelphia.

BUSEY, SAMUEL C., M.D., Attending Physician and Chairman of the Board of Hospital Administration of the Children's Hospital, Washington, D.C.

CARSON, WILLIAM, M.D., Physician to and Clinical Lecturer at the Cincinnati Hospital, Cincinnati.

CHEW, SAMUEL C., M.D., Professor of Materia Medica, Therapeutics, and Clinical Medicine in the University of Maryland, Baltimore.

CUTLER, ELBRIDGE G., M.D., Clinical Instructor in Auscultation in the Harvard Medical School; Physician to Out-Patients, Massachusetts General Hospital.

DACOSTA, J. M., M.D., LL.D., Professor of Theory and Practice of Medicine in the Jefferson Medical College, Philadelphia.

DAVIS, N. S., M.D., LL.D., Professor of Principles and Practice of Medicine in the Chicago Medical College, Chicago.

DONALDSON, FRANK, M.D., Clinical Professor of Diseases of the Throat and Chest in the University of Maryland, Baltimore.

ELSBERG, LOUIS, A.M., M.D., Late Professor of Laryngology and Rhinology in the New York Polyclinic and in Dartmouth Medical College; Physician to Charity Hospital, Blackwell's Island (Throat Wards), New York.

FLINT, AUSTIN, M.D., Professor of the Principles and Practice of Medicine and Clinical Medicine in the Bellevue Hospital Medical College, New York.

GARLAND, G. M., M.D., Formerly Professor of Thoracic Diseases in the University of Vermont, and Assistant in Clinical Medicine in Harvard Medical School.

GEDDINGS, W. H., M.D., Aiken, South Carolina, and Bethlehem, N.H.

JACOBI, ABRAHAM, M.D., Clinical Professor of Diseases of Children in the College of Physicians and Surgeons, New York, etc.

JOHNSON, HOSMER A., M.D., LL.D., Emeritus Professor of Practical Medicine in the Chicago Medical College, Chicago.

LEFFERTS, GEORGE M., A.M., M.D., Professor of Laryngoscopy and Diseases of the Throat in the College of Physicians and Surgeons, New York; Consulting Laryngoscopic Surgeon to St. Luke's Hospital, etc.

LONGSTRETH, MORRIS, M.D., Physician to the Pennsylvania Hospital, Philadelphia.

LOOMIS, ALFRED L., M.D., LL.D., Professor of Pathology and Practice of Medicine in the University of the City of New York.

LYNCH, JOHN S., M.D., Professor of Principles and Practice of Medicine in the College of Physicians and Surgeons, Baltimore.

OSLER, WILLIAM, M.D., Professor of Clinical Medicine in the University of Pennsylvania; formerly Professor of the Institutes of Medicine in McGill University, Montreal.

PEPPER, WILLIAM, M.D., LL.D., Professor of the Theory and Practice of Medicine and of Clinical Medicine in the University of Pennsylvania, Philadelphia.

ROBERTS, JOHN B., A.M., M.D., Professor of Applied Anatomy and Operative Surgery in the Philadelphia Polyclinic and College for Graduates in Medicine.

ROBINSON, BEVERLEY, M.D., Clinical Professor of Medicine in the Bellevue Hospital Medical College, New York.

SEILER, CARL, M.D., Instructor in Laryngoscopy in the University of Pennsylvania; Professor of Acoustics and Vocal Physiology at the National School of Oratory, Philadelphia.

SMITH, ANDREW HEERMANCE, M.D., Professor of Therapeutics and Clinical Medicine in the New York Post-Graduate Medical School; Physician to the Presbyterian Hospital, New York.

ILLUSTRATIONS.

FIGURE PAGE 1. LARYNGEAL MIRROR . . . . . . . . . . . . . . . . . . . . . . . 21

2. HEAD REFLECTOR . . . . . . . . . . . . . . . . . . . . . . . . 23

3. SEILER'S ELECTRIC ILLUMINATOR FOR THE LARYNGOSCOPE . . . . . . 24

4. POSITION OF HAND IN HOLDING THE LARYNGEAL MIRROR . . . . . . . 27

5. SECTION OF THE HEAD, SHOWING THE POSITION OF LARYNGEAL MIRROR IN THE PHARYNX . . . . . . . . . . . . . . . . . . . . . . . 27

6. ELSBERG'S SPONGE-HOLDER AND EPIGLOTTIS FORCEPS . . . . . . . . 29

7. LARYNGEAL IMAGE DURING RESPIRATION . . . . . . . . . . . . . . 31

8. LARYNGEAL IMAGE DURING PHONATION . . . . . . . . . . . . . . . 31

9. LARYNGOSCOPIC DIAGRAM, SHOWING VOCAL CORDS WIDELY DRAWN APART, AND THE POSITION OF THE VARIOUS PARTS DURING QUIET BREATHING 31

10. THE SAME, SHOWING APPROXIMATION OF VOCAL CORDS AND POSITION OF THE VARIOUS PARTS DURING VOCALIZATION . . . . . . . . . . . 31

11. VERTICAL SECTION OF THE HEAD . . . . . . . . . . . . . . . . . 33

12. NASAL SPECULUM . . . . . . . . . . . . . . . . . . . . . . . . 36

13. BOSWORTH'S NASAL DILATOR . . . . . . . . . . . . . . . . . . . 36

14. SEPTOMETER FOR MEASURING THICKNESS OF NASAL SEPTUM . . . . . . 37

15. FOLDING TONGUE DEPRESSOR . . . . . . . . . . . . . . . . . . . 38

16. COHEN'S TONGUE DEPRESSOR . . . . . . . . . . . . . . . . . . . 38

17. JARVIS'S RHINOSCOPIC MIRROR AND TONGUE DEPRESSOR . . . . . . . 39

18. RHINOSCOPIC IMAGE . . . . . . . . . . . . . . . . . . . . . . 39

19. SHOWING ANTERO-POSTERIOR SECTION OF BONES OF THE FACE IN POSITION . . . . . . . . . . . . . . . . . . . . . . . . . . 48

20. BELLOCQ'S CANULA . . . . . . . . . . . . . . . . . . . . . . . 52

21. ALLEN'S NASAL FORCEPS . . . . . . . . . . . . . . . . . . . . 54

22. THE GALVANO-CAUTERY SNARE . . . . . . . . . . . . . . . . . . 56

23. DOUBLE BATTERY AND FLEMING ELECTRODE FOR USE IN NASAL DISEASES 56

24. TWO ELECTRODES OF PECULIAR SHAPE, FOR USE IN NASAL DISEASES . 58

25. ACUTE TRACHEITIS: ANTERIOR WALL . . . . . . . . . . . . . . . 135

26. SAME CASE AS FIG. 25: POSTERIOR WALL . . . . . . . . . . . . . 135

27. TUBERCULOUS ULCERATION OF THE TRACHEA, AS SEEN DURING LIFE . . 137

28. SAME CASE AS FIG. 27: POST-MORTEM APPEARANCE . . . . . . . . . 137

29. SYPHILITIC ULCERATION OF TRACHEA, AS SEEN DURING LIFE . . . . 137

30. SAME CASE AS FIG. 29: POST-MORTEM APPEARANCE . . . . . . . . . 138

31. PAPILLOMA OF TRACHEA . . . . . . . . . . . . . . . . . . . . . 141

32. INVOLUTION OF TRACHEA, DUE TO ANEURISM . . . . . . . . . . . . 142

33. A TYPICAL CASE OF LOBAR PNEUMONIA IN THE ADULT: RECOVERY . . . 324

34. LOBAR PNEUMONIA, WITH CRISIS MARKED BY EVENING EXACERBATIONS REACHING NEARLY THE HIGHEST PYREXIA OF THE SECOND STAGE . . 325

35. A TYPICAL CASE OF LOBAR PNEUMONIA IN A CHILD: RECOVERY . . . . 326

36. A CASE OF LOBAR PNEUMONIA IN A BOY TEN YEARS OLD, IN WHICH TEMPERATURE WAS TAKEN EVERY FOUR HOURS . . . . . . . . . . . 327

37. A TYPICAL CASE OF SENILE LOBAR PNEUMONIA . . . . . . . . . . . 327

38. CROUPOUS PNEUMONIA IN THE ADULT, TERMINATION OF, IN PURULENT INFILTRATION . . . . . . . . . . . . . . . . . . . . . . . . 333

39. ACUTE LOBAR (CROUPOUS) PNEUMONIA IN A CHILD: RECOVERY . . . . 341

40. ACUTE LOBULAR (CATARRHAL) PNEUMONIA IN A CHILD: RECOVERY . . . 341

41. SPHYGMOGRAPHIC TRACING OF AORTIC OBSTRUCTION (AFTER FOSTER) . 656

42. SPHYGMOGRAPHIC TRACING OF AORTIC REGURGITATION . . . . . . . . 662

43. SPHYGMOGRAPHIC TRACING OF AORTIC OBSTRUCTION AND REGURGITATION 662

44. SPHYGMOGRAPHIC TRACING OF MITRAL OBSTRUCTION . . . . . . . . . 667

45. SPHYGMOGRAPHIC TRACING OF MITRAL AND AORTIC OBSTRUCTION AND REGURGITATION . . . . . . . . . . . . . . . . . . . . . . . 669

46. SPHYGMOGRAPHIC TRACING OF MITRAL REGURGITATION . . . . . . . . 672

47. SPHYGMOGRAPHIC TRACING OF MITRAL AND AORTIC REGURGITATION . . 672

48. SPHYGMOGRAPHIC TRACING OF TRICUSPID REGURGITATION . . . . . . 679

49. ROBERTS'S PERICARDIAL ASPIRATING TROCAR . . . . . . . . . . . 797

50. SPHYGMOGRAPHIC TRACING OF NORMAL PULSE . . . . . . . . . . . . 809

51. SPHYGMOGRAPHIC TRACING OF RIGHT AND LEFT RADIAL PULSE IN ANEURISM OF THE AORTA . . . . . . . . . . . . . . . . . . . 810

52. ARCH OF AORTA DURING EARLY FOETAL LIFE . . . . . . . . . . . . 826

53. SARCOMATOUS TUMOR OF ANTERIOR MEDIASTINUM . . . . . . . . . . 866

54. SECONDARY MYELOID SARCOMA OF MEDIASTINUM . . . . . . . . . . . 868

55. RESECTION OF STERNUM FOR REMOVAL OF ENCHONDROMA . . . . . . . 880

DISEASES OF THE RESPIRATORY SYSTEM.

{19}

LARYNGOSCOPY AND RHINOSCOPY.

BY CARL SEILER, M.D.

The laryngoscope is a combination of instruments designed for the examination of the interior of the larynx and upper part of the trachea, while the rhinoscope is a similar combination of instruments designed to explore the posterior nasal cavity; and both are comparatively recent inventions.

HISTORY OF THE LARYNGOSCOPE.--In medical literature before the middle of the eighteenth century no mention is made of an instrument or apparatus resembling the laryngoscope, but recent excavations at Pompeii have brought to light small polished metal mirrors attached to slender handles which are supposed to have been used to inspect the cavities of the human body. The first authenticated attempt at laryngoscopy and rhinoscopy was made by the distinguished French accoucheur M. Levret in the year 1743, who invented, among other surgical instruments, an apparatus by means of which polypoid growths in the cavities of the nose, throat, ear, etc. could be seen, and a ligature be passed around them for their removal.[1] This apparatus consisted mainly of a polished metal mirror which "reflected the luminous rays in the direction of the tumor," and on whose surface the image of the growth was seen to be reflected. The great value of this apparatus for the diagnosis and treatment of nasal and laryngeal diseases was, however, not recognized, and it shared the fate of many other valuable discoveries which were made before the world was ready to receive them: it was forgotten.

[Footnote 1: Mercure de France, 1743, p. 2434.]

In 1807 a certain Dr. Bozzini, living in Frankfort-on-the-Main, published a work describing an apparatus which he had invented for the illumination and examination of the cavities of the human body.[2] This apparatus consisted of a peculiarly-shaped lamp and of a number of metal tubes, polished on their inner surface, of various shapes and sizes adapted for the different cavities of the body. The one intended for the examination of the larynx was bent near its end at a right angle, and had a mirror placed at the bend, which served to throw the light downward toward the opening of the larynx when the tube was inserted into the mouth. When reflected light was to be used, the interior of the tube or speculum was divided into two portions by a longitudinal septum, and two mirrors were inserted at the bend--one for the reflection of the light downward, and the other for receiving the reflected image. This invention of Bozzini was treated, however, with derision by the medical profession, probably on account of the extravagant descriptions given of it in the papers, which were not verified by its performances.

[Footnote 2: "Der Lichtleiter," Philipp Bozzini, Med. und Chir. Dr., Weimar, 1807.]

In 1825, Cagniard de Latour, an investigator of the physiology of the voice, made some unsuccessful attempts to examine the living larynx.[3]

[Footnote 3: Physiologie de la Voix, par Ed. Tournié, Paris, 1865.]

{20} Senn of Geneva in 1827 endeavored to examine the larynx of a little girl suffering from an affection of the throat by means of a small mirror which he had made and which he inserted into the pharynx, but he failed to see the glottis, because, as he says, the mirror was too small, and because he used neither direct nor reflected light to illuminate the cavity below the mirror.[4]

[Footnote 4: Journal de Progrès des Sciences, etc., 1829.]

In the year 1829, Benjamin Guy Babington published[5] an account of what he called the glottiscope, an apparatus which consisted mainly of two mirrors. One of these was small and attached to a slender stem, and was used to receive the image, while the other, an ordinary hand-glass, was used to reflect the rays of the sun or ordinary daylight upon the smaller mirror in the fauces. This combination was essentially the same as is used at the present day in the laryngoscope, with the difference that we now use artificial light in most instances, and a concave mirror instead of a plane one for reflecting the light.

[Footnote 5: Lond. Med. Gazette, 1829, vol. iii.]

While Babington was still engaged in perfecting his instruments, a mechanic named Selligue, who suffered from an affection of the throat, in 1832 invented a speculum for his physician, Bennati of Paris, with which the latter was able, as he asserted,[6] to see the vocal cords. This instrument was similar to the one invented by Bozzini, and consisted of a double speculum bent at right angles and carrying two mirrors--one for illuminating the cavity, and the other for reflecting the image. Selligue was rewarded for his efforts by a complete cure of his affection.

[Footnote 6: Recherches sur le Mécanisme de la Voix humane.]

A number of others worked in the same direction, and endeavored to see the interior of the larynx in the living subject by employing different apparatus and methods of illumination. Thus, in 1838, Baumès of Lyons described a mirror the size of a two-franc piece (1-1/8 inches in diameter) as useful in examining the larynx and posterior nares.[7] Then Liston in 1840 used a dentist's mirror,[8] and Warden of Edinburgh employed a prism of flint glass attached to a long stem as a laryngeal mirror.[9] In the latter part of the same year Avery of London employed a speculum with a mirror in its end for examining the larynx, using as an illuminator a concave reflector with a central opening, which was supported by a frame to be worn on the head of the operator.[10]

[Footnote 7: Compte Rendu des Travaux de la Société de Médecine de Lyons, 1836-38.]

[Footnote 8: Practical Surgery, 1840.]

[Footnote 9: Lond. Med. Gazette, vol. xxiv. p. 256.]

[Footnote 10: Med. Circ., June, 1862.]

Up to this time all efforts at laryngoscopy had been made with a view to diagnose diseases of the larynx, with the exception of those made by Latour. In the year 1854, however, Signor Manuel Garcia of London, without any knowledge of previous efforts, conceived the idea of studying the changes in the larynx during phonation in his own throat. For this purpose he placed a small dentist's mirror against the uvula and reflected the rays of the sun into his mouth and upon the small mirror by means of a hand-glass held in the other hand. By arranging his position in relation to the sun in such a manner that he could see the reflected image of the small mirror in his throat in the hand-glass, and in it the illuminated image of his larynx, after a few ineffectual attempts his efforts at auto-laryngoscopy were crowned with such success that he was enabled to study the movements of the vocal cords during phonation, and accurately describe the registers of the voice in a paper read before the Royal Society of London in 1855.[11] Although Garcia was the first who practised laryngoscopy successfully, his communication to the Royal Society attracted little attention, and would have been forgotten if it had not been that, in 1857, Tuerk of Vienna, having heard of Garcia's paper, began to use the laryngeal mirror on the patients in the K. K. Algem. Krankenhaus for {21} diagnostic purposes.[12] At first he was not very successful in his attempts, and began to experiment with laryngeal mirrors of different sizes and shapes. While thus engaged Czermak borrowed Tuerk's mirrors, and modified them until he succeeded in the greater number of cases in seeing the vocal cords,[13] using artificial light for illuminating the larynx. Meanwhile, Tuerk continued his experiments, and also succeeded in almost all cases of throat disease which came to his department of the hospital in seeing the interior of the larynx and in treating the lesions. Both Tuerk and Czermak improved their apparatus, and especially the latter, who by substituting artificial light for sunlight, and by inventing a number of different illuminating apparatuses, has given us the laryngoscope in the form in which it is used at the present day. It is but natural that Tuerk should have claimed priority in the successful use of this instrument, and in consequence of this claim a controversy was carried on for a number of years in the medical press between him and Czermak, which at times became quite spirited, but which left Czermak master of the field. In the winter of 1858-59, Madam E. Seiler, having heard of Czermak's experiments, had a laryngeal mirror constructed from his description, practised laryngoscopy successfully on herself and others, among them the writer, with a view to study the physiology of the voice. Her efforts being crowned with success, she was able not only to verify Garcia's observations in regard to the registers, but also discovered the so-called head register of the female voice, as well as two small cartilages in the vocal cords.[14]

[Footnote 11: Proc. Royal Society of London, vol. vii. No. 13, 1855.]

[Footnote 12: Zeitschrift der Ges. der Aerzte zu Wien, April, 1858.]

[Footnote 13: Wien. Medicin. Wochenschrift, March, 1858.]

[Footnote 14: Altes und Neues, Leipzig, 1861.]

HISTORY OF THE RHINOSCOPE.--Rhinoscopy, or the art of viewing the naso-pharyngeal space by placing a small mirror behind the velum palati, naturally suggested itself almost as soon as any attempts at laryngoscopy were made, but in the literature we find that Bozzini was the first to clearly express the idea.[15]

[Footnote 15: Loc. cit.]

A number of years later Wilde endeavored to see the opening of the Eustachian tubes by means of a small mirror: an account of these experiments he published in his famous work on the diseases of the ear.

In 1836, Baumès used the rhinoscope, and claimed to have seen ulcerations in the naso-pharyngeal cavity.[16] It remained, however, for modern times to develop this field of research, and it is again Czermak whom we have to thank for the perfection of this valuable means of diagnosis.

[Footnote 16: Loc. cit.]

THE LARYNGOSCOPE.--The laryngoscope as it is used at the present day, both by the specialist and the general practitioner of medicine, consists of a so-called laryngeal mirror and of an illuminating apparatus more or less complicated. The laryngeal mirror is a small circular glass mirror mounted in a metal frame varying in size from ¾ inch to 1½ inches in diameter, and attached to a wire stem at an angle of 120°. This stem, about 4 inches in length and about 1/10 inch in thickness, should be soldered to the back of the mirror in such a manner that the rim of the frame forms the angle with the stem, and should not be below it, as this would increase the diameter of the instrument without increasing its reflecting surface. The stem is made to slide into a hollow handle of wood, ivory, or ebonite, and is clamped at any desired length by a set-screw. This arrangement is preferable to having the stem permanently fixed in the handle, inasmuch as the stem can be pushed entirely into it, thus economizing space and rendering the instrument more portable, and also allowing an adjustment of the length of the stem when in use. The handle should be 4 inches in length, and of the thickness of an ordinary lead-pencil (Fig. 1).

Mirrors of various shapes have been used, but it has been found that the circular form is the one most easily borne by the patient, and can be used in {22} a greater number of cases than any other shape, at the same time giving the largest reflecting surface for its size. However, in cases where an hypertrophy of the tonsils is present an oval mirror can be introduced between the protruding glands more easily than a round one.

This laryngeal mirror, however, would be of little or no value as an instrument of diagnosis if used by itself, for in order to see the cavity of the larynx it must be illuminated, lying as it does far below the level of the back of the tongue; and this cannot be done satisfactorily by merely allowing ordinary daylight to fall into the oral cavity. It becomes, therefore, necessary to use a stronger light to illuminate the larynx, and for this purpose either direct or reflected artificial or sunlight may be used.

Direct illumination, by allowing a strong artificial light or sunlight to fall into the patient's mouth, although it is used by several of the eminent laryngologists of Europe, is both inconvenient and unsatisfactory, because the observer must either place his head in the path of the light in order to be able to see the surface of the laryngeal mirror, as in the case when sunlight is used, or he must place the lamp, candle, or other source of light between himself and the patient, which materially interferes with the freedom of his motions. For these reasons reflected light is now almost universally employed in laryngoscopy.

Reflected light may be obtained by throwing the light of a lamp, candle, gas-jet, or light from any other source into the mouth of the patient by means of a round concave reflector. This concave mirror--which, when made of glass, should be silvered and not backed with amalgam--is from 3 to 4 inches in diameter, and should have a focus of from 12 to 14 inches. The metal frame in which it is mounted is attached by means of a ball-and-socket joint to some contrivance by which it can be supported on the observer's head or be attached to the source of illumination if a stationary artificial light, such as a gas-lamp, is used at the physician's office.

A variety of devices for fastening the reflector on the head of the observer is in use, among which the head band, introduced by Cramer, will be found the most serviceable. It consists of a broad strap of some strong material which passes around the head and is fastened at the back by a buckle. To the part of the band or strap resting on the forehead is attached a padded plate, to which the reflector is fastened with its ball-and-socket joint (Fig. 2). The reflector usually either has a small hole in the centre or a small space in the centre is left unsilvered. This opening is intended to be brought before the pupil of one or the other eye of the observer in such a manner that the line of vision and that of light have exactly the same direction. Using the reflector in this way like the reflector of the ophthalmoscope, it is easier to obtain the image of the larynx well illuminated, but with the great disadvantage of {23} monocular vision, which makes all objects appear on the same plane and prevents a correct interpretation of distances--a very important point in laryngoscopy. It will therefore be found more advantageous to place the reflector on the forehead, and from thence reflect the light into the patient's larynx. Both eyes may thus be employed in viewing the laryngeal image, and a correct idea of the relations of parts in regard to distance may be formed.

The line of vision and the path of the beam of light in order to obtain the best results should be in the same plane as though the light emanated from the pupil of the observer; but practically the position of the reflector upon the forehead is nearly as good as when the hole in it is brought before the eye, because a line drawn from the pupil of the eye to the laryngeal mirror, and a line from the reflector upon the forehead to the mirror, do not form an angle sufficient to make any very great difference in the reflection of the light downward, and very little difficulty will be experienced in obtaining the desired image.

The head reflector should be concave when artificial light or ordinary daylight is used, but be plane when direct sunlight is employed, for the concentration of the sun's rays by a concave reflector produces so much heat as to become painful to the patient.

THE SOURCE OF LIGHT.--As an artificial source of light a candle, coal oil lamp, gas-flame, or incandescent electric lamp suffices for ordinary purposes. But frequently it is desirable to have a much stronger light than can be obtained without concentration, and several forms of apparatus for concentrating artificial light have been constructed and are in use. Among these, Tobold's lamp and Mackenzie's light concentrator are the most convenient and most universally used.

Tobold's lamp consists of a brass tube containing several lenses, which are placed, one before the other, at such distances as to give the greatest possible amount of concentration of light. The back part of the tube is closed, while near the end two large holes are cut in its sides opposite to each other, through which the chimney of the lamp projects. The whole is fastened by means of clamps to a stand, to which is also attached a jointed arm bearing the reflector. This apparatus is used either in connection with a student's lamp or with an argand gas-lamp, and it will be found very convenient to have it mounted upon a gas-bracket which can be raised and lowered and swung from side to side.

Mackenzie's light concentrator consists of a cylinder of sheet iron about 6 inches long by 2½ in diameter. Near one end a hole is cut in the side of the cylinder, and a short piece of tube holding a condensing lens is attached to the edge of the hole. This lens, which is plano-convex with a spherical curve, and of 2½ inches diameter, is placed with the plane side toward the light. {24} This concentrator is intended to be slipped over the chimney of an argand burner, and should be so adjusted that the centre of the flame corresponds with the centre of the lens. It may, however, be used in connection with a student's lamp, incandescent electric lamp, or even a candle, giving in all cases a very satisfactory light, which, however, must be reflected from the head mirror into the patient's mouth.

The best light, however, when the examinations are conducted in the office of the physician, is the electric incandescent light, which presents numerous advantages over the gas or oil lamp. It is more brilliant and whiter than any other suitable artificial light, giving off neither gases nor heat, nor does it consume the oxygen in the room; and since the introduction and perfection of storage batteries it has become available and convenient for use in private houses. Numerous experiments which the author has carried on for some time have resulted in the application of this form of light for laryngoscopy in two ways which are both very satisfactory. The incandescent lamp is mounted upon the universal gas-bracket in place of the argand burner, and either the Tobold lamp or Mackenzie's light concentrator is slipped over it, so that it comes opposite the centre of the lens. In fact, the electric lamp is substituted for the gas-burner, and the whole apparatus is used as described above. The arc light may also be used in the same manner, but does not give as satisfactory results on account of its unsteadiness.

The second method is to mount the electric lamp on the head mirror in such a way that it projects a little from the surface and is a little to one side of the centre of the reflector (Fig. 3). The light is then thrown forward in a cone, and can be directed with great ease into the mouth of the patient. Since thus the source of the light moves with the mirror, the observer can follow the motions of the patient more easily; and if, in the first place, an easy position of the head has been assumed when adjusting the light, much less {25} fatigue is experienced by the examiner with this apparatus than when the light is reflected from a stationary source. Still another mode of using the incandescent lamp, which was suggested by Trouvé, is to mount the lamp within a tube one end of which is closed by a plano-convex lense, while the other end is covered by a metal cap carrying in its centre a ball-and-socket joint, by means of which it is fastened to the frontal plate of the head band. In this way the light with its condensing apparatus is carried on the forehead like the head mirror.

Sunlight is certainly the best source of light for the illumination of the interior of the larynx and nasal cavities, but, unfortunately, it is not available at all times and in all localities. When it can be obtained, however, the student should not neglect the opportunity, and should not be deterred from using it for examination by the little extra apparatus and trouble necessary.

The most convenient plan is to place a small plane mirror mounted upon a stand in such a manner that it can be turned in any direction, such as a small toilet-glass, in the direct rays of the sun coming through a southern window. Then turn the mirror until the reflection falls upon a second plane mirror supported by a jointed arm and placed in a distant corner of the room, and in front of the chair upon which the patient is seated, with his back to the first mirror. The light from the second mirror is then thrown into the patient's mouth in the same manner as when a light concentrator is used. The second mirror may also be mounted on the head band and used as a head reflector, but this latter plan is not as satisfactory, because the reflected light from the first mirror is apt to strike the observer's eye and temporarily blind him.

Sunlight, as well as the light from the oxyhydrogen and electric-arc lamps, is white, and therefore shows us the parts in their natural coloring, which is claimed as a great advantage over all other sources of light. It is true that the yellow rays which are predominant in all other artificial lights make the mucous membrane appear redder than it really is, and the observer may be led to believe that a congestion exists if the patient be examined by white light first, and then by yellow light on different occasions. But as all our knowledge and appreciation of shades of color depend upon a comparison with a standard, it makes no difference whether this standard, as in the case before us, is a little redder when viewed by yellow light or not so red when seen by white light. This advantage of the white light is, therefore, not of much practical value, and the expense and difficulties connected with the use of the oxyhydrogen or electric arc-light for laryngoscopy fully outweigh any advantage which can be claimed for it.

THE ART OF LARYNGOSCOPY.--Before entering upon a description of the details of the art it will be necessary to clearly understand the optical principle upon which the use of the laryngoscope is based, and, further, to remember that the object to be viewed is situated below the straight path of light and vision. The optical law referred to is, that "The angle of incidence is equal to the angle of reflection," and consequently, in order to illuminate the cavity of the larynx and to see its details, the laryngeal mirror must be placed in such a position in the fauces that the light is reflected downward. The light rays forming the laryngeal image will then be reflected from the surface of the laryngeal mirror into the eye of the observer. It should always be borne in mind that the image seen in the mirror is a reflected one, like the image of one's self seen in a looking-glass, so that what appears to be right is left, and vice versâ. On account of the difference in height of the parts forming the image, and because the mirror must be placed above and slightly behind the opening of the larynx, the picture appears reversed in an antero-posterior direction. The same holds good when viewing a drawing of a laryngeal image.

{26} POSITION OF PATIENT AND OBSERVER.--The relative positions of the patient, observer, and the source of light are of very great importance, especially to the beginner, and a want of proper adjustment will often make it extremely difficult, if not impossible, to obtain the desired view of the larynx. The patient having been seated upon a chair, or better still upon a piano-stool, the source of light is placed upon a table at his right, at such a height that the centre of the flame is on a level with his eyes and a few inches behind. The observer then takes a seat directly in front of the patient, and, separating his knees, places his feet on either side of those of the patient, thus being able to grasp the patient's knees with his own should occasion require him to do so. This position is preferable to the one in which the knees of the observer are either on one side or the other of the patient's knees, because then the observer, in order to throw the light from the head mirror into the mouth of the patient, has to assume a constrained position which very soon becomes fatiguing. Under no circumstances should the patient be allowed to grasp the observer's knees, for then the latter is powerless to restrain the struggles of his patient, and cannot quickly leave his seat should vomiting occur. When the examination is made at the physician's office or wherever it is practicable, it is of advantage to have a head-rest, such as photographers use, for the patient's head.

The positions having been taken, the observer places the head reflector upon his forehead a little above the left eye, and by rotating it upon its ball-and-socket joint reflects the light from the lamp- or gas-flame upon the patient's face so that the circle of light is bounded above by the tip of the nose and below by the tip of the chin. It is of great importance that the adjustment of the reflector should be made by means of its joint, and not by rotating or inclining the head, for it is necessary that the head should have an easy position which can quickly be resumed should it become necessary to move the head. It requires considerable practice to quickly reflect the light from the head mirror in any desired direction, and it is therefore well for the beginner to practise this by throwing the light upon a spot on the wall before he attempts to examine a patient, as he will thus save himself, as well as the patient, unnecessary annoyance. If a light concentrator be used which supports the reflector on the jointed arm, this of course is not necessary, but the practice with the head mirror will even then be found advantageous, because when a patient is to be examined in the sick room a light concentrator cannot usually be employed, and the physician has to fall back upon the head mirror for illuminating the laryngeal cavity.

When the reflector has thus been properly adjusted the patient is required to incline his head backward and open his mouth as wide as possible, when it will be found that the centre of the circle of light falls upon the root of the uvula. A careful examination of the oral cavity, the anterior and posterior pillars, the tonsils, and the wall of the pharynx should be made before the laryngeal mirror is introduced, not only because the condition of these parts often imparts valuable information, but also in order to be sure that no infectious sores be present which might contaminate the instruments to be introduced. The laryngologist cannot be too careful to prevent the carrying of infectious material from one patient to another; and if he should by this preliminary examination discover a specific sore, he should use only such instruments as are reserved for this class of cases, and which are kept in a separate box or drawer of the instrument-case.

Everything being in readiness, the laryngeal mirror is held over the lamp, with the glass side down, for a few seconds until it is warm, so as to prevent the condensation of moisture on its reflecting surface, and is then introduced in the following manner: The handle is held between the thumb and fore finger of the right hand like a pen-holder (Fig. 4); the hand is bent {27} backward upon the wrist and held below the chin of the patient. Meanwhile, the protruded tongue is grasped between the folds of a napkin or towel held in the left hand, and gently but firmly pulled out of the mouth. Great care should be exercised to prevent the frænum of the tongue from coming in contact with the sharp edge of the front teeth, for this soon becomes very painful and may prevent a successful examination. Many laryngologists are in the habit of letting the patient hold his tongue, which becomes necessary when operations or applications are to be made to the larynx; but for the purpose of examining only it is better for the observer to hold the tongue, as he thus gains more control over the movements of the head of the patient.

The mirror is now rapidly introduced into the mouth of the patient, without touching the tongue or the palate, and carried backward until its rim touches the wall of the pharynx, when it is lifted upward, carrying on its back the uvula, and the stem is brought into the angle of the mouth, so as to be out of the line of vision (Fig. 5). In this position the light of the reflector will fall upon the reflecting surface of the laryngeal mirror, and will be reflected downward so as to illuminate the laryngeal cavity and reflect the laryngeal image into the eye of the observer.

{28} There are, however, numerous obstacles and difficulties which must be overcome to successfully practise laryngoscopy--obstacles which are partly due to the want of skill on the part of the operator, and partly to over-sensitiveness and want of control of the patient, or, finally, to abnormal positions of the parts. Taking them up one by one, in the order named above, the reader will soon learn to overcome these obstacles by practice and careful attention to details.

As has already been pointed out, a satisfactory view of the laryngeal image cannot be obtained if the position of the light, of the patient's head, and of the observer is not properly arranged; further, if the laryngeal mirror is either too cold or too hot. In the former case the moisture of the breath will condense on its reflecting surface and render it non-reflecting, and in the latter case the patient will feel the heat and will object to the presence of the mirror in the fauces. The examiner should therefore carefully test the temperature of the mirror on the back of his hand before introducing it. Many laryngologists are in the habit of testing the temperature by placing the mirror against the cheek, but this is a dangerous practice, for a slight scratch or abrasion of the skin from shaving may be inoculated with infectious material from a specific sore, and the writer knows of more than one instance in which such infection has occurred; while a scratch on the hand is not so likely to be overlooked, and therefore the danger is much less. Pulling too hard upon the tongue, so that the frænum becomes injured by the edge of the teeth, is another obstacle, for the patient will not bear the pain thus occasioned. Touching the tongue or palate in the act of introducing the mirror, besides coating the reflecting surface with the secretions of the mouth, causes in most patients gagging, and should therefore be avoided. When the mirror has been introduced it should be held very still, and if it becomes necessary to rotate it, this should be done slowly and steadily, because the slightest trembling motion of the rim of the mirror resting against the wall of the pharynx produces gagging and cuts the examination short at once. It is therefore advisable to steady the hand holding the mirror by placing the third finger against the cheek of the patient, or, better still, against the thumb of the hand holding the tongue.

Undue irritability of the fauces is of very rare occurrence, and is almost invariably produced by one or the other of the above-mentioned mistakes of the examiner. When it does exist independently, it can in a measure be overcome by letting the patient drink a large draught of ice-water immediately before introducing the mirror, and by holding the mirror so that it does not touch either the pharyngeal wall or the palate. In this manner but a very unsatisfactory view of the larynx can be obtained, and it is better to overcome the irritability by practice on the part of the patient--i.e. by introducing the mirror frequently and removing it before gagging sets in, and by directing the patient to introduce a teaspoon into the fauces before a looking-glass several times a day. Even the most obstinate cases can thus be educated to allow of a lengthy examination. No matter how tolerant a patient may be, however, the mirror should never be left in the fauces after the first symptoms of gagging show themselves, but should at once be removed. It is better in all cases to leave the mirror in the mouth but a short time and to introduce it frequently, thus studying the different parts of the image one after the other, than to attempt to see everything at once. In laryngoscopy, as in many other arts, not only the hand, but also the eye, must be educated to appreciate all the details and the variations from the normal.

Among the malformations of the parts which present obstacles to laryngoscopy are, in the first place, hypertrophied tonsils, which by narrowing the space in the fauces make it impossible to introduce the ordinary-sized mirror. A smaller mirror or one of oval shape can, however, usually be slipped past the {29} enlarged glands and the desired image obtained. An elongated uvula does not exactly prevent a view of the larynx, but it materially interferes with a good image, because its end by hanging below the rim of the mirror is seen in the reflecting surface and obscures part of the image. Removal of the uvula by surgical means is of course the best remedy.

The third and most serious obstacle presented by malformation or malposition of parts is a pendent epiglottis--i.e. an epiglottis which by being bent too far over covers the laryngeal opening and prevents a view. This obstacle exists to a certain extent in most cases that come under observation, but is easily overcome by letting the patient sound the vowel sound of eh, which causes a rising of the epiglottis and opens the laryngeal cavity to view. There are some cases, however, in which this expedient does not sufficiently raise the epiglottis to obtain a glimpse of the vocal cords, and only the arytenoid cartilages are seen, from the motion and color of which we can often obtain valuable information in regard to pathological processes. In these cases, when it becomes absolutely necessary to see the whole extent of the vocal cords, we may succeed by causing the patient to laugh in a high key, but when this fails the only resource left is to lift the epiglottis by grasping its upper margin with a pair of curved forceps especially designed for this purpose and called epiglottis forceps (Fig. 6). If this instrument is not at hand, the same object may be attained by clasping the edge of the epiglottis with a bull-nose forceps, to which is fastened a string weighted at the other end by a small weight, such as a rifle-bullet. The string with its weight hanging out of the mouth of the patient makes traction upon the forceps, and thus the epiglottis is raised. In cases of operation within the laryngeal cavity this method of raising the epiglottis is even preferable to the epiglottis forceps, because it leaves the hands of the operator free to use the mirror and the instrument to be used in operating.

AUTO-LARYNGOSCOPY.--There is perhaps no better method for the beginner to overcome the difficulties besetting laryngoscopy than to practise the art on himself, for then only will he be able to appreciate to its full extent the necessity of observing all the minute details described above, as the pain and inconvenience which he inflicts upon himself by his false movements will teach him better, and enable him to attain proficiency in the use of his instruments quicker than any other method of practice. Nothing need, for auto-laryngoscopy, be added to the stock of instruments necessary for the examination of others, except a stand to which the reflector is fastened and a small toilet-mirror. The observer seats himself beside a table upon which, at his left, is placed the lamp a little behind his head and the centre of the flame on a level with his eyes. The stand, an ordinary retort-stand, is placed in front of him, and to it is fastened at the proper height the reflector. On the same stand, and immediately above the reflector, is attached the plane mirror in such a manner that it can be inclined at an angle. Inclining the head slightly backward, the observer then by watching his face in the plane mirror directs the light upon his mouth by moving the reflector upon its ball-and-socket joint until the circle falls upon his mouth. He then opens his mouth as wide as possible, grasps his protruded tongue between the folds of a towel or {30} napkin held between the thumb and fore finger of the left hand, and introduces the laryngeal mirror with the right hand in the manner described above. The laryngeal image as it appears on the surface of the laryngeal mirror is reflected by the toilet-glass above the reflector, and can be seen in all its details by the person practising auto-laryngoscopy. By substituting a perforated mirror for the toilet-glass the student can demonstrate the image to others in his own person if the observers look through the perforation in the mirror.

Before giving a description of the laryngeal image it will be well, for the sake of completeness, to mention the fact that of late photography has been employed to reproduce this image, both in this country by T. R. French of Brooklyn[17] and by Lennox Browne of London, England, with very gratifying results. The writer himself several years ago made experiments in this direction, which, however, were not very satisfactory in their results. The method employed by French is a very simple one, and it will be best to give his own description of the process:

"The camera consists of a box 4½ inches long, 1-7/8 inches wide, and ¾ of an inch in thickness. The back opens upon hinges, and admits of the introduction of either the ground glass or the plate-holder. On the anterior face a tube 1-1/8 inches long is attached, in the outer end of which the lens is placed. This lens has a focus of 1¼ inches. At the side of the tube a part of the handle of a throat mirror is fixed, and into that the shank of the throat mirror is passed and fastened by a thumb-screw. The shank of the mirror is somewhat curved, and is attached to the side of the frame holding the mirror. The object of this is to allow the lens being held opposite any part of the opening of the mouth, and also to prevent the possibility of a shadow being cast upon the mirror. In the front part of the box is a shutter made of lead and perforated with a hole just the size of the lens. The shutter is held in position by a lever acting as a key on the anterior face of the camera.

"The apparatus is used in the following manner: A reflector, either plane or concave, attached to a head band, is arranged over the left eye so that the pencil of sunlight from the solar condenser is received upon it and thrown into the mouth. The patient, with the head inclined slightly backward, now protrudes the tongue and holds it well out between the fore finger and thumb of the right hand. The throat mirror with the camera attached, held in the right hand of the observer, is placed in position in the fauces, and the light adjusted so that the larynx can be seen with the observer's left eye to be well illuminated. If, now, the tongue does not mount above the level of the lower edge of the lens and the lower edge of the mirror, it may be taken for granted that when the plate is exposed the picture received upon it will be nearly the same as that seen with the left eye in the throat mirror. The photograph is taken by pressing upon the key with the index finger; this releases the shutter, which in falling makes an instantaneous exposure amounting to perhaps one-seventh of a second.

"In using condensed sunlight with a small camera it is important to throw the circle of light from the inner side of the reflector, that nearest the nose; for in this way a part of the larynx exposed to the lens of the camera may be illuminated which cannot be seen with the eye. To ensure this it is best to cover the outer half of the reflector with black silk. On account of the parallax or displacement of the image due to the difference in point of view between the eye and the camera, some skill is necessary in managing the illumination so that the part which it is desired to bring out will be exposed to the lens if not to the eye."

[Footnote 17: Archives of Laryngology, vol. iv. No. 4.]

THE LARYNGEAL IMAGE.--When the mirror is introduced and is held in the proper place, and the light is reflected downward, the laryngeal image {31} will appear on the surface of the mirror. As it is, however, so different from what might be expected after having examined a larynx removed from the body, it requires a detailed description, and the student will do well to refer to the diagrams frequently while examining patients, to make himself familiar with the details he sees, and to recognize them when they are altered by disease or when they are slightly different in shape in different individuals. Figs. 7 and 8 represent the image of the larynx in the act of respiration and of phonation as it appears on the surface of the mirror, while Figs. 9 and 10 are diagrammatic, and are intended to represent the same.

The first detail to attract the eye is the epiglottis, which appears as a yellowish-red arch reaching from side to side across the image. It is thicker in the middle than at either end, and a protuberance is usually seen in the centre pointing forward. This arch is the upper margin of the epiglottis, and the protuberance is the tubercle, situated near the insertion of the epiglottis into the thyroid cartilage. The shape as well as the color of the epiglottis is very variable in different individuals, being sometimes rounded as in the drawings, sometimes rolled up like a dried leaf, sometimes notched in the centre, and sometimes presenting a point at this place. However, all these variations in shape have nothing to do with any pathological process, and may therefore be termed normal. The color of the organ also varies from a bluish-yellow to a pink-red, and these variations are also normal, being due to a greater or less thickness of the tissue covering the cartilage, which by shining through imparts its bluish color to the tissue. The superficial blood-vessels also are more prominent in some individuals than in others, and may not be noticeable in some cases.

{32} Immediately behind the epiglottis we see two pit-like depressions, separated from each other in the middle by a fold of mucous membrane and bounded on either side by similar folds less prominent. These folds are the glosso-epiglottic ligaments, and serve to connect the tongue with the epiglottis, while the depressions are the glosso-epiglottic grooves, in which we usually find the foreign bodies which have accidentally been swallowed.

The ends of the epiglottic arch are lost in folds of mucous membrane, which run forward and inward to meet in the median line some distance in front of the epiglottis. Along their course several nodules of different size are noticed, which are symmetrically situated on either side. The one nearest to the epiglottis is the cartilage of Wrisberg, a small cartilaginous nodule imbedded in the tissue. The larger one, situated at the end of the fold of mucous membrane, is the arytenoid cartilage, and a third small nodule is noticed close to the arytenoid cartilage between it and the cartilage of Wrisberg, which is called the capitulum Santorini. The folds of mucous membrane are termed the aryteno-epiglottidean or ary-epiglottic folds. Their color is normally of a pinkish-red, and does not vary much in different individuals.

The arytenoid cartilages forming the ends of the ary-epiglottic folds are movable, approaching and separating alternately during the act of respiration, while during phonation they are pressed against each other, thus obliterating the space between them which is seen when they are separated. This space is the inter-arytenoid space or commissure, and is formed by the lateral walls of the arytenoid cartilages and the upper margin of the posterior portion of the cricoid cartilage. The mucous membrane in this commissure is very loosely attached to the deeper structures, and is thrown into folds by the approximation of the arytenoid cartilages. Its color is much lighter than that of the ary-epiglottic folds, due to the shining through of the cricoid cartilage. Outside of the ary-epiglottic folds and the inter-arytenoid commissure is the tissue forming the posterior and lateral walls of the oesophagus (not shown in the diagrams), and near the epiglottis a space called the pyriform sinus is noticed between the ary-epiglottic folds and the wall of the oesophagus.

Running from the epiglottis to the ary-epiglottic folds are two broad bands, one on either side, covered with mucous membrane and of a pinkish-red color, which are lost on either side in the tissue forming the walls of the laryngeal cavity, while toward the middle of the image they present concave and tolerably sharp edges. These are the ventricular bands, which were formerly termed the false vocal cords, and which form the lip to the opening of the ventricle of the larynx. Between the ventricular bands filling up the central portion of the image are seen the vocal cords, two bands of a pearl-white color which are attached to a cartilaginous process of the arytenoid cartilages, and run from these parallel with each other to the angle of the thyroid cartilage immediately below the tubercle of the epiglottis. These present sharp edges toward each other, and follow the motions of the arytenoid cartilages to which they are attached, so that when in inspiration the cartilages are separated the edges of the vocal cords are also some distance apart, forming, together with the inter-arytenoid commissure, a triangular opening called the glottis. That portion of the opening which is bounded on either side by the edges of the vocal cords alone is called the membranous portion, while the base of the triangle is termed the cartilaginous portion, being bounded on either side by the vocal processes of the arytenoid cartilages. This portion is readily distinguished from the membranous portion by its slightly yellow color, and by the fact that a very obtuse angle is formed at the junction of the two portions when the glottis is wide open during respiration. Through the open glottis the lower edge of the cricoid cartilage and several of the rings of the trachea can usually be seen, and there are a few cases in which even the bifurcation of the trachea can be dimly illuminated, showing in the {33} laryngeal image the openings of the bronchi. The distance is, however, too great for bright illumination, and nothing can be seen distinctly, so that it is of little value in a diagnostic point of view. During phonation the glottis is narrowed to a slit by the approximation of the arytenoid cartilages and inner edges of the vocal cords, and, as has already been stated, the inter-arytenoid space becomes obliterated. In the higher notes of the female voice, the so-called head tones, the cartilaginous portion of the glottis remains closed entirely, while the membranous portion appears as an elliptical opening which is diminished in its longitudinal diameter with each rise in pitch. This becomes possible because of the presence in the vocal cords of a slender rod-like cartilage attached to the end of the vocal process, which can readily be seen in the female larynx, but which is only rudimentary in the male.

This description, intentionally, has been made without reference to the anatomical relation of the parts, but to give a clear idea of what is seen in the laryngeal mirror. The reader should therefore always bear in mind that the laryngeal image, being a reflected one, is reversed, and that, on account of giving a bird's-eye view of the larynx from a point above and behind the organ, distances are materially diminished; and the image is also reversed in an antero-posterior direction, so that the epiglottis appears to be posterior when in reality it is anterior.

RHINOSCOPY.--Rhinoscopy, or the art of inspecting the nasal cavities and the naso-pharyngeal space, is divided into two portions--viz. anterior and posterior rhinoscopy; and it will be convenient to observe this division in the following description of the methods employed. But before proceeding with the description it will be well to briefly review the topographic anatomy of the parts, because in most works on general anatomy the nasal and naso-pharyngeal cavities are discussed in a few sentences, and they are rarely if ever examined in the dissecting-room, so that the student has but a very imperfect knowledge of the relation of the parts belonging to these cavities. (See Fig. 11.) The nasal cavities, which are wedge-shaped, with a narrow arched roof, extend from the nostrils to the upper portion of the vault of the pharynx. Their outer walls are formed by the nasal process of the superior maxillary and lachrymal bones in front; in the middle, by the ethmoid and inner surface of the superior maxillary bones; behind, by the vertical plate of the palate bone and the internal pterygoid process of the sphenoid and the turbinated bones. These latter run before backward, three on each side, and are designated as the inferior, middle, and superior, the latter being the smallest of the three. The sinuses or spaces between these turbinated bones are called meatuses; so that the space between the floor of the nose and the lower turbinated bone is called the inferior meatus, the one between the lower and middle turbinated bones is the middle meatus, and the one between the middle and superior turbinated bones is the superior meatus.

The nasal cavities are separated from each other by a septum or division wall composed of the perpendicular plate of the ethmoid bone and the vomer posteriorly and the cartilaginous septum anteriorly, thus presenting a smooth surface as the inner wall of each cavity. The floor is formed by the palatine process of the superior maxillary bone and by the palate bone, and runs in a slanting, downward direction from before backward. The roof is formed by the nasal bones and nasal spine of the frontal in front, in the middle by the cribriform plate of the ethmoid, and posteriorly by the under surface of the body of the sphenoid bone. Directly communicating with the nasal cavities are other cavities situated in the bones of the skull, the lining mucous membrane of which no doubt is largely affected by the pathological processes in nasal diseases: these are the antra of Highmore, large triangular cavities situated in the body of the superior maxillary bone and communicating with the nasal cavities by an irregularly-shaped opening in the middle meatus; {34} then the frontal sinuses, two irregular cavities situated between the two tables of the frontal bone. The communication between them and the nasal cavities is established by the infundibulum, a round opening in the middle meatus, and finally the sphenoidal cells or sinuses, found in the body of the sphenoid bone, communicating with the nasal cavities by small openings in the superior meatus. That portion of the nasal cavities which projects beyond the end of the nasal bone is surrounded by cartilages forming the alæ of the nose.

In the cartilaginous septum of the lower animals we find a small cavity lined with mucous membrane, called after its discoverer Jacobson's organ, the minute anatomy of which has lately been described by Klein.[18] This {35} organ in man is, however, only rudimentary. The nasal cavities are lined with mucous membrane, which varies greatly in thickness in different localities, and which materially decreases the size of the cavities in the living subject from that seen in the denuded skull. This mucous membrane is covered by ciliated epithelium in man, with the exception of that portion which lines the vestibule--i.e. that portion of the cavity of the nose surrounded by cartilage only--which is covered by pavement epithelium.

[Footnote 18: Quarterly Journal of Mic. Science, January, 1881.]

In the lower animals we find that in the olfactory region the ciliated epithelium is either absent, or that ciliated and non-ciliated epithelium alternates in patches.[19] The author has not been able to find a statement in the literature on the subject as to the kind of epithelium found in the accessory cavities in man, but it is very probable that the mucous membrane of the frontal sinuses and the antra of Highmore is covered with ciliated epithelium; otherwise it would be difficult, if not impossible, for the secretions of that mucous membrane to pass through the narrow channels into the nasal cavities. The color of the normal nasal mucous membrane is of a light pink shade in what is termed the respiratory portion, while it is of a yellowish hue in the olfactory region, that portion of the mucous membrane which covers the roof and the outer walls of the nasal cavities down to the upper margin of the middle turbinated bone and the septum down to about the same level. It is in this region that the nerve-ends of the olfactory nerve are distributed. Immediately beneath the mucous membrane, and between it and the periosteum of the bony walls and the perichondrium of the cartilaginous portion of the septum, we find a tissue which bears a striking resemblance to the erectile tissue of the genital organs.[20] It is composed of a network of fibrous tissue, the trabeculæ of which contain a few organic muscular fibres. Its meshes of various sizes and shapes are occupied by venous sinuses lined with endothelium. These are supplied with blood by small arterioles and capillaries, which are quite numerous in the fibrous tissue and can readily be demonstrated under the microscope. In this arrangement of elements of the nasal mucous membrane we find a ready explanation of the fact that liquids of greater or less density than the serum of the blood when introduced into the nasal cavities produce pain, for we have here the most favorable conditions for osmosis, which will cause either a contraction or a distension of the sinuses. In the larger masses of fibrous tissue between the sinuses or caverns we find imbedded the glands, with their ducts opening out between the epithelial cells of the mucous membrane. There are two kinds of glands in this region, which have been described by Klein[21]--viz. serous and mucous glands.

[Footnote 19: Haenle, Anatomy des Menschen, vol. ii.]

[Footnote 20: Haenle, loc. cit.]

[Footnote 21: Loc. cit.]

This cavernous erectile tissue is most abundant at the lower portion of the septum and of the lower turbinated bones; and, although it has been recognized and described as true erectile tissue by Haenle, Virchow, and others, yet to Bigelow of Boston belongs the honor of having first called attention to the part which this tissue plays in nasal diseases. He gave to it the name turbinated corpora cavernosa.[22] The expansion of the nasal cavities formed by the alæ of the nose is termed the vestibule, which is lined with pavement epithelium and forms the entrance to the cavities proper. The naso-pharyngeal cavity extends from the posterior ends of the turbinated bones and the edge of the vomer to the line where the velum palati touches the pharyngeal wall during the act of deglutition or phonation. In this cavity we find the openings of the Eustachian tubes, two crater-like elevations, with a pit-like depression of variable size and shape, one on either side; and a collection of glands with a central duct-like opening disposed on the roof and posterior wall of the cavity. This gland was named by Luschka[23] the pharyngeal {36} tonsil. The openings between the edge of the vomer and the lateral walls of the naso-pharyngeal cavity are termed the posterior nares.

[Footnote 22: Boston Med. and Surg. Journal, April, 1875.]

[Footnote 23: Der Schlundkopf des Menschen.]

ANTERIOR RHINOSCOPY.--Anterior rhinoscopy is a very easy and simple procedure, and is practised as follows: The patient is placed in position as for laryngoscopy, and the light directed upon his face so that the centre of the circle of reflection from the head mirror falls upon the tip of the nose. The examiner then elevates the tip of the nose with his left hand, resting the fingers on the forehead of the patient, and lifts the ala away from the septum with a slightly bent probe, when he will be enabled to see a considerable distance into the nasal cavity. It is, however, better to employ a speculum instead of the bent probe, because the parts then are seen in their usual relation to each other, and are not distorted by the forcible traction necessary when the probe or a dilator is employed. The nasal speculum (Fig. 12) is best made of hard rubber and shaped like the ordinary ear speculum, except that the narrow end is oval instead of round. This instrument is to be introduced by a sort of rotatory motion until the end has passed the edge of the vestibule, when it will remain in position, displaying the interior of the nose. Great care should be exercised, when introducing the speculum, not to scratch the mucous membrane of the septum, for this will give rise to pain and start hemorrhage, both of which are to be avoided as much as possible. When applications are to be made to the mucous membrane of the septum or turbinated bones, or when operations are to be performed within the cavity, it is best to employ an instrument called a nasal dilator, of which there are a large number of different forms, the most satisfactory of which is shown in Fig. 13. The dilator is introduced by compressing the blades between the thumb and fore finger, and pushing them into the nostril until their ends have passed the edge of the vestibule. The pressure is then removed, and the spring separating the blades holds the nostril open; the handle or stem of the instrument, hanging down, need not be held or supported, as the blades press sufficiently upon the tissues to retain the instrument in position. If the pressure is too great, however, it will soon produce pain, and the patient will object to the use of the instrument.

The view obtained both by the speculum and the dilator is rather limited, and usually comprises only the anterior portions of the lower and middle turbinated bones, together with the cartilaginous portion of the septum. In order to get a good view of the lower and middle meatus and of the floor of the nose the patient's head should be inclined forward or backward as occasion requires. The student should, however, not be satisfied by simply inspecting the parts, but should aid the eye by the sense of touch, for pathological changes are of common occurrence, and their nature, whether soft and fleshy or hard and bony, erosions of the mucous membrane, or deep ulcerations, can often only be determined by the aid of the probe. In the same manner can the permeability of the meatuses be determined better than by inspection {37} only. In cases where it becomes necessary to determine whether the anterior portion of the septum is of normal thickness, or whether a projection seen through the speculum is due to localized deflection, an instrument called the septometer is of great assistance (Fig. 14). This instrument is similar to the one used by mechanics to determine the diameter of a piece of wood or iron being turned on the lathe. In using it the long straight shanks are introduced one in each nostril, and, being closed upon the septum, the rounded points are gently moved up and down and backward and forward over the bulging portion of the septum. The motion of the index attached to the curved shanks of the instrument accurately indicates the relative thickness of tissue grasped between the points in the nose. By means of this instrument we can thus ascertain whether we have to deal with a deviation or a localized thickening of the septum; for if it is a deviation the index will move but slightly, while it will travel a considerable distance when the points pass over a thickened portion.

Although simple in its details, anterior rhinoscopy is often made difficult or altogether prevented by obstacles which are mostly due to malformation of the parts, such as deviation of the cartilaginous portion of the septum, exostoses from the superior maxillary bones reaching into the nasal cavity, adhesion between the anterior portion of the lower turbinated bone and the septum, nasal polypi, anterior hypertrophies of the mucous membrane, and so forth; or they may be due to faulty instruments, as too much pressure in the spring of the dilator; or, finally, they may be caused by want of care in the handling of the instruments, as when the septum is scratched by the edge of the speculum and hemorrhage ensues.

POSTERIOR RHINOSCOPY.--Posterior rhinoscopy is much more difficult than laryngoscopy or anterior rhinoscopy, and requires more patience and dexterity on the part of the examiner than either of the former, because but very few persons have control over the movements of the velum palati, and in most of these the upper portion of the pharyngeal wall is so sensitive that the slightest touch with an instrument gives rise to reflex cough and to gagging. In many cases, however, with patience and skill the naso-pharyngeal cavity and the posterior portion of the nasal cavities can be illuminated and inspected. To do this the patient is placed in the same position as for laryngoscopy, except that the head is not inclined backward, and after the mouth is opened as wide as possible the light from the reflector is thrown into the oral cavity. The tongue is then depressed with a tongue depressor. This instrument in its simplest form in which it is daily used by the practitioner for examining the fauces is the handle of a spoon. For laryngoscopic or rhinoscopic purposes, however, the spoon is not to be recommended, because the hand holding it must be on a level with the mouth, thus obstructing the view and light. An instrument has therefore been constructed which obviates this difficulty. It consists of a leaf-shaped blade of silver or German silver bent at right angles and inserted into a flat wooden handle. The lower surface of the blade is slightly concave, and ribbed so as to take a better hold of the slippery back of the tongue, and from the bend is about 3 inches in length. It is introduced into the mouth as far back as possible, and pressed upon the back of the tongue while the hand of the examiner is below the chin of the patient. For the sake of convenience in carrying the instrument the blade has been so hinged to the handle that it will fold up against the latter and will {38} open at a right angle with it (Fig. 15). A more elegant and lighter instrument of the same description has lately been introduced in which the handle is also made of metal, and, like the blade, is heavily nickel-plated, and which when folded can be carried in a pocket-case. Soon, however, the metal tongue depressor becomes tarnished by the secretions of the mouth or by the substances used for applications to the throat, and then presents an appearance disgusting to many patients, who will not on that account submit to its use. For the sake of greater cleanliness, J. Solis Cohen devised a tongue depressor made of hard rubber, which is known as Cohen's tongue depressor (Fig. 16). It consists of a piece of ebonite bent upon itself, either end being a little over 3 inches long. The bend being more than at right angles, the hand holding the instrument rests underneath the chin of the patient; but if a different curve be desired for any particular case it can easily be obtained by placing the instrument for a little while in hot water. When soft it can be bent into any shape, which it will retain when cooled by immersion in cold water. Great care should be exercised not to carry the blade of the instrument too far back, as then gagging will at once set in. In cases where the tongue resists the pressure of the tongue depressor, it is better to exert but a gentle pressure upon the back of the organ, under which it will slowly recede, than to try to subdue it by force, for in the latter case it will unavoidably slip from under the blade of the instrument, and the desired space in the fauces is not obtained. With children the writer has found the fore finger of the left hand to be the best means of depressing the tongue, for the little patients as a rule have a horror of the formidable-looking instrument.

After the tongue has subsided into the floor of the mouth a small laryngoscopic mirror is introduced into the pharyngeal space behind the velum palati, with the reflecting surface upward, and is held there without touching the wall of the pharynx. The handle of the mirror, as in laryngoscopy, is brought into the angle of the mouth, so as to be out of the line of vision. As is usually the case, the velum palati at the approach of the mirror will rise and apply itself to the posterior wall of the pharynx, when of course the naso-pharyngeal space, being shut off, cannot be illuminated. Under these circumstances the velum must be made to hang down as in the act of nasal respiration, which is most easily accomplished by telling the patient to breathe through his nose. It is of course impossible to do so when the mouth is open, but the patient, not being cognizant of the fact, will make the attempt, and the palate will come down, permitting illumination and inspection of the naso-pharyngeal space and the posterior nares. In those cases in which this {39} expedient fails it becomes necessary to forcibly pull down the velum by means of a blunt hook made by bending a silver laryngeal probe, or to tie it down by passing small elastic bands through the anterior nares and bringing the ends through the mouth and tying them over the upper lip. The smallest black rubber tubing is admirably suited for this purpose, as it can be introduced without an instrument. When the palate is pulled down with the palate hook, or when operations in the naso-pharyngeal space are to be performed, the patient must hold the tongue depressor himself, so as to leave the other hand of the operator free. Few persons can do this, however, satisfactorily, and it will be found more convenient to use Jarvis's tongue depressor and rhinoscope, as modified by the writer (Fig. 17). The instrument consists of a stout wire, which, after having been forked or divided at some distance from its insertion into the handle, forms the loop for the tongue depressor. The two branches then cross each other, and are bent to form another loop at an angle to the larger one. The ends of the wire are somewhat flattened and press against each other, thus closing the smaller loop and forming a sort of pincette, which can be opened by pressing the sides of the larger loop toward each other. The ends of the pincette are perforated by a small hole, which receives a pin attached at right angles to the short shaft of a small mirror, thus forming a hinge, so that the mirror can be placed at any desired angle with the handle or stem. The spring of the pincette cannot be made strong enough to prevent a change of the angle of the mirror by coming in contact with the pharyngeal wall, and therefore a ratchet was placed at the shaft of the mirror where it hinged to the end of the pincette, and a small steel spring, coming from one of the branches of the wire where they cross each other to form the small loop, by engaging in the teeth of the ratchet holds the mirror at the angle given to it before introducing. The large loop acts as a tongue depressor, so that with this admirable instrument the examination of the post-nasal cavity can be made with one hand, leaving the other free for the manipulation of other instruments. In order to be able to exert more pressure upon the tongue and to bring the hand out of the line of vision, the handle may be attached to the stem at an angle like the one in the folding tongue depressor. Except in cases of cleft palate the naso-pharyngeal cavity cannot be illuminated in its whole extent, and must be studied in parts, which when placed together in the mind of the examiner form the rhinoscopic image, a slightly diagrammatic drawing of which is seen in Fig. 18.

THE RHINOSCOPIC IMAGE.--In the middle of the drawing we see a triangular plate with its apex downward; this is the posterior margin of the vomer or nasal septum. On either side we notice curtain-like folds projecting against the septum; these are the posterior aspects of the turbinated bones. On either side of these and on the margin of the drawing we notice pointed elevations projecting toward the interior of the cavity, with a crater-like {40} depression on their apices; these are the lateral pharyngeal walls with the orifices of the Eustachian tubes. Above we see the vault of the pharynx, and below the posterior surface of the velum palati with the uvula.

Another method of examining the laryngeal and naso-pharyngeal cavities, which is especially valuable in cases where neoplasms or impacted foreign bodies hide the parts forming the laryngoscopic and rhinoscopic images, is by means of digital palpation. Even where no obstruction is present the beginner will do well to resort to this method in all cases, for he will thus become better acquainted with the topography of the parts than by inspection only. The procedure is not as difficult nor as disagreeable to the patient as might be imagined, and needs but little description.

When the laryngeal cavity is to be examined by palpation, the head of the patient is thrown back, and steadied in that position by the left hand of the examiner while he introduces the index finger of the right hand into the mouth and slides it along the back of the tongue until the tip comes in contact with the upper margin of the epiglottis. Passing downward along its lateral margin on either side, the ary-epiglottic folds and the tips of the arytenoid cartilages can be felt, and likewise the upper surfaces of the ventricular bands. The vocal cords are, as a rule, too low down to be reached by the tip of the finger. An examination of this kind should of course be made quickly while the patient is holding his breath, so as not to obstruct respiration too long, which in cases of narrowed glottis by neoplasms might give rise to serious results. When the naso-pharyngeal space is to be explored by the finger, the patient's head is bent forward, and the index finger is gently pushed upward between the velum and the pharyngeal wall. When this is accomplished, the velum is drawn forward and the finger pushed along its posterior aspect until the different portions forming the rhinoscopic image are reached and explored by the sense of touch.

{41}

DISEASES OF THE NASAL PASSAGES.

BY HARRISON ALLEN, M.D.

Coryza.

Coryza is an acute inflammation of the mucous membrane of the nasal chambers. The disease is ordinarily idiopathic, but may be produced by irritative vapors, pollen, or dust. In the idiopathic form the symptoms of coryza are often preceded by malaise, with chilly sensations, and in severe attacks with headache. The attack itself is divided into two stages: that of determination or congestion, and that of exudation. In the first stage the excessive quantity of blood flowing into the arterio-venous network and the capillaries of the nasal mucous membrane distend them and obstruct the nasal chambers.

The symptoms are referable either to such obstruction of nasal respiration--in which group are included oral respiration, sensations of distension, and throbbing in the nose--or to reflexes, such as frontal headache, attacks of sneezing, and dull aching pain in the teeth.

The first stage lasts for a period varying from a few hours to several days, and is followed by the stage of exudation. This is characterized by a free watery or mucoid discharge from the nasal chambers, and by the cessation of the symptoms due directly or indirectly to pressure of the layers of swollen mucous membrane against each other. The discharge at first is watery, and is doubtless composed of transuded liquor sanguinis. It is followed by a mucoid fluid, which in severe or neglected cases may assume a purulent character. In many instances, even in mild cases, the discharge becomes muco-purulent toward recovery. The second stage is associated in children and adults of delicate constitution with excoriations of the nostrils.

Suppuration may take place in nurslings and in old people. It would appear that in coryza, as it exists in the northern countries of Europe, the beginning of the second stage is apt to be marked by free suppuration.

Acute coryza may involve the sinuses of the face, particularly the maxillary sinus. The involvement of the frontal and sphenoidal sinuses, while possible, is infrequent. Pharyngitis, laryngitis, and occasionally acute aural catarrh, often coexist with the disease.

The symptoms of coryza are so distinctive that the diagnosis is easily made. But since any obstructive or catarrhal state of the nose is described by patients as a cold in the head, it is necessary for the medical attendant to distinguish the various diseases so denominated. Acute coryza may be confounded with angiose hypertrophy; with the obstruction to nasal respiration due to deflection of the nasal septum or to an inflamed soft polypus; with catarrhal irritation affecting surfaces which are already enlarged by hyperplasia or which are undergoing atrophy; or with the effects of operative interference in the nose.

In angiose hypertrophy the swollen membranes will contract under a mild {42} current of electricity or by change in the position of the body. Both chambers are rarely involved at the same time. Reflexes are of infrequent occurrence. Obstruction to nasal respiration due to a deflected septum arises from causes which are insignificant and do not affect the constitution. The genuine influenzal or catarrhal element is absent. In an inflamed soft nasal polypus an attempt at inspiration will, as a rule, detect the presence of the growth. In diffuse multiple polypi the case is different. Many persons who are reputed to take cold readily, or who may be said never to be free from cold, are really sufferers from neglected polypi. Persons suffering from atrophic catarrh always speak of an exacerbation of their symptoms as a fresh cold, and describe the disease itself as a cold. The sense of fulness, the throbbing, the heat, and the characteristic discharge of coryza are absent. A fresh cold in atrophic catarrh is an attack of inflammation (often catarrhal in character, it is true) which affects the involved surfaces, but is attended with an increase of plastic exudation and accompanying fetor.

It is a common occurrence for patients who have had a cautery application made or a polypus removed to return after a few days' absence with the report that they have contracted a cold. While the condition may be an attack of acute coryza, the chances are in favor of the symptoms being excited by the manipulation or the reaction from the operation. The symptoms are mild in character.

TREATMENT.--The treatment of coryza is both local and constitutional. The local treatment consists in applications of agents which tend to constrict the vessels of the nasal mucous membrane. In the first rank of such agents may be named cocaine, which in a 2 per cent. or a 4 per cent. solution will often give notable relief by overcoming the sense of obstruction. Individuals will be found in whom the effect is of short duration, and in some persons I found the medicine to have no effect whatever. In more favorable subjects the relief will be acknowledged for a period varying from four to six hours. Next in rank may be named a current of constant electricity (say from six to ten cells) passed through the cheeks. Should neither of the above-named agents be available, inhalations of iodine vapor, a few drops of chloroform rubbed upon the palms and inhaled, or the inhalation of the spirits of ammonia may be recommended. Toward the later stages of the disease detergents and mild astringents are well borne. The constitutional treatment includes the administration of diaphoretics and minute doses of opium, especially in the early stages of the disease. Coryza is commonly self-limited, and by far the larger number of cases do not come under the care of the physician.

Chronic Nasal Catarrh.

Chronic nasal catarrh embraces those more or less persistent affections of the nasal chambers whose symptoms resemble those of acute coryza. The term catarrh is inexact. It is used to include several diseases associated by a single characteristic--namely, the existence of an increased amount of mucous secretion upon the affected membranes.

In order to understand the varieties of nasal catarrh, it is necessary to have clear conceptions of the uses of the nasal chambers. The normal performance of the function of respiration demands that when the mouth is closed the currents of air should pass through the nose. These currents, however, do not sweep over the entire nasal surfaces, but are confined to those portions which answer to the inferior meatus and the space bounded within by the septum, without by the median surface of the inferior turbinated bone, and above by the under surface of the middle turbinated bone. In the lower mammals this space is separated posteriorly by a transverse bony lamina which {43} effectively excludes the upper portion of the nasal chambers from the tract just named. Anteriorly, at the termination of the inferior meatus and the middle turbinated bone, the tract is in freer communication with the upper spaces. The passage thus briefly defined may be called the respiratory tract, and when it remains patulous no serious interference with nasal respiration can occur.

The transverse diameters of the tract are subject to frequent changes, owing to the erectile character of the mucous membrane in its walls. But as long as the surfaces do not touch one another obstruction cannot exist. The passage, even when narrowed to a chink or line intervening between the median and lateral walls of the tract or between the floor and the roof of the inferior meatus, is sufficient evidence that there is room for the transit of the currents of air. The membranes themselves are subject to changes in form which are dependent upon the degree of development of their erectile tissue.

There is doubtless a disposition on the part of the erectile tissue to grow in the direction of the least resistance, and thus to occupy, by a process of compensative hypertrophy, the spaces left as the result of variations or defects in development in the bones composing the framework of the nasal chambers. The greater development of the erectile tissue may in this way be found on the side answering to the larger respiratory tract, which may therefore be more apt to suffer from changes in the conditions of nasal breathing than the chamber having the smaller tract. The erectile tissue acts as a monitor to the throat and lungs by presenting warm surfaces over which the air passes, thereby having the temperature raised before it enters the throat and lungs. It also acts by occluding the chamber, and thus aids in shutting out irritant vapors and dust. The lower animals possess a higher degree of development of the tissue at the point where the adducted ala presses against the septum. This point answers to the position of the organ of Jacobson. With man, the locality of the adduction corresponds to the junction of the premaxillary with the maxillary portion of the nasal chambers, and is often the seat of a delicate band of mucus extending across from the inferior turbinated bone to the septum.

That portion of the nasal chamber above the respiratory tract may be called the olfactory tract. It does not appear to be involved in the diseases under consideration, or, if it is, no clinical signs or symptoms are presented with which the author is acquainted. It will therefore receive no attention in this article.

For convenience the varieties of chronic catarrh may be classified as follows:

FIRST VARIETY--that dependent on defective nasal respiration.

This variety is caused by--

(a) Osseous obstruction in the nasal chamber.

(b) Membranous obstruction in the nasal chambers from compensatory hypertrophy of the erectile tissue, alone or with hyperplasia.

(c) Obstruction arising from hypertrophy of the adenoid tissue in the pharyngeal vault.

(d) Contracture of the levator palati muscles.

SECOND VARIETY--that dependent on structural changes in the component parts of the nasal chamber.

This variety is associated with--

(a) Chronic inflammation of the nasal mucous membrane without hypertrophy of the erectile tissue.

(b) Atrophy of the turbinals and their associated mucous membrane.

(c) Necrosis of the bones which enter into the framework of the nasal chambers.

FIRST VARIETY.--Defects in nasal respiration induce hyperæmia, distension of the erectile tissue, hyperplasia of the mucous membrane, and {44} inevitable distress in the nose. A sense of fulness across the bridge of the nose and at its sides is complained of. Frontal headache may be present.

(a, b) When the septum is deflected and the left nasal chamber is narrowed, the labor of sustaining nasal respiration is thrown on the right side. This arrangement invites a flow of blood to the already large turbinals, and creates obstruction which is frequently referred to the right side, although both are alike affected. Thus, subjects in which the initial obstacle is osseous complain of distress caused by cavernous-tissue hypertrophy of the lining membrane of the opposite side. This represents a very common class of cases.

When the septum is not deflected, but projections from it impede the current of air, there may be either unilateral or bilateral obstruction, dependent upon the shape of the septum itself. Hypertrophy of the cavernous layer of the mucous membrane usually coexists. These cases are numerous, but less common than those last described.

Infrequently, cases are seen where the distress is occasioned by defects of the osseous structures not accompanied by cavernous hypertrophy.

Treatment of the above disorders consists in restoring nasal respiration by removing obstructions, whether they be osseous or membranous. The septal projections may be drilled or filed away, or, if marked deflection of the anterior portion be present dependent upon a malposition of the triangular cartilage, an operation simple in character may be performed for its correction. This consists in severing the connection of the lower margin of the cartilage with the maxilla and slipping the partially free cartilage to a new position. The details attendant upon the operation need not be here given. The reduction of the hypertrophied membranes can be best accomplished by cauterization. The most efficient method is by means of the electric cautery. The electrode used should be flexible and of small size. The points which most frequently require cauterization are the premaxillary portion of the inferior turbinated bone, the under surface of the same, and the septum at the maxillary spur. Rarely the inferior surface of the inferior turbinated bone at the palatal region requires attention. The applications are best made over small surfaces at a time, and should be repeated at intervals of from two to three days until all suspected points have been at least once cauterized. Not infrequently, the effect of the cauterization at one spot will cause constriction to take place in the vessels of the entire mucous surface, so that while this condition lasts it is impossible to tell what additional points of the membranous obstruction demand removal. At the following visit, however, the vessels have become relaxed, the membranes are again turgescent, and if obstruction now occurs it can easily be detected.

The galvano-cautery can only be used in the nasal chamber in patients who are earnestly seeking relief and are willing to assist the physician in all his efforts. With the tractable, intelligent subject it can with proper care be limited exactly to the spot intended. It is scarcely necessary to observe that any erratic or unexpected motion of the head will sear unaffected and sensitive surfaces. The interior of the vestibule is perhaps the most sensitive of these, and should always be protected by the use of the nasal speculum. No additional protection is needed, though in the judgment of others, among whom may be mentioned E. Shurly of Detroit, Michigan, an ivory shield passed in the nose parallel to the electrode is a necessary safeguard.

The pain of the application is generally slight, and can be in part annulled by a previous application of a 4 per cent. solution of cocaine. Some annoyance is acknowledged on the following day from the pressure of the eschar. Traumatic congestion of the entire mucous surface of the corresponding chamber is at the same time detected, and is usually sufficiently decided to produce some of the effects of acute coryza. This condition will spontaneously terminate in from thirty-six to forty-eight hours. The most annoying features {45} following an application of the galvano-cautery which has been too freely made do not belong to the group just indicated, but rather to reflex disturbances. Pains are occasionally excited in the teeth, in the temple, eye, nape of the neck, and the middle ear. On one occasion in the writer's experience a unilateral reflex excitation of the entire opposite side of the body occurred, and a prickling sensation, followed by numbness, ensued, which lasted for twenty-four hours. Very rarely a congestion of the pharynx, of the larynx, and the larger bronchial tubes ensues, which can scarcely be directly attributable to the application, yet it has followed in a sufficient number of cases to lead me to believe that the two are in some remote way associated. Perhaps such a condition is analogous to the slight irritation of the respiratory tract following excision of the tonsil. Careful use of the galvano-cautery will obviate the conditions above described. They are important to remember as serving as limitations to the use of this valuable agent.

(c) It will be seen that osseous obstruction in the nasal chamber and hypertrophy of the cavernous nasal tissue often coexist. More rarely, a third element occurs as a complication, or it may be found independently of all other morbid processes. I allude to the presence of hypertrophy of the adenoid tissue in the pharyngeal vault. When this tissue is only moderately developed, it need not, and does not, interfere with nasal respiration; but when it projects downward to such a degree as to lie within the axis of the lower portion of the posterior nares, it produces the same effect upon nasal breathing as though obstruction existed within the chamber. The growths can be easily detected, as a rule, from behind by the aid of the rhinal mirror, but it should not be forgotten that they also can be seen from in front, provided the chamber is free from obstruction along the respiratory tract. In some individuals the ribbed or lobate structure of the mass can be discerned, but more often its presence is revealed by the minute points of light reflected from the lobules. If it be a matter of doubt whether these points of reflection are within the nasal chamber or beyond it in the pharyngeal vault, the patient may be requested to swallow, or to pronounce the letter e; when, if the point of reflection is within the nasal chamber, it will not change its position, but if it be within the naso-pharynx, it will be moved slightly from side to side, or it may for a moment disappear.

The symptoms of nasal catarrh which are provoked by the presence of such a growth can be alone successfully treated by the removal of the offending mass. In young individuals--say, from twelve to eighteen or twenty years of age--the finger inserted into the naso-pharynx from behind can often break down the growth. Slight hemorrhage follows this procedure, and the tags of imperfectly-destroyed tissue can be subsequently treated by caustics and powerful astringents. In the event of the patient proving intractable, the growth may be reached from in front through the nasal chamber, and the galvano-cautery can be used by passing the electrode backward through the nostril until it meets with resistance, which is invariably at the pharyngeal vault. Should this method of treatment not be permitted by an undisciplined or nervous person, the prolonged use of a glycerole of iodine may gradually reduce them in size; but no definite result can be promised from such treatment.

(d) Very rarely, through inordinate elevation of the soft palate owing to over-action of the levator palati muscles, the passage of communication between the naso-pharynx and the oro-pharynx is inadequate. Consequently, the nasal chamber is imperfectly ventilated, and its secretions, not flowing backward or being displaced to the normal extent, become semi-inspissated, and create obstruction by lodging in the respiratory tract, either in the premaxillary or palatal portions. To successfully combat this condition it is evident that no local treatment is demanded, either in the nose or the naso-pharynx, other than to increase the tonicity of the pharyngeal and palatal {46} muscles. Very frequently in such cases there is a symmetrical atony in the muscles last named, which demands the internal use of strychnia and iron and the application of galvanism.

PROGNOSIS.--When nasal catarrh has proved to be dependent on defective respiration, the removal of the causes entering into this condition may with reason be expected to effect recovery. The prognosis, therefore, is favorable. In young persons, in whom reparative power is present in the highest degree, and in whom a secondary hypertrophy of the cavernous tissues is least developed, a prompt cure may be obtained by removal of the osseous or other forms of obstruction. In adults, however, the prognosis is less favorable, especially with those who have approached or passed middle life, and who have contracted vicious habits of breathing, which are likely to persist even after the removal of their causes. It is also tenable that in such subjects the mucous lining of the cranio-facial sinuses has become involved. Should anosmia persist after the capacity of the chambers has been augmented--in a word, should this condition not be dependent upon obstruction, but upon changes in the olfactory surfaces--the prognosis is less favorable than in any of the cases of the above-named group.

Treatment will, however, always secure amelioration of the symptoms, and few cases occur which cannot be greatly improved. The general health is invariably benefited. Should a tendency to asthma exist, it is apt to disappear, the complexion clears, and in adolescence the rate of general development is accelerated.

SECOND VARIETY.--The group of nasal diseases included under this head is not a natural one, since it embraces disorders characterized by a negative feature--viz. absence of obstruction to nasal respiration. Nevertheless, it is convenient to consider under a single head a number of relatively infrequent disorders in which there is invariably an underlying constitutional cause. Subjects of disorders herein embraced are not merely sufferers from insufficient oxygenation of the tissues, but have impaired general vitality or possess a decided constitutional taint, whether specific or otherwise. The nasal condition is simply the most prominent of the local manifestations.

Three distinct disorders are herein named: first, chronic inflammation of the nasal mucous membrane; second, atrophy of the turbinals and their associated mucous membrane; third, necrosis of the bones entering into the framework of the nasal chambers.

(a) Inflammatory thickening is a rare affection. It is more frequent in males than in females, and in persons of a sedentary occupation than in those who are actively employed. Those subject to it are apt to have light-blue or gray eyes and auburn or sandy hair. On examination, the chambers may be found free from peculiarities of bony structure, capacious, and without hypertrophy of the cavernous tissues, yet the membranes be of a deep-red color and of cushiony consistence, yield bright reflexes, and the shank of the instrument introduced into the nose is mirrored upon them. The most conspicuous alteration is not seen on the turbinals, but on the septum. The parts are very vascular, and the most moderate manipulation will often end in free capillary oozing. The discharge, though moderate in quantity, is inclined to be purulent, and resembles semi-coagulated albumen. Quite frequently, in the examination of a neglected case, minute flecks of this modified secretion are seen scattered over the septum and the inferior turbinated bone. Rarely, the discharge is maintained by the presence of a morbid growth or inflammatory products, either in the nasal chamber or a chamber accessory to it. The discharge then appears to consist of pure pus mixed with the normal secretion of the nose, and, thus rendered viscid and tenacious, it excites by its presence a condition of the lining mucous surface quite similar to that above described.

{47} Under excitement, as after an attack of coryza, the discharge becomes more serous in character, and is occasionally of a chocolate color from its admixture with blood. It is without odor. There is no obstruction to respiration except during sleep, when, in aggravated cases, mouth-breathing may be established. Thus, the patient will often complain of an obstruction which is never present at the time of the examination. He further complains of a sense of dryness in the nose, with some pharyngeal irritation. The palato-pharyngeal and palato-glossal muscles are weak and often asymmetrical; the tonsils are small, but the adenoid tissues are generally unaffected. In a dry atmosphere, especially if it be loaded with irritating particles, the pharyngeal irritation is increased--a complication which is probably due to the inspired air passing too rapidly through the capacious and imperfectly-guarded nasal chambers and throat. Although I have carefully searched for all indications of aural complications, especially for the symptoms of progressive dry catarrh, I have never detected them but in a single instance.

The prognosis is to be guarded, although a careful course of treatment and proper care of the general health will greatly improve, if not entirely cure, the disease.

TREATMENT.--This consists in the application of nitrate of silver, either in strong solution or in the solid stick, to the under surface of the inferior and middle turbinated bones, of washing the parts with a dilute solution of carbolic acid, and of passing through the cheek tissues a constant electrical current of a strength of from five to ten cells. Tonics and alteratives should not be neglected, and an outdoor life, as far as is practicable, should be enjoined. The galvano-cautery may be used to destroy any nodules of tissue which resist other treatment. All applications are well borne, if indeed we may not look upon the condition of the surfaces as partially analgesic, and thus far of unfavorable significance. It is certain that indurated tags of oedematous and chronically inflamed mucous membrane overlying a bone, such as the middle turbinated or the alveolar line about the necks of the teeth, will never yield to anything but the most powerful astringents. Upon such tissues the most concentrated solutions of nitrate of silver are never caustic. The premaxillary portion of the inferior turbinated bone is frequently seen hopelessly infiltrated, and it must then be destroyed by the electro-cautery. When a discharge of a pus-like character exists, careful search should be made for the cause. If a tumor or foreign body be found, it should be removed, but if the cause lie in one of the outlying spaces of the nasal chamber, it is evident that the above treatment is palliative only.

(b) In atrophy of the nasal mucous surfaces and turbinals we have, as in the last-named group, spacious chambers, a purulent discharge, pharyngeal irritation (in many cases), and always associated a thin and relaxed, if not a paretic, condition of the velal muscles. These cases might be looked upon as an advanced stage of the preceding affection, since it may be surmised that the stage of infiltration has been succeeded by one of atrophy. The mucous membranes are everywhere pale, and closely bound to the underlying bony framework. The discharge is purulent and confluent; where in contact with the air it is desiccated, but where protected, as by crust-like surface-layers, it is semi-fluid and tenacious. There is, consequently, no disposition for the discharge to escape from the nose, and it accumulates until the sense of obstruction induces the patient to remove it by artificial means. When first seen, the nasal chambers are frequently so fully occupied with discharge as to conceal the characteristic appearances of the mucous surface. This prolonged retention induces incipient decomposition of the mass, which gives rise to the odor so characteristic of this group of cases.

The subjects of atrophic catarrh (ozæna) are never in robust health. They are, as a rule, of spare habit, anæmic, and with family histories which, while {48} not distinctive, indicate that the affection is, to some degree at least, hereditary. A few cases have come under my notice in which all the general features of atrophic catarrh were present, but with very slight although confluent discharge, unaccompanied by fetor. Such cases are, strictly speaking, examples of atrophic catarrh, while they could not, under the old nomenclature, be included under the head of ozæna.

The prognosis is unfavorable for entire recovery, but treatment systematically pursued will make the patient entirely comfortable to himself and others--will arrest the progress of the disease and vastly improve the general health. As in other forms of nasal disease, should anosmia be present the prognosis is less favorable.

TREATMENT.--The parts should be carefully cleansed--an act which, while imperfectly accomplished by either the syringe or the douche, is, in my judgment, best performed by the galvano-cautery. This instrument, the one relied upon for the subsequent treatment of the case, is to be selected for its initiation. The largest speculum which the nose will admit being placed in position, a spiral-looped electrode is introduced cold into the nose and held against one of the crusts. When heated it will effect so firm an attachment to it as to enable the mass to be withdrawn with great ease. In patients with {49} whom the palatal portion of the floor of the nose is depressed below the level of the maxillary a considerable quantity of discharge may lie concealed from observation. When, after the removal of all visible crusts, the fetor persists, it is reasonable to suppose that the palatal depression is filled with decomposed pus and mucus. To test such a condition, the electrode should be appropriately curved and introduced. I have been surprised at the quantities of discharge which can in this way be withdrawn from a locality which, as far as I know, cannot be cleansed in any other way.

With the removal of the crust relief is at once experienced, and if the discharge could be removed as fast as it forms the disease would not really be a source of offence. The general health would also improve, from the fact that an atmosphere tainted with a burden of decomposition would no longer be breathed. But in practice this cannot be attained, and it is imperative, after the chambers have been entirely cleansed, to cauterize the lining membrane throughout. I have been in the habit of beginning such cautery treatments with the middle turbinated bone, passing thence to the inferior turbinated bone, then to the roof of the nose in front of the sphenoidal sinus, and lastly to the septum. Small surfaces only should be covered at a single treatment, so that it may take a month or six weeks to finish a single series of applications. This treatment is almost always well borne, nothing ever ensuing beyond a slight headache or a temporary establishment of a serous discharge. Notwithstanding that the condition in question is one of atrophy, the reparative power of the mucous membrane remains apparently unaffected. At all events, no danger from sloughing is to be dreaded after such extensive destruction of tissue. The thin eschars separate within from three days to a week, leaving a healthy mucous membrane beneath. In one instance the cauterization had extended to a sufficient depth to expose the bone, and yet from this denuded surface no exfoliation took place, the parts healing rapidly and satisfactorily. No other local treatment is relied upon for fetid atrophic catarrh than the one mentioned. No disinfectant washes are required if the discharge is removed as described. Should the patient be so situated as to be unable to report regularly for its removal or treatment, a wash composed of one part of Labarraque's solution to sixteen parts of water may be ordered with advantage, or a solution of carbolic acid, gtt. j to fluidounce j, with a little glycerin, may be snuffed up the nose twice a day, or listerine, diluted one-half with water, may be used with advantage. The general health, of course, should be cared for, and any complications met. I have found that during the winter months arsenic and cod-liver oil are well borne, associated with minute doses of Lugol's solution. For adolescents earthy and the calcareous phosphates are indicated, and for all abundant exercise and careful dieting. When the symptoms have been relieved, the patient should be requested to report once a month, for it is not to be expected that all symptoms will disappear, and some point of advice can be advantageously offered at this interval.

(c) Necrosis in the nasal chamber is a cause of catarrh, inasmuch as the fragments of bone lying within the nose excite irritation and induce discharge. I have never seen a case of this form of disease which was not due to syphilis. The remains of syphilitic angina are apt to be present, and the general manifestations of constitutional syphilis are well developed. The septum is more frequently affected than the turbinals.

Discharge due to necrosis can be readily distinguished from that arising from any other cause by the presence of detached fragments of denuded bone, by the characteristic fetor, and by the history of the case.

The prognosis is favorable, for all symptoms will cease upon the extraction of the fragments, or at least those which remain are of an entirely different character, and are due to the resultant imperfections of the septum, and consequent irritation arising from the too free entrance of air into the {50} nose. I have seen in one case an extensive tumefaction and infiltration of the tissues covering the middle turbinated bone at the same time that the septum was breaking down. These masses require treatment with the galvano-cautery and astringents after the dead fragments have been removed.

A TABLE OF NASAL DISEASES GROUPED BY SYMPTOMS.

Cases in which interference with nasal respiration is a conspicuous symptom: Due to deflection of nasal septum (common). Due to angiose hypertrophy of the mucous membrane (common). Due to tumors lodged in the nasal chamber. Due to adenoid hypertrophy in the naso-pharynx. Due to over-activity of the levator palati muscles (rare).

Cases in which discharge is a conspicuous symptom: Due to hyperplasia of the mucous membrane over the turbinated bones (common). The discharge when flowing backward is described as a dropping; when forward, as a running at the nose. The discharge is either mucoid or muco-purulent. Due to tumors lodged in the nasal chambers or appendages. The discharge is usually excessive. When due to myxomata (polypi) the discharge is mucoid (common). In inflammatory complications of the same the discharge is muco-purulent (common). When due to neoplasms other than myxomata the discharge is purulent, and rarely muco-hæmic (rare).

Cases in which retention of mucus in the nose or upper part of the throat is a conspicuous symptom: Due to retention of inspissated mucus at the roof of the naso-pharynx (common). Due to the mucous secretion of the nose and throat being excessively tenacious (rare).

Cases in which fetor is a conspicuous symptom: Odor putrid. Due to retention and decomposition of plasmic exudation from atrophied bone and mucous membrane (common). Due to necrosis of the bones within or bordering upon the nose (rare). Due to decomposition of muco-pus in the maxillary sinus (rare). Odor musty. Due to partial decomposition in small patches of desiccated mucous crusts (common). Due to morbid secretion unaccompanied by profound alteration in the structure of the nose (rare). Due to ulcerations of the mucous membrane (rare).

Cases in which a sense of dryness is a conspicuous symptom: Due to ineffective erectile tissue permitting air imperfectly warmed to enter the nose and the pharynx (often met with in neurosis). It is caused by temporary constriction of the erectile tissue or by the atrophy of the tissue. Due to neurosis. Neurotic patients will often complain of a sense of dryness in the nose and the naso-pharynx when all the conditions of excessive mucoid discharge are present.

Cases in which hyperæsthesia exists, so that slight lesions that in any way interfere with the nasal functions form the basis of persistent complaint (not infrequent).

Epistaxis.

Epistaxis, or nose-bleed, is a form of local hemorrhage perhaps of more frequent occurrence than hemorrhage from any other mucous surface of the body. This is doubtless owing to the extreme vascularity of the lining membrane of the nose and the special arterio-venous (cavernous) spaces of the turbinated bones; and the bleeding may be said to be of grave character in proportion as these spaces are involved. In some individuals a special disposition to nasal hemorrhage exists. From the fact that the affection is transmitted from parent to offspring, and is frequently found in all members of a given family, this form of hæmophilia is probably dependent upon some structural peculiarities in the cavernous spaces.

The causes of epistaxis are both local and general. Among the local causes may be included traumatism, either from blows or other injuries, attempts on the part of the patient to relieve irritation by picking the nose, or from the {51} use of cutting or other instruments in the hands of the surgeon. Septal ulcerations in this way are often accompanied by moderate bleeding. In a case reported by R. G. Curtin the nasal branch of the ophthalmic artery was thought to have been ruptured. Among the general causes the most frequent is undoubtedly the depressed state of the system preceding or accompanying typhoid and other anæmic states. Thus, among the prodromes of typhoid fever epistaxis holds a conspicuous position. It is also seen in chlorotic females, especially in those suffering from that phase of anæmia known as Grave's disease. It also occurs in vicarious menstruation and in local facial or encranial congestions. In those disorders of nutrition accompanied by a tendency to capillary extravasation, such as purpura and scurvy, the nasal mucous surface participates in the general disorder. In a case of the former disorder coming under the notice of the writer the blood had forced its way out in large quantities by every capillary avenue.

TREATMENT.--Epistaxis when a symptom of a dyscrasia is of course to be treated as a local expression of a general condition. In typhoid fever, scurvy, and purpura or anæmia the bleeding is a sign of the general distress, and requires no special local method of treatment. Epistaxis when of local character should be treated, first, by removing the cause; second, by diminishing the flow of blood to the part; third, by cold and astringent washes to the affected surface; and, fourth, by compression.

First. Should the bleeding be kept up by fragments of bone impinging upon or lacerating the mucous membrane, they should be restored as far as possible to their natural position and retained there by appropriate apparatus. If they are entirely denuded of their periosteum and mucous membrane, they should be removed. Foreign bodies should be extracted, and if septal ulceration be present it should be carefully treated, the crusts removed, the ulcerated surfaces touched with nitrate of silver in stick, and the nasal chamber plugged from in front to exclude the outside air.--Second. The position of the body is of great importance in treating epistaxis. The recumbent position is no doubt to be preferred. The patient often holds one arm elevated or ties a cord about the proximal end of a limb. These innocent accessories to treatment may be permitted, since they are based upon well-known physiological principles, although it must be said that the bleeding can in all instances be checked without their aid. Cold applications to the nape and sides of the neck are often of service. Various internal remedies, such as ergot, gallic or sulphuric acid, and erigeron, may be administered with good effect in addition to the local measures.--Third. Astringent washes, such as a solution of alum--about drachm j to the pint--will often check a moderate degree of capillary bleeding without other aid. Tannic or gallic acid may also be used. Should these measures fail, the Monsel solution may be used on pledgets of cotton carried up to the bleeding spots. In Curtin's case, already quoted, a pledget saturated with the solution of the perchloride of iron placed over the nasal branch of the ophthalmic artery promptly arrested the bleeding. In lieu of these styptics the platinum wire loop of the galvano-cautery battery may be used. The writer has often succeeded in checking bleeding after a removal of a polypus or the use of the galvano-cautery when the exact position of the hemorrhage is known by laying upon the affected spot a little square of patent lint. It acts much as in checking the bleeding from a leech-bite.--Fourth. Compression of the mucous lining of the nose and exclusion of these surfaces from the air--a method familiarly known as plugging the nose--is the dernier ressort in the treatment of epistaxis, and is to be relied upon in the event of failure of other methods. This failure is, however, relatively infrequent. Observers agree in describing the procedure tedious and rather disagreeable, as much to the operator as to the {52} patient, who has already been exhausted by loss of blood and the previous measures resorted to for his relief.

The instrument usually relied upon for this purpose is known as Bellocq's canula (Fig. 20). This little instrument consists of a hollow curved tube of metal fashioned somewhat like a Eustachian catheter, and bearing within it a flexible and adjustable metallic band which carries at its extremity an eyelet. Any one who has used the Eustachian catheter will recall the number of instances in which it could not be passed, or if passed the frequency in which great distress followed. If this be true of the Eustachian catheter, it is also true of the Bellocq canula, the difficulty in the case of the catheter, indeed, being the lesser of the two, inasmuch as the physician has a number of sizes to select from. Conceding, however, that the instrument (with a long stout thread passed through the eyelet of the stylet) has been placed in position in the nasal chamber, one end of the thread is seized within the mouth and brought out between the lips, while the other, carried by the instrument, is withdrawn through the nose and is allowed to hang from the nostril. The two ends of the thread are now tied firmly together, and a pledget of lint or cotton, fashioned somewhat after the shape of the posterior naris, is tied to the thread. Traction is now made upon the nasal portion of the thread until the plug is firmly lodged against and within the posterior naris. The remaining portion of the oral thread is now cut off close to the velum, and the free end of the nasal thread secured by adhesive plaster to the integument. The nostril should next be stopped from in front by pledgets of lint or absorbent cotton. The size of the nasal chamber and naso-pharyngeal varies so markedly that a rhinoscopic examination is of use in fixing upon the size of the plug. If it be too small, it will be drawn entirely within the nose, and possibly beyond the bleeding spot. If it be too large, it will partially or entirely occlude the posterior naris of the opposite side, and thus by interfering with nasal respiration greatly increase the distress, or by pressure against the Eustachian fossa and velum interfere with the hearing and with deglutition. The plug should be retained in position until a purulent mucus appears within the nose: this is usually about the third day. The plug now usually becomes a little loose, and can readily be withdrawn by pushing it back into the pharynx, where it is seized with forceps. Too long retention of the plug in position is followed by great fetor and the free formation of muco-pus--conditions which tend to debilitate the patient.

D. Hayes Agnew informs me that he for a long time practised stopping nasal hemorrhage by plugging the chamber from in front. Strips of patent lint four inches long by half an inch wide are employed for this purpose. They are gradually pushed into the chamber until the entire space is filled as far as is practicable. An essentially similar method is described by F. H. Bosworth in his Manual of Diseases of the Throat and Nose.

Morbid Growths.

These may be said to include the myxoma, sarcoma, fibroma, carcinoma, also the true hypertrophies and submucous inflammatory thickening.

{53} The myxoma, more commonly known by the name of soft or gelatinous polyp, is the most prominent of the morbid nasal growths. It occurs ordinarily in small pedunculated seed-like masses, ranging in size from that of a grain of wheat to a grape. The most common seat is on the anterior portion of the middle turbinated bone and on the median surface of the inferior turbinated bone at the palatal portion. Instead of being pedunculated, they may be sessile; that is, each tumor may have a base equal to, if not exceeding, any diameter of the tumor.

The symptoms of nasal polypus are of three kinds: (1) those arising from obstruction of the nasal respiration; (2) those arising from the irritation excited by their presence; (3) the symptoms, reflex in character, manifested at points beyond the limit of the nasal chambers.

(1) The polypi necessarily tend to obstruct the respiratory tract of the nasal chamber. The first symptoms are of this character, and as a rule furnish the first intimation to the patient that trouble exists. Difficulty of nasal respiration is acknowledged, accompanied with a sense of tension and fulness, which is found to be worse during damp weather than when the air is dry and bracing. If the growths are freely pendulous, the act of blowing the nose may change the position of the mass and secure temporary freedom from distress. Incidental to obstruction, an intonation of the voice is often present. Loss of smelling and of taste is a frequent result of the mass interfering with the movement of the odoriferous particles. The loss of the sense of taste is dependent upon the loss of the sense of smelling.

(2) Polypi when large enough to press against the membranes of the nose excite an increased flow of mucus. As a rule, this flows forward, and is removed by the handkerchief. The quantity of fluid thus escaping is often very great. Patients often report the necessity of carrying about with them for a single day's use from eight to ten handkerchiefs. In the turgesence excited by an attack of coryza the mucus becomes thicker and of a yellowish color. Occasionally a sensation of dropping of mucus from the nose into the throat is a source of complaint.

(3) The reflex symptoms belonging to the presence of nasal polypi are, as a rule, referred to the forehead. This is especially the case if the growths involve the middle turbinated bone. When the tumors are so located, and have not impinged upon the respiratory tract, the symptoms of obstruction may be absent, and those of mucus excitement so moderate as not to excite attention, while the tension in the forehead, especially over the frontal bos, is pronounced. This sensation is intensified by prolonged inclination of the head forward, being especially aggravated in the acts of writing at a desk, working at a sewing-machine, kneeling at prayer, etc. Occasionally tinnitus aurium and suffusion of the conjunctivæ are present.

Neglected polypus ends in deformity of the nasal chambers and bones of the face. The face assumes a peculiar expression called by the older observers frog face. This is rarely if ever seen in this country, owing doubtless to the fact that the sufferers from nasal polypus seek medical advice in the early stages of the affection. Moderate degrees, however, of deformation of the turbinated bones are often seen.

Since the symptoms of soft nasal polypus are produced entirely by mechanical means, they can be closely imitated if not replaced by other morbid states of the mucous membrane. A hyperplastic state of the membrane over the middle turbinated bone will give rise to all the symptoms of a sessile polypus in the same situation. It is well to remember that this condition of the membrane often coexists with polypus, and of course will persist after the polypus has been removed. It follows that a guarded prognosis should always be made in case of sessile polypus. A tedious course of treatment of the indurated and chronically inflamed membranes may be required after the {54} tumors have been removed before a cure is effected. The prognosis of soft polypus is more favorable as to the immediate results of treatment than in sessile polypus. The liability to recurrence can be materially lessened by carefully conducted after-treatment.

The diagnosis of soft pedunculated polypus is readily accomplished if the examination is made by aid of an appropriate speculum, the rhinal mirror, and a powerful light. Even without these aids the tumors can be seen by direct sunlight within the nostril if they are entirely occluding the chambers, and even in the event of nothing being visible by such inspection the movement of the masses by the act of blowing the nose will be noticed. The fact that the nasal obstruction is aggravated by damp weather seems to assist the physician in framing a diagnosis.

The diagnosis of sessile polypus requires a careful use of all the aids of rhinoscopy. They can be distinguished from hyperplasia of the mucous membrane by their lobulated form, and from the fact that the probe can move them slightly from their base. They can be distinguished from adenoid growths at the root of the pharynx by the fact that they remain unmoved during the act of swallowing.

The disease is not apt to recur if the treatment is thoroughly carried out.

The treatment of soft polypus consists in their removal. All observers are now agreed on this point. Injection by astringents and acetic acid--a process that at one time held out much promise--has been generally abandoned. In removal of the polypus one of two methods may be resorted to: that by avulsion, and that by the use of the snare. Avulsion is effected by forceps adapted for this special use. With such an instrument the polyps can readily be seized and removed. The rule that nothing should be seized which is not seen is subject to no exception. In no other way can the operator be secure against accidents. Incautious operators have frequently torn away strips of mucous membrane or portions of the turbinated bones in their crude attempts to remove these growths. Severe hemorrhage and death through violent lacerations of the ethmoid bone near the cribriform plate, and subsequent extension of the inflammation thereby excited to the membranes of the brain, have been known to follow these crude surgical procedures.

W. C. Jarvis of New York has modified the wire snare for application to the nose for the removal of polypi and hypertrophied tissues, and reports that it is a safer, more expeditious, and less painful method of operation than the forceps, which he unqualifiedly condemns. His instrument, while undoubtedly an ingenious adaptation of the principle of the snare, and a valuable addition to our means of treating nasal affections, cannot, in my judgment, take the place of the forceps in removing nasal polypi. As the aurist finds both the forceps and the snare useful in removing growths from the external meatus of the ear, so I am sure the physician will need both in the treatment of nasal polypi. In many cases the malformations of the nasal septum are such that {55} I have been unable to use the snare where the forceps could be used with relative ease. I find when the loop is quickly drawn the same amount of bleeding follows as when the forceps are used. When it is slowly drawn, the sitting is tedious, and both the patient and attendant find the process wearying. The amount of blood lost when the forceps are properly used is not considerable, and is always under control. F. H. Bosworth[1] describes the operation as extremely painful. So far from this being the case in my experience, I find the patients complain greatly of the constriction of the wire loop on the pedicle of the polypus, and invariably prefer the forceps. I must add that this preference was in no way influenced by myself, for I was disposed at one time to agree with the writers who have of late criticised the method of removal of the polyps by avulsion.

[Footnote 1: A Manual of Diseases of the Throat and Nose, 1881, p. 241.]

No matter which of the methods be accepted, the treatment of polypus resolves itself into two simple propositions. When one or two large polypi are present in a capacious nasal chamber, the removal of the growths either by avulsion or snaring is a simple matter, and can often be accomplished in a single sitting. When numbers of small polypi are scattered over a large surface, particularly if they grow from the sides of the middle turbinated bone, the treatment is tedious, and even after the growths are removed a series of applications are required to cure the thickened and infiltrated mucous membrane.

Sarcoma, fibroma, and carcinoma are infrequent causes of nasal disease. When located in the nasal chambers they do not present any characters with which I am familiar which distinguish them from the expressions they assume in other parts of the body. When involving the respiratory tract they alike create symptoms by obstruction, by excitement of the secretions, and by the reflexes due to the involvement of the branches of the fifth pair of nerves. When situated in the olfactory track the obstruction to nasal respiration is absent, but the reflex symptoms are pronounced: the patient is liable to depression of spirits and to frontal headache. Encroachment upon the orbital, pharyngeal, and encranial spaces is common in the last stages.

Perhaps the most common way in which these morbid growths induce symptoms referable to the nose is by obstruction of the respiratory tract by the incursions of a mass originating at a point beyond the limits of the nasal chambers. In this way a growth in the pharynx may close one or both choanæ, or protrude into the nose from the spheni-palatine space by breaking down the ascending plate of the palatal bone as it forms the median wall of this space; or the growth may project inward from the superior maxilla.

In one case under my care, of obscure growth high up within the nose, which ended fatally by involvement of the membranes of the brain, a tenacious mucus of a dark chocolate color was withdrawn from the nose into the throat. The peculiar color of the mucus was found to be caused by a mixture of blood. In my judgment, this peculiar mixture of blood and pus was significant. The blood and mucus had not been mixed in the nasal chamber to cause the chocolate or rusty hue, for then we would have had the appearance customary in epistaxis of bright blood and frothy mucus mechanically held together. The even dissemination of the blood through the mucus would point to the conclusion that the blood had escaped in small quantity at the time of the formation of the mucus. Why such mucus does not constantly form in inflammatory states of the mucous membrane of the nose, as it does from the pulmonary mucous membrane in pneumonia, I am not prepared to say. But existing as it did in a case where a deep-seated disease was present may be accepted as a fact in some way connected with the invasion of a morbid growth in and upon the nasal mucous surface.

The pharynx is always in a state of hyperæmia when morbid growths of {56} the above groups are present in the nose. The front of the velum is apt to be covered with a great number of minute papillæ, which, however, are often seen in anæmic individuals, and are not therefore pathognomonic.

The treatment of the growths enumerated and the general conduct of the cases are subjects for the general surgeon, and a consideration of them here would be out of place.

It may, however, be well to describe a few instruments which have been found useful in the large group of cases where cauterization is the principal treatment indicated. Foremost among these is the instrument shown in Fig. 22, which combines advantageously the essential features of the galvano-cautery and the wire snare.

It is well known that a loop of wire which is steadily narrowed has great power in severing the attachment of tumors and other outgrowths. When of a large size, it may be sufficiently powerful to pass through bony structures, as well as the softer parts of the body. The principle of the snare has been employed both in the throat, the ear, and the nose; but when my attention was first directed to this subject the forms available were too large and heavy for the delicacy of manipulation demanded in removing small tumors lodged in the narrower recesses of the nose. Moreover, no snare that I could then find would permit the galvanic current to pass through the loop at the time it was being narrowed. I was led, therefore, to inquire into the practicability of an instrument which would at once be light, be of small size, and yet be sufficiently powerful to remove that class of hypertrophied tissues and polypoid growths which are of such frequent occurrence in the nasal chambers. The instrument shown in Fig. 22 combines these qualifications, and satisfactorily performs the service for which it was designed. The only feature of an essential character which may be said to be novel is the fact that the platinum wire (3, Fig. 22) forming the snare is covered with a uniform coat of copper, excepting alone the portion forming the loop, which is bare. As a consequence of this arrangement the current of electricity from the battery is conducted through a double canula (2, Fig. 22) by means of the copper. The length of the instrument being about 9½ inches, and its weight less than ½ ounce, delicacy of manipulation is not interfered with. Besides possessing all the features of the cold wire snare, it has the additional advantage of securing a more rapid and painless operation, without any hemorrhage. Sessile (pyramidal) or resilient growths may be removed by first burning a groove of any depth into them, after which the loop is drawn while the current is passing through it. For this task the cold wire snare is obviously incompetent. Growths of unusual size or hardness may be destroyed by the same procedure, and nodules no larger than a grain of wheat may also be excised with great nicety. {57} It will be seen that failure to remove at least a portion of the growth attacked is an event exceedingly unlikely to occur. I have been particularly struck with the facility with which hypertrophies of the inferior turbinated bone can in this way be treated; and if cocaine be freely applied before the operation, it constitutes, in my judgment, the most speedy and the least painful of any means by which such conditions can be reduced. By using a canula with a curved end it is easy to snare growths situated on the posterior portion of the inferior turbinated bone. The current passing through the battery (Fig. 23, B) to the instrument can be interrupted by any of the numerous devices with which the practical electrician is familiar; or the treadle of the battery can be depressed and locked by the lever-catch, and the interruption of the current be determined by the pressure of the finger {58} on the knob in the handle (Fig. 23, A). This is under all circumstances desirable, since the weight of the cells is sufficient to demand considerable force to be exerted by the foot--always enough to destroy the delicacy of the manipulation of the instrument.

An electrode which is wrapped nearly to its distal end (Fig. 24), and used either in a straight or a curved form, is of great advantage in reaching growths within the naso-pharynx. The straight form can be thrust directly back through the nasal chamber, and the curved form can be passed from the oro-pharynx to the naso-pharynx without danger of burning the posterior border of the soft palate.

{59}

NEUROSES OF THE LARYNX.

BY HOSMER A. JOHNSON, M.D., LL.D.

DEFINITION.--Disorders of sensation or motion, or of both sensation and motion, due to disease, first, of the centres from which the nerves of the organ are derived; second, to disease along the track of the nerves; third, to disease in the terminal distribution of the nerves; fourth, to reflected irritation from neighboring or distant parts; and fifth, to myopathic change. This last condition is not necessarily a neurosis; it is nevertheless a cause of modification of the function of the parts to which the nerves are distributed, often a result of paresis or paralysis, and therefore inseparably associated with the neuroses of the organ. Disorders of innervation, depending upon structural disease of the larynx, such as ulceration or tumor, are not included in this definition.

ANATOMICO-PHYSIOLOGICAL CONSIDERATIONS.--The framework of the larynx consists of cartilages securely but rather loosely articulated with each other. The movements of these cartilages produce changes in the position and tension of the soft parts. The thyro-cricoid articulation allows ginglymoid and sliding motion; the aryteno-cricoid, rotatory and sliding motion; the hyo-thyroid, ginglymoid motion. The physiology of the muscles of the larynx is quite complex, since nearly all have fibres taking a number of different directions, and the changes in the form and positions of the parts depend upon the combined action of different muscles and parts of muscles which may be individually brought into action to produce the required results. The muscles may, however, be roughly divided into groups: 1. Constrictors of the superior strait; 2. Dilators of the superior strait; 3. Adductors of the vocal cords; 4. Tensors of the vocal cords, external, internal; 5. Relaxers of the vocal cords; 6. Abductors of the vocal cords.

The superior strait of the larynx is closed by the action of the oblique portions of the arytenoideus, acting in conjunction with the ary-epiglottici, into which some of its fibres are continued, thus drawing the cartilages of Santorini downward and inward and approximating the ary-epiglottic folds and depressing the epiglottis; while the thyro-epiglottici complete the closure by further depressing the epiglottis. Fibres of the latter muscle, acting alone, may dilate the superior strait by drawing apart the ary-epiglottic folds.

The transverse portion of the arytenoideus and the superior fibres of the crico-arytenoidei postici approximate the arytenoid cartilages. The crico-arytenoidei laterales, and also in a slight degree the external fibres of the thyro-arytenoidei, rotate these cartilages, turning their vocal processes inward: the action of the latter two muscles as adductors is imperfect unless the arytenoids are drawn backward and fixed by the arytenoidei postici.

The tensor group comprises a number both of the extrinsic and intrinsic muscles of the larynx. The crico-arytenoidei postici draw the arytenoids back, external rotation, and consequent abduction, being prevented by other muscles. The anterior fibres of the crico-thyroid and those fibres of the {60} sterno-thyroid inserted anterior to the crico-thyroid articulation approximate the cricoid and thyroid cartilages, and thus tighten the vocal bands. The posterior fibres of the crico-thyroid slide the thyroid upon the cricoid, lengthening the antero-posterior diameter of the larynx. This muscle, acting as a whole, also compresses the alæ of the thyroid with the same effect. The constrictors of the pharynx have a similar function. The hyo-thyroidei, acting in conjunction with the elevators of the hyoid bone, draw the thyroid forward and tilt it downward upon the cricoid. The form and internal tension of the vocal bands are greatly influenced by the thyro-arytenoidei, especially their inner fibres, while the ascending fibres of the muscle draw the inferior portions of the vocal bands upward and prevent the sagging of their edges. This muscle, acting alone, has been thought to cause extreme relaxation of the vocal bands. Modern research renders this statement of relaxation doubtful. The contraction of those fibres of the sterno-thyroidei inserted posteriorly to the crico-thyroid articulation tilts the thyroid upward, and thus relaxes the tension of the bands.

The crico-arytenoidei postici rotate the arytenoid cartilages outward, separating the vocal processes, and, acting in conjunction with the posterior fibres of the crico-arytenoidei laterales, draw the cartilages outward and downward.

In the cadaveric condition, which is one of relaxation of all the laryngeal muscles, the glottis is neither closed nor widely open; the epiglottis is erect against the dorsum of the tongue; the arytenoid cartilages are slightly separated, so that the glottic opening is a triangle with the base posteriorly, as in the act of inspiration, but the separation is much less than in the act of breathing. This condition is met with in paralysis affecting all the muscles of the organ.

The nerves of the larynx are derived from the pneumogastrics. The superior laryngeal is mainly a nerve of sensation for the parts above the edges of the vocal bands. There are some notable exceptions to this statement: a branch, external, descends to the crico-thyroid muscles and is motor in its function. Filaments from the superior laryngeal endowed with motor functions are also distributed to the folds extending from the arytenoids to the epiglottis; these are the ary-epiglottidean bands, and are concerned in the movements of the epiglottis. It is probable that the arytenoids are also in part supplied by the superior laryngeal; in other words, that both the superior and inferior laryngeal nerves are mixed, branches from the spinal accessory, as well as from the pneumogastric proper, entering to each of these nerves. Beclard[1] states that the one, the spinal accessory, is a nerve of phonation; the other, the pneumogastric, is a nerve of respiration. The sensations of the mucous surfaces below the glottis depend upon filaments from the pneumogastrics returned along with the motor fibres from the spinal accessory. The two orders of fibres go to make up the recurrents. The relations of the recurrents themselves to the large vessels, as well as to the bronchial glands, are of importance. At the point of their origin they are in close relation with the aorta and right subclavian; they are also in close relation with the top of the lungs. Disease of these organs and structures, especially of the large blood-vessels, such as aneurism of the aorta or subclavian, disease of the glands, tumors, abscess, traumatism, etc., may modify or completely destroy the functions of the laryngeal nerves. In short, anything or any condition by which pressure may be made upon the pneumogastrics or recurrents may become a cause of nervous disturbance in the larynx. In addition to this general source of innervation, Elsberg[2] describes a special centre of sensation for the throat in the medulla oblongata. He also describes three kinds of sensibility in the larynx--tactile, dolorous, and reflex. Rossbach[3] details experiments from which he concludes that there are nerve-cells in {61} the mucous membrane of the larynx which preside over the function of secretion. The larynx is endowed with at least two kinds of sensibility: the one tactile--when exalted it becomes painful; the other, reflex sensibility, is double. First, there is as a result of excitement a contraction of the subjacent muscle, and there follows closure of the glottis. This is seen in the application of irritants to the parts, such as solutions of nitrate of silver or other escharotics. There is no cough, but great difficulty of inspiration. Expiration is free and easy. There may follow some degree of pain for several hours. It will be seen that the phenomena are the same as those observed in the irritation of other mucous surfaces. The irritation is immediately translated into motion; this motion is probably reflex, but not necessarily through the centres, such as the brain or cord. The motion is of the subjacent muscles. Second, the mechanical irritation produced by the presence of a drop of water or a morsel of food in the larynx results in violent and explosive cough. The cough persists until the offending drop or body has been removed. This kind of sensibility calls into action distant muscles. There is no spasm of the adductors of the glottis, as in the case of the application of caustics. It is probable that the filaments of the nerves, the irritation of which gives rise to spasm, are distributed more generally than those which preside over reflex action at a distance and produce cough. The one set of functions are designed probably to protect the organ from the intrusion of foreign bodies; the other for their expulsion, as well as for the removal of the secretions of the parts or of matter brought up from below. The hypothesis of a third form of sensibility, as described by Elsberg--namely, the dolorous--seems hardly to be demanded for the larynx more than for all other mucous surfaces subject to pain. The nerve-cells of Rossbach in the mucous membrane may be peculiar to the larynx and trachea, as he claims, but further observations are required for the demonstration of this as a special histological fact distinguishing laryngeal from other mucous surfaces.

[Footnote 1: Dic. Eng. des Sci. med.]

[Footnote 2: Int. Med. Cong., 1881.]

[Footnote 3: Ibid.]

PERVERSION OF SENSATION OF THE LARYNX.

There is some difficulty in grouping the derangements of the sensibility of the larynx, for the reason that in many cases the perversion of this function is only a symptom of some other disease of the organ. Probably in all cases the trouble is, in fact, an expression either of disturbance in the structures of the larynx, involving more than the sensory nerves, or it is the result of change in structure or function of neighboring or distant parts. Various attempts have been made to classify these disorders according to the kind of perversion and also according to the cause of the trouble. Elsberg, in a paper presented to the International Congress, London, 1881, p. 224. vol. iii., makes an attempt at a scientific classification based upon anatomico-physiological facts. That there is yet much to learn in regard to these facts, especially the physiological facts, will be admitted by every one at all familiar with the literature of the subject. Elsberg, under the term of dysæsthesia, makes two principal divisions--namely, first, disorders having reference to the quantity or intensity of the sensation; this embraces simple hyperæsthesia and simple anæsthesia. The second grand division relates to the quality of the sensation, and includes only paræsthesia or sensory delusions. These grand divisions are still further subdivided.

In fact, we have to do with exaltation of sensibility simply, with sometimes pain; second, with delusion of sensation; and, third, with lost or diminished {62} sensation. For all practical purposes, therefore, we may adopt this arrangement, but should consider it as only provisional, as has been well observed by Schnitzler. These conditions are described under the terms hyperæsthesia, with or without pain; paræsthesia; anæsthesia.

Hyperæsthesia.

DEFINITION.--Exalted sensibility of the larynx, not necessarily associated with pain or other disorders of function. This condition is rare, but it is nevertheless met with. We sometimes find that the larynx is abnormally sensitive to touch or to an irritant, even though there is no marked inflammation. The symptoms and history justify the consideration of the condition apart.

ETIOLOGY.--Predisposing causes are probably to be found in the general condition of the nervous system. Persons of a highly susceptible nervous organization are, other things being equal, more prone to this affection. Certain habits of life, such as confinement to the house or want of exercise in the open air, excessive use of the voice in singing, especially in unnatural keys or after unnatural methods, have seemed to me to predispose to the exaltation of the sensibility of the organ. It must be confessed, however, that so little is accurately known of the history of the disease that we are left in much doubt as to the rôle of these conditions in the production of the abnormal state. The exciting causes of hyperæsthesia of the larynx are the long-continued action of the predisposing causes--acute and chronic inflammation, mechanical and chemical irritants, etc. So far as my own experience goes, the use of the voice in an unnatural key, or perhaps rather the strain upon the parts by efforts to force the organ to perform the function of phonation in an abnormal manner, has more frequently been assigned by the patient as the cause than any other one thing. I have seen quite a number of singers who have by an effort of the muscles, apparently, produced an intensified irritability of the mucous surfaces. It is possible that in rare instances there may be an exalted activity of the receptive centres, and that the local trouble in the larynx is only a manifestation, in the distribution of the nerves, of the central disease. In such cases, however, the disorder should reach all the parts supplied by the pneumogastrics. Inflammation of the pharynx, soft palate, posterior nares, and perhaps of the structures of the ear, have an influence over the sensibility of the parts below, probably through the relations of the glosso-pharyngeal and other nerves to the laryngeal branches of the pneumogastrics. E. F. Ingals of Chicago has seen a case of laryngeal hyperæsthesia produced apparently by a varicose condition of the vessels about the base of the tongue. Frankel, Tornwaldt, Bayer, Schnitzler, A. H. Smith, Glasgow, and others have reported cases in which there were symptoms of hyperæsthesia or of reflex motor disturbances due to trouble in the nose or pharynx. The general health has much to do with the development of the local trouble. Asthenia is associated so frequently with hyperæsthesia of other parts that we should expect to find this relation also in the larynx.

SYMPTOMS.--The symptoms of hyperæsthesia of the larynx are in part involved in the definition of the affection--exalted susceptibility to the touch, intolerance to the presence of mechanical irritants, a sensation of discomfort in the presence of chemical agents, such as gases or impure air, and, when the exaltation is excessive, positive pain. This pain may be only a soreness or tenderness or it may amount to neuralgia. This last form of exaltation is rare. When present it has been considered a special disease and treated as a separate affection. Von Ziemssen and Mackenzie regard it as a variety of hyperæsthesia. Schnitzler, Jones, Wagner, and Mackenzie report cases. The {63} pain is said to be not confined to the larynx, but to extend up toward the ear and along the course of the superior laryngeal nerve. In two cases observed by the writer the pain not only extended along the course of this nerve, but into the pharynx and posterior nares as well. In these cases the patients were both singers, and both had adopted with great enthusiasm a new method by which the abdominal muscles were brought into action at the expense of the muscles of the thorax. The pain was always aggravated by any effort to sing, but more especially by any return to the method noted. The pain not unfrequently extended to the face as well as to the ear.

Neuralgia of hysterical origin, according to Thaon,[4] is more frequently met with on the left side than on the right. Instead of being general, it is not unfrequently limited to points or circumscribed patches.

[Footnote 4: Proceedings Laryng. Cong., Milan.]

COURSE AND TERMINATION.--The course of the affection is very uncertain. In the neuralgic variety the pain may be transient, passing away in a few days or hours even, but generally there are frequent recurrences extending through weeks or months. Simple exaltation of the common sensibility is much more persistent and more uniform in its character.

Hyperæsthesia of the larynx is so largely dependent upon the general health that not only is it very irregular in its course and duration, but its termination is equally uncertain. It can hardly be said to be a cause of death, as it does not involve structures necessary to life. It disappears occasionally without treatment. When complicated with other affections, such as acute or chronic inflammation, alterations of the function of the pneumogastrics, with disease of the thoracic viscera or with general derangements of the nervous system, its course and termination must depend largely upon the persistence of these complications.

PATHOLOGY.--So far as the pathology and morbid anatomy have been studied, there is no appreciable change of structure. This is true, of course, only of those cases which are not complicated. Whether the primary lesion is in the mucous membrane, denuding, pinching, or otherwise modifying the terminal portions of the nervous filaments, or whether there is an alteration of the conducting portion of the sensory nerves, or, in fine, whether there is some lesion of the receptive centres, it is impossible in most instances to say. It is probable, however, that in some cases the first morbid fact has been an alteration in the nerves themselves. The cases induced by unnatural methods of using the vocal organs are apparently of this character.

The diagnosis, prognosis, and treatment will be considered in connection with Paræsthesia.

Paræsthesia.

Closely connected with hyperæsthesia of the larynx is a form of sensory delusion consisting of the impression that some foreign substance is lodged in the organ or that there is some alteration an the structure of the parts. This is known as paræsthesia.

ETIOLOGY.--The first variety of sensory delusion depends on a primary injury to the parts. A bone or pin or some other foreign body, perhaps having lodged in the parts for a short time, has left a persistent impression upon the mucous surfaces. It is possible that in some instances there may have been no foreign body in the parts, as we have in many cases only the statement of the patient. Local inflammations, small in extent, may possibly have left the parts in a morbidly sensitive condition justifying on the part of the subject the hypothesis of a foreign body.

The second variety of paræsthesia is the expression of some disturbance in {64} a distant part. It is usually hysterical in its character or a variety of hysteria associated with neurasthenia. It belongs to the same class of phenomena as the sensory delusions in other parts of the body. The globus hystericus is one of its forms. Thaon[5] says that hysteria may give rise to neuralgia as well as to other forms of hyperæsthesia of the larynx. It also, according to this author, produces that form of paræsthesia in which there is a sense of a bone or pin or some foreign substance in the larynx. The general condition of asthenia, and especially of neurasthenia, may be assigned as a predisposing cause. The local injury in the one case and the general hyperæsthetic condition in the other, with some determining fact, such as the mental impression or an apprehension of trouble in the larynx, constitute the exciting causes.

[Footnote 5: Proceedings of the International Congress of Laryngology.]

SYMPTOMS.--It usually comes on after an injury or as a result of the presence of a mechanical obstruction or irritation, the presence of a bone or pin being frequently invoked as an explanation of the feeling. In a few cases the sensation is suggestive of an alteration of the structure of the parts. Patients are inclined to think that they have a tumor or that there is some deformity. In the first class of cases there is a sense of pricking or of scratching in the larynx. This is not constant in locality or in intensity. There will be times, occasionally days, in which the sensation may be entirely absent, after which it returns with great severity, the patient insisting that the cause of the trouble has simply changed its location--in other words, that there is a migratory body in the throat. That form of paræsthesia in which the sensation is that of a tumor or malformation is also irregular in the mode of its manifestation or kind of disturbance. Like the other forms, it comes and goes, changes its location, and undergoes modification in its character. It may be associated with neuralgia.

DIAGNOSIS.--Hyperæsthesia and paræsthesia are recognized by the symptoms already described and by the aid of the laryngoscope. The mirror reveals the fact that the parts are normal in structure and that there is no foreign body present. The mucous membrane may be hyperæmic or anæmic, but is not the seat of any active inflammation. The excessive sensibility and pain of the larynx in ulceration of the parts will be excluded from this group of troubles by the revelation of the laryngeal mirror. Cases of pain or perverted sensation dependent upon the disorders of the nerve-centres usually involve the whole range of functions supplied by the pneumogastrics, and will generally be recognized by this fact. Such cases can hardly be called local, and do not belong to the group of affections embraced in this article.

PROGNOSIS.--The prognosis of simple paræsthesia of the larynx is not grave. Though it may exist for a long time, it, so far as we know, does not terminate in death. While it sometimes results in recovery without treatment, it in a large proportion of cases yields only to both local and general treatment. Its duration is uncertain. Paræsthesia coming on after the presence of a foreign body in the organ may last many months and then gradually disappear. This result will be largely aided by the moral support which is gained if we can convince the patient that the sensation is entirely a delusion.

TREATMENT.--For the purpose of meeting local indications in hyperæsthesia we may apply with a brush or by the means of the atomizer a solution of morphine and alum of the strength of 15 centigrammes of morphine and 2 grammes of alum to 50 grammes of water, or to this may be added 20 centigrammes of carbolic acid and 10 grammes of glycerin. Of this solution an application may be made each day with the hand-atomizer. The hand-atomizer is preferable to the steam-atomizer, for the reason that we know in the use of the former the strength of the solution. In the use of the steam-atomizer the medicated solution is diluted with the water of the steam, and we are {65} ignorant as to the strength of the application. The method of application by the use of the atomizer is to be preferred to the brush or sponge probang, for the reason that we produce by it no mechanical irritation of the parts. The brush or sponge can hardly be used without giving pain or discomfort. In addition to the solution above indicated, solutions of borax, of sulphate of zinc, of tannin and glycerin with chloroform, of nitrate of silver not too concentrated--2 to 10 centigrammes to 30 grammes of distilled water--tincture of aconite, solutions of the bromides, cocaine and other anæsthetics, may be used with benefit. In many cases the administration of general tonics along with the local treatment will be of the greatest value. The application of electricity to the parts through the surfaces--that is, from one side of the larynx to the other--will add to the efficacy of other local treatment. The strength of the current should not be so great as to give rise to any discomfort. The current should be continuous, and should be repeated every day for several weeks if the disorder does not yield sooner. In cases which have been induced by vicious habits of living or of exercise of the organ there should of course be an entire change of the habits. The producing cause should, if possible, be removed. The exposure of the parts to anything which gives rise to pain is to be avoided. If hyperæsthesia has been induced by unnatural methods of singing or of speaking, these should be remedied.

In neuralgia the general treatment for that affection is indicated. Quinine and iron have especially been found useful. In the hysterical variety of both hyperæsthesia and paræsthesia general treatment is of more value than local measures. General tonics, moral support, such as will be secured if we can convince the patient that there is really no serious trouble with the organ, but that it is only a morbid sensation, will be of the greatest value. In these cases change of climate, change of occupation, diversion by new associations, with expectation of recovery on the part of the patient, often bring about the most satisfactory results. The diagnosis should be certain and the physician should be able to speak with confidence in the matter. This will go far toward effecting a cure. For the purpose of diminishing the general irritability of the system bromine in some of its combinations, potassium, sodium, iron, quinine, etc., may be useful.

Anæsthesia.

DEFINITION.--Diminished sensibility of the mucous surfaces dependent upon lesion of the nerve-centres, alteration of the conductivity of the nerve-trunks, or upon disease in their terminal distributions. It is usually bilateral, but may be limited to one side. This alteration of the sensitive condition of the mucous membranes is usually observed after diphtheria. It is also met with in bulbar paralysis. In this last condition it is only one of the phenomena of paresis or paralysis involving several different organs. It is not, therefore, properly a disease of the larynx, and the consideration of it will not be embraced in this article. It has been stated that hysteria is frequently accompanied with anæsthesia of the larynx. Von Ziemssen, Chairou, and Schnitzler have published cases. It seems very improbable that this condition of the organ is so generally present in hysteria as is claimed by Chairou. It is, however, certain that anæsthesia as well as hyperæsthesia of the larynx exists as a complication of hysteria. In the later stages of all exhaustive diseases, as cholera, etc., the sensibility of this organ is either diminished or abolished. This is not, however, a true paralysis in the sense in which we generally use the term. It is only one of the manifestations of the general failure of the life-forces. The special senses, the reflex functions, all share in this paresis, this severing of the relationships of life. Anæsthesia of the larynx is usually {66} confined to the parts supplied by the superior laryngeal nerves, and is sharply limited by the edges of the vocal bands. If there is anæsthesia of the parts below these bands, it is of much less significance and hardly requires our consideration.

ETIOLOGY.--So far as we know, there are no predisposing causes. The chief exciting cause of this affection is unquestionably diphtheria. It is, in fact, a sequel of diphtheria. It will hardly be necessary to repeat here what the reader will find fully discussed in the sections devoted to diphtheritic inflammation of the fauces and adjacent parts: we are mainly concerned with the phenomena. Just how this morbid process produces paralysis is not known. It is believed by some observers that the disease is produced by the alteration of the nutrition of the parts during the progress of the diphtheria. It is stated that the parts most nearly related to the seat of the exudation are most likely to become involved. This is thought to sustain the theory of the direct propagation of the morbid changes from the mucous surfaces to the nerves and muscles. That the paralysis following diphtheria is not, however, produced alone in this manner seems to be made evident by the fact that distant parts, parts which have not been at all involved in the disease, do nevertheless become affected with paralysis. This paralysis develops when the general health and the nutritive changes are all improving. It is quite evident, therefore, that the loss of power in the laryngeal muscles, as well as the altered sensibility, in part at least, must be due to some lesion of the nerve-centres. In addition to the causes above noted, anything which impairs or destroys the function of the superior laryngeal nerve may produce this affection. In the anæsthesia from hysteria we know only the fact, but do not know just how the derangements of the nerves in a distant part, or in the nerve-centres perhaps, are so reflected as to change the function of this organ. The hyperæsthesias, the paræsthesias, and the anæsthesias of hysterical character are all probably produced in the same manner. Anæsthesia in bulbar paralysis is easily understood, but need not, for the reasons already given, engage our attention.

SYMPTOMS.--This condition is usually associated with paresis or paralysis of the muscles of the part. One of the first symptoms of loss of sensibility is, therefore, a failure of the constrictors of the larynx to protect the organ from the intrusion of foreign substances in the form of food and drink. Particles swallowed find entrance into the respiratory tube, and this with no sense of discomfort. If the paralysis is complete both above and below the glottis, the intrusion of these substances is not recognized. There may be no cough or spasm to indicate the fact. In the mean time, the particles of food descend into the bronchi, and may become the exciting causes of broncho-pneumonia. It is often noticed after tracheotomy for diphtheria that food and drinks gaining access to the respiratory tract are discovered at the tracheal opening. In several cases within the knowledge of the writer this fact has led the operator to fear that the posterior wall of the trachea had been opened. In all cases in which the pharynx is in a state of paresis a careful examination should be made by means of the laryngeal mirror.

There are no subjective symptoms, and this fact makes it probable that the affection is more common than has been supposed. The patient complains neither of pain nor of any other discomfort. This statement is only true, however, when there is simple loss of sensation. There may be paræsthesia associated with partial anæsthesia. In such cases there will be noted the usual symptoms of paræsthesia. In hysterical forms of anæsthesia the appearance of the parts is often variable from day to day. The location of the disordered function is well defined at the time of one examination, while at the next the condition may be quite different. It is stated by Thaon[6] that {67} in one-sixth of the cases of hysteria the larynx is in some way affected. The epiglottis is more usually the seat of the affection in the hysterical variety. Several authors have noted that with the laryngeal disorder there is often a zone of modified sensation beneath the chin and on each side of the larynx. This sometimes amounts to absolute loss of cutaneous sensibility.

[Footnote 6: Loc. cit.]

COURSE AND TERMINATION.--According to Mackenzie, Von Ziemssen, and others, the anæsthesias following diphtheria usually terminate in recovery. It is quite possible, however, that the literature of the subject does not give us elements on which to base an opinion. I am inclined to think that cases die from this disorder in which the nature of the affection is never recognized. It is quite certain that paralysis of the fauces is not unattended with danger. It is also probable that in many of these cases the real danger is not so much from the loss of muscular power in the pharynx, and consequent inability to swallow, as from the fact that the larynx is not protected from the introduction of foreign substances, that the intrusion of these substances is not recognized, and the consequent disorders of the lungs become the cause of death more frequently than has been supposed.

DURATION.--Paralysis of the sensory nerves of the larynx usually lasts only a few weeks. When a result of diphtheria it disappears with the motor trouble with which it is associated. As a complication of hysteria, or rather when hysterical in character, it may last indefinitely. When dependent upon changes in the centres from which the pneumogastrics are derived it has a history commensurate with that affection.

The PATHOLOGY AND MORBID ANATOMY have been suggested in the discussion of the cause and symptomatology of the disorder. The question of the local or general changes in the diphtheritic variety is noted in the history of the disease.

The DIAGNOSIS is made mainly by the examination with the laryngoscope. The probe will at once determine the presence or absence of the sensibility of the mucous membrane of the parts. In addition to touch, electricity may be employed. In these cases the alteration involves both the tactile and reflex sensory functions. There will therefore be neither cough nor spasm resulting from a mechanical irritation. The surfaces are usually quite normal in color and form. The epiglottis is erect, abnormally so, and there will often be more or less paresis, or even complete paralysis, of the other muscles of the organ. In some cases the difficulty in deglutition due to derangement of the reflex functions may be also suggestive of alterations of sensation in the parts within the larynx, but it is only a suggestion.

The PROGNOSIS is usually favorable, but for the reasons given above this should be accepted with some degree of reservation. The diphtheritic varieties share in the uncertainty of other forms of paralysis in that disorder. The hysterical forms are not dangerous, but may continue so long as the primary affection persists.

TREATMENT.--This should be both local and general. The local treatment consists almost entirely in the application of electricity. Both the galvanic and faradic currents are recommended. In my own practice I have been accustomed to resort to the galvanic, but modified by the introduction of a shunt or switch, so as to produce a wave of electricity. The manner in which this is accomplished is to connect in the circuit a coil such as that used for the faradic current. This takes out of the direct current, with each closure of the circuit in the coil, a portion of the quantity of the current, and without entirely interrupting the working circuit gives a wave of electricity, producing, so far as I can judge, the results of both the primary and secondary currents. There is not the shock of complete interruption, while there is the stimulus of the irregular quantity. The electrode which will be found most convenient is that devised by Mackenzie or some modification of it. It {68} should be applied through the parts from one side of the larynx to the other by placing the tip or point of the instrument in one of the pyriform sinuses over the superior laryngeal nerve. A double electrode will often answer better, placing one point in one sulcus, while the other is in contact with the mucous membrane of some other part of the organ or in the opposite sinus; that is, on the other side of the larynx. The current then passes through the parts and stimulates all the tissues between the two poles. The application should be made every day, and for several minutes at each sitting, interrupted, of course, as required by the variable condition of the parts. The current should not be so strong as to produce positive pain. This is not easily reached, however, for the reason that the response is slow and uncertain. The strength of the current should be tested upon the normal surfaces of the patient, or, better, upon the mucous membranes of the operator, before applying it to the morbid parts.

In case a reliable tangent galvanometer is used, much more certainty can be reached than when the strength is determined solely by the sense of touch. With this exhibition of electricity there should also be administered such remedies as are best calculated to restore the general strength of the patient--quinia and iron, with the bitter tonics, and especially strychnia in what would be considered large doses (.003-.005 grammes), two or three times a day, with interruptions every few days. In the hysterical cases, as well as those following diphtheria, electricity is often of great value.

Attention should also be given to the proper treatment of any local trouble in the viscera of the abdomen or pelvis. Uterine disease, if present, as it frequently is, demands attention. It is believed by some authorities that the unilateral disorders of the larynx dependent upon ovarian irritation generally manifest themselves upon the side corresponding to the diseased ovary. It is, however, rare to meet with complete unilateral anæsthesia. In addition to the use of these measures, change of surroundings, especially in the hysterical variety, diversion by new associations, new occupations, etc., are to be secured whenever practicable.

DISORDERS OF MOTION.

Disorders of motion are perhaps more complex than those of sensation. They may be divided into two general groups--1st, exalted action; 2d, diminished or arrested action. The first group is susceptible of a subdivision: first, those in which the sensory functions are exalted as well as the motor. In some of these cases the real disturbance is very probably hyperæsthesia rather than increased irritability of the nerves going to the muscles. Generally, however, the morbid phenomena are mixed; the two sets of nerves are both in a state of over-action. Spasm, for instance, may be the result of excessive activity of the sensory function coupled with the exaltation of the motor impulses, or exaggerated irritability. Second, the spasm or exalted activity of the muscles may be entirely independent of sensory impressions, possibly, in some instances, dependent upon muscular conditions, but generally only the local expression of some central nervous trouble. Chorea may be cited as an example. The diminished action of the motor system may also be due to either a want of the sensory common or special impressions; or it may be due to failure of the motor centres or some interruption of the continuity of the conducting media; or, lastly, it may be for the reason that the muscles themselves are so changed that they do not respond to the normal stimuli, such as the {69} commands of the will or reflex impressions. It will be seen from this brief statement that the subject of motor derangements is one of much complexity. From the very nature of the complications it is often impossible to satisfactorily analyze the symptoms and to determine with certainty, in a given case, whether we have to deal with a simple or a compound result. We may, it is true, in some instances arrive at approximately correct conclusions by resorting to the physiological methods of testing the muscle by galvanism and faradism. In other instances we may by a careful study of the history of the disease reach at least a provisional opinion. We must, after all, admit that much will in many of these derangements remain to be conjectured.

Exalted Action.

There is quite a difference among authorities as to the place in the classification of disease of the larynx which should be assigned to spasm as met with in childhood, and which is also occasionally encountered in adult life. It is not possible, perhaps, in the present state of knowledge, to separate in every instance those cases in which there is disorder of the circulation and nutrition of the larynx from those in which the spasm is the result of disturbance simply of innervation, or in other cases the reflex manifestations of nervous irritation elsewhere. Generally, however, this can be done. I have for a long time been accustomed to consider the affection known as spasmodic croup to be a mild inflammation of the larynx, and that it differs from the same affection in the adult for the reason that the lumen of the tube is smaller, the cartilages are more yielding, and the susceptibility of the parts is greater, and further for the reason that the nervous system in childhood is always more prone to spasm than in the adult. Stridulous laryngitis, however, is a real disease, and is for the reasons above given a neurosis, even though it is an inflammation. It is entitled to a separate description for the reason that the symptoms are so well marked and differ in so many particulars from those of ordinary inflammations. That there is, besides, a true spasm of the muscles of the larynx, independent of inflammation, by which the vocal cords and the constrictors are brought into action and possibly kept in a state of tonic contraction, is possible.

In a majority of instances of laryngeal spasm there is a degree of inflammation, as above stated, or at least a degree of congestion of the mucous membranes. It is certainly true, however, that in exceptional cases there are no indications of such a condition of the parts, so far as we can determine by ante- or post-mortem study. It seems to be evident, then, that under this name of spasm of the larynx or of some synonym of it many careful observers have recorded facts and have grouped them with the thought that the functional derangement was the main trouble. The real difficulty appears to be that the spasm is in fact a symptom--a symptom of perhaps several different disorders, but so prominent and creating so much alarm that it has seemed for the time being to be the disease itself; and yet in most cases there is a mild form of inflammation, local in its extent, and producing, so long as there is no interference with the function of respiration, no general disturbance. It is perhaps appropriate to include in the discussion not only the purely nervous cases, but also those conditions in which, while there is hyperæmia, and probably always some derangement of secretion, nevertheless the symptoms and dangers concern mainly the motility of the muscles of the organ.

The disease occurs both in children and in adults. There is, however, in its etiology, course, and terminations quite a marked difference, as observed before and after puberty. We shall therefore consider, first, spasm of the glottis in children; second, in adults.

{70} Spasm in Children.

SYNONYMS.--Laryngismus stridulus, False croup, etc.

ETIOLOGY.--Predisposing Causes.--The disease occurs most frequently in children from a few months to two or three years old. It is occasionally met with in those still older and up to puberty. It seems to be more often encountered in patients of a strumous habit than in those of a healthy constitution. Rickety children are especially liable to the affection: the German pathologists especially insist upon this factor. Patients of a nervous temperament predisposed to general spasms are especially predisposed to this affection in the larynx. It is a general law that muscles weakened either by disease or by fatigue or by deficient nutrition are especially irritable. In them mechanical as well as other forms of stimuli produce local contraction with great readiness. These contractions are, it is true, rather the expression of the condition of the muscles than of the nerves. The muscular condition must, however, be regarded as a predisposing cause of the spasm. In the same way, perhaps--namely, by the inherited tendency to lower forms of vitality, weakened muscular power--we may account for the fact that family history of similar conditions, such as false croup in other members or in the parents, should be considered as among the evidences of predisposing tendencies to spasm of the glottis.

Sex has in this affection, as well as in most laryngeal diseases of children, a predisposing influence. Mackenzie has collected in all, from different sources, 8248 cases. Of these, 5378 were boys and 2870 girls--a proportion of nearly 2 boys to 1 girl. In adults the reverse holds good, females being much more frequently seized than males. It is certain that season has something to do with the development of the disease, but this influence should be regarded rather as a producing than a predisposing cause.

Dentition, worms, weaning, or anything which produces an irritation of the alimentary canal may also, by exciting the reflex irritability of the nervous system, become predisposing causes of laryngismus. The influence of dentition has, however, been probably over-estimated.

The exciting causes of spasm of the glottis are not well defined. In a few cases we are able to definitely fix upon something as the occasion of the attack. It is possible that there may be some central lesion, and this may be well defined. This is rare, however. It is nevertheless true that the onset is generally preceded by some derangement of the general health. There has been for a day, or perhaps only for an hour or two, a slight cold, a little hyperæmia of the respiratory mucous surfaces, or disturbances of the digestive tract, or the child has been unusually fatigued or excited from play or study. The secretions have in other cases been deranged. No one of these causes has perhaps been of sufficient gravity to attract the attention of the mother or nurse. The indisposition, if it has been noticed at all, has been regarded as only one of the many ephemeral troubles that so often occur in infancy, and no anxiety has been felt. Of all these possible causes, the one most frequently invoked after the attack is a cold, slight, it is true, but nevertheless, in the light of the subsequent history, evidently a mild form of inflammation of the laryngeal mucous membranes.

SYMPTOMS.--Spasm of the glottis usually takes place at night. It is true that some authorities deny that this is the case. Stefen says "that it is quite as likely to occur during the day as night." In a great majority of instances, however, it will be found that the attack occurs after the child has been asleep. During the day there has been perhaps a slight disturbance of the general health, a little inclination to cough, or there has been a catarrh of the fauces or bronchial mucous surfaces; nothing, however, of a serious character has been observed. At midnight or later the little one awakes with a crowing or {71} whistling inspiration. It starts up in bed, and evidently experiences great difficulty in breathing; this difficulty is manifestly in inspiration; expiration is easy and free. The eyes are prominent, the lips blue, the surface often bathed in perspiration; pulse frequent, small, at times irregular; there is, if the child be old enough to reason in the matter, great alarm; there is often cough, and this cough is characteristic: it is a hoarse, metallic, barking, peculiar cough, described as croupy. If the spasm is limited to the larynx, the other muscles not being affected, the patient clutches at whatever it can reach, and often seizes the throat as though there was something there to tear away. The general surface becomes cyanotic and all the symptoms of asphyxia are present. The voice, though not generally extinct, is altered; it becomes hoarse, or husky, as it is called; in a few minutes the severity of the attack is passed, and the little sufferer sinks exhausted into a sleep more or less disturbed. A second attack may occur the same night, or there may be nothing more to alarm the attendants till the next night. The second attack, if it occurs, as it generally does, on the succeeding night, is less severe than the first; the third still more mild; and this generally ends the case for the time being. During the intervals--that is, during the day--the patient in a majority of cases is up, and seems to be but slightly affected by the seizure of the night before. There will perhaps be a slight cough, with some loss of appetite and indisposition to engage in play. This is the most usual type of the disease. In a few cases there is more marked derangement of the general health. The spasms are more severe; the cramp is not confined to the laryngeal muscles, but involves other parts, such as the muscles of the chest and the extremities. During the intervals of the attack there is perhaps a little fever, the digestive tract is disordered, the cough may be marked during the day, there may be an increase in the secretions of the respiratory surfaces. Attacks may recur during the day and for several days; the cough may retain its croupy character, and the voice may continue to be hoarse.

COURSE AND DURATION.--Spasm of the larynx is usually a transient phenomenon, lasting only from a few seconds in the milder cases to several minutes in the more severe forms of the disease. The attacks are intermittent. The seizures are relieved by intervals of comparative relaxation of the muscles of the parts. Even in the intervals there is, however, a degree of contraction of the constrictors, so that the relief is not absolute. Two or three days elapse before the attack may be said to have entirely ceased. In the severer forms the consequences of the spasm may continue even for a still longer time. There are usually no sequelæ. When the patient has recovered there is nothing left of the disease, though there is often a predisposition to a recurrence; the same causes that produced the first attack, or even slighter causes, may produce a second. These causes are generally persistent; the seizures are therefore usually repeated.

PATHOLOGY.--In cases dependent on central disease the pathological changes are to be sought for outside of the larynx. In rickets and other morbid conditions which by reflection produce spasm of the glottis the pathology proper is distant and not in the organ; there is only an excess of motility in the nerves and muscular apparatus. Efforts have been made to differentiate spasm and false croup, but the confusion is only equalled by the disagreement as to the relation of diphtheria to true croup. It is probably true that the cramp is generally due to some excess of motility in the system at large, and that the larynx is the seat of pathological changes that determine the spasm in that organ. This is especially true in those cases associated with rickets, derangement of the alimentary canal, etc. It seems to be a fact, nevertheless, that in a majority of cases the mucous membranes are, as already stated, the seat of a very mild inflammation. Or perhaps we should say they are slightly hyperæmic. So far as we can judge from {72} examination in cases which have terminated fatally, as well as from ante-mortem observation, there is no structural change of tissue to be recognized by the naked eye, unless it be, during life, a slight fulness of the vessels. There is a change, however, in the form of the organ, at least at the entrance to the larynx. The constrictors are in a state of action, so as to partly close the superior opening to the larynx, and the epiglottis is rolled so as, in some instances, to become almost a tube. I have repeatedly recognized this in the image seen in the laryngeal mirror. Cohn reports a case of impaction even of the epiglottis in the vestibule of the larynx (p. 627). This fact is also suggested by the difficult inspiration and the altered voice and cough. In young children the yielding character of the cartilages probably adds largely to the obstruction produced by spasm of the muscles about the vestibule.

DIAGNOSIS.--The diseases with which spasm of the larynx is most likely to be confounded are true croup, simple inflammation of the larynx, foreign bodies in the larynx, and possibly, in the absence of the history of the case, tumor situated in the glottis or along the vocal cords.

It will readily be distinguished from true croup by the fact that in the one case, true croup, the attack is insidious: the patient has been sick some time, usually several days before spasm occurs; there is also fever, with usually more cough; the voice is altered before the appearance of spasm; the first seizure is slight, almost imperceptible, and the subsequent attacks become more and more severe; dyspnoea is continuous. All these facts are in marked contrast with the picture of an attack of spasm of the glottis as we have attempted to describe it. In the one case the most alarming symptoms are at the beginning. There is an explosion of morbid phenomena, each recurrence less alarming till complete convalescence is established. In the other disease the symptoms and dangers are constantly increasing in severity, till at last the spasms become as fearful as the initial seizure in laryngismus. The morbid anatomy of the two diseases is also widely different; and this difference can be recognized during life. Simple ordinary inflammation of the larynx may give rise to hoarseness and cough; the hoarseness is, however, different from that in laryngismus. There is fever, and the hyperæmia of the organ can be readily recognized. The disease is progressive, does not present its most alarming symptoms at the beginning, and spasm, if it occurs, is a late event.

It is possible that spasm of the larynx might be mistaken for a foreign body in the organ. It will be remembered that the attacks of spasm usually occur at night after the child has been asleep. The history of foreign bodies in the larynx reveals what we should expect--namely, that the accident almost always occurs during the day. In a great majority of cases this history also furnishes reliable information of some substance or object which was in possession of the child, and which has disappeared. The dyspnoea is more continuous and the course and symptoms more variable. There will therefore be no great difficulty in any case, and in most cases no difficulty at all, in making a certain diagnosis as between these two conditions. In a few cases of laryngeal tumor the symptoms are very similar to those of the disease under consideration. The attacks in the case of a pedunculated tumor on the vocal cords may take place at night and may be intermittent. The rarity of this affection in children in comparison with spasm of the larynx, and the further fact that in the case of tumor there is a more continuous disturbance of respiration, make the differentiation easy. Paralysis of the adductors gives rise to more dyspnoea during sleep, but the history and laryngeal mirror make the diagnosis easy and certain.

PROGNOSIS.--The large majority of cases of spasm of the larynx recover. Statistics show that there are deaths from this disease, but in proportion to {73} the number attacked I think the mortality is small; how small we do not know. The confusion in classification is so great that we cannot place much dependence upon published statistics. In our climate I think most observers will admit that a patient seldom dies from this affection unless there be associated with it some morbid condition of a serious nature.

TREATMENT.--The immediate and pressing indication in spasm of the larynx is for something to relax the constrictors and allow the act of inspiration to be accomplished without embarrassment. For the accomplishment of this purpose three methods of treatment may be resorted to: First, heat; second, emetics if there be time; third, anæsthetics and antispasmodics. Of all these measures, the first is the most easily applied, and will probably in a great majority of cases prove efficient. It is usually within the reach of the attendant or nurse. It can in any event do no harm. This fact is not to be overlooked, as the symptoms are so alarming that friends and physicians are often tempted to do too much. Heat may be applied by means of cloths dipped in hot water (110° F., or even more) applied to the neck and chest of the patient, or the child may be placed in a bath of 105° F., while the head is kept cool by cloths wet with cold water. This treatment may be continued till the spasms yield. The second of the measures suggested is usually safe, and may be resorted to along with the first. Those agents should be selected which act with most promptness, and the doses should be adapted to the age and condition of the patient. Alum, sulphate of zinc, sulphate of copper, are perhaps the best, but by no means the only ones. Ipecacuanha, by the relaxing effect which it has upon the muscular and nervous system, may be useful not only in overcoming the spasm, but in preventing the recurrence of the attack. Antimony is unsafe, and the other emetics are quite as useful in relaxing the muscles. The third of the measures suggested should be used with great caution. It may be doubtful whether, in fact, anæsthesia is ever indicated in simple spasm of the muscles of the larynx. The dyspnoea renders it very difficult to produce full anæsthesia, and without this the relaxing effect is not reached. In cases in which there is serious disease outside of the larynx there should be appropriate treatment directed to the extrinsic trouble. During the intermission--that is, during the day following the spasm--attention should be directed to the condition of the digestive and excreting organs as well as to the respiratory tract. In malarial districts I have thought that quinia given in antiperiodic doses the morning after the seizure has been of benefit in preventing or diminishing the severity of the next spasm. In addition to these measures, for the prevention of the subsequent attacks bromide of potassium or bromide of sodium in 3 to 5 grain doses may be given once in three to six hours after the spasm has ceased. Five grains of chloral, as advised by Mackenzie, given at bedtime the night after the attack, will also diminish in a certain number of cases the severity of subsequent seizures, or possibly entirely prevent them. Musk, myrrh, camphor, castor, and other similar antispasmodics are theoretically indicated, but, in fact, are of but little if any value. If the disease is central, involving the floor of the fourth ventricle, the local and general spasms are only symptoms, and the treatment must be directed entirely to the preservation of life. It should be remembered in this connection that in the floor of the fourth ventricle the pneumogastric and the glosso-pharyngeal, as well as filaments of the spinal accessory, have their origin. The range of distribution of these nerves marks to some extent the range of the morbid phenomena in disease of central origin. It may of course be true in any given case that only a small portion of the central gray matter is involved, but as a rule the organic change in one of the nerves at the point of origin does give rise to disorder of function of one or both of the others.

General tonics and attention to hygienic conditions are of great {74} importance for the purpose of giving vigor and regularity to all forms of nervous and muscular activity.

Spasm of the Glottis in the Adult.

The affection is usually bilateral; that is, all the muscles guarding the vestibule of the larynx, and probably in most cases the adductors of the vocal cords, are involved. That this is not always true, however, I am convinced by a case now under observation in my own practice. The patient is an adult, and I have been able to determine by laryngoscopic examination that the muscles on the left side are the seat of the spasm. The epiglottis is drawn downward and backward on that side. The top of the left arytenoid cartilage is drawn forward, while the similar parts of the right side remain in their normal position except the change necessarily produced in the epiglottis. This condition is not constant, and is not a paralysis of the opposite side. This is the only case that I have seen, and I do not know of any similar case on record. Nothnägel[7] reports a case of spasm of the adductors upon making an effort to phonate. The cords were normally separated in inspiration, but at the first effort to speak they closed firmly, leaving no line of opening between them. The attack seemed to have been produced by a powerful impression made upon the nervous centres. It seems probable that it was hysteria. Krishaber describes a form of what he calls spasm of the larynx in adults, which seems to be rather a local manifestation of a central disease than a neurosis of the larynx. It is in many respects similar to epilepsy. The danger, even in cases in which life is threatened, is not from asphyxia, but from the arrest of the functions of circulation and respiration--an arrest of the effort even to breathe. It hardly seems proper to include this among the troubles of which we are treating. He calls it ictus laryngé.

[Footnote 7: Deutsch. Arch. für klin. Med.]

ETIOLOGY.--It is certain that the same causes that produce spasm in childhood are efficient in the adult, though there is an absence of some of the conditions that render the disease so frequent in infancy. The cartilages have become more firm, and consequently are not so easily moved by the action of the constrictor of the vestibule of the glottis; the size of the cavity in proportion to the necessities of the body for air is larger; the control of the voluntary over the automatic actions of the muscles of mixed function is greater; the reflex irritability of the nervous apparatus is less. These facts all render the probability of spasm in the adult much less than in the child. On the other hand, the development of the generative organs, and the widespread influence which they have upon the respiratory and circulatory as well as upon the central nervous system, introduces a new factor as a cause of motor disturbances of the larynx. This new element is a reason for the fact that in adults the predisposing influence of sex is reversed: after puberty the disease occurs more frequently among females than among males. The hysterical character of many of these cases may be inferred from this preponderance of one sex over the other among the subjects attacked.

This fact has been seen and described by Charcot, Lefferts, and others. Irritation along the track of the nerves, morbid conditions of the mucous surfaces, or muscular irritability, may be each a cause of spasm.

SYMPTOMS.--The symptomatology of spasm in the adult does not differ in any material respect from the phenomena observed in children. It is in the rarity and the comparatively milder character of these symptoms that the difference is to be found. The attacks occur at night, as in children, but, so far as I have observed them, they may also take place during the day. When very severe they occasion great alarm to the patient, and for this reason {75} produce a profound impression, not only upon the physical, but also upon the mental and emotional, state.

The duration and termination of the affection are about the same as in children. In the mortality-tables we find every year a certain number of deaths from spasm of the larynx in adults. It is probable that among these there are quite a number which should be placed elsewhere. A patient may die from spasm of the larynx, which spasm is produced by an ulceration, by a tumor, by the presence of a foreign body in the organ. As in children it is quite certain that the deaths reported as from spasm of the larynx include many that should be referred to central or other diseases, so here the immediate cause of death is not unfrequently given instead of the real and essential cause. This fact makes it difficult to reach anything like a definite conclusion as to the termination of the disease; only this can be said: the great majority of cases recover.

PATHOLOGY.--With the exception of those cases in which there is disease of the central nervous system or along the course of the nerves, we know nothing of the morbid anatomy of this affection. In fact, there is no appreciable alteration of the tissues or of the relations of parts; the spasm is to be considered as a symptom of disease, and not as the disease itself, or necessarily even as a sign of morbid structure in the organ.

DIAGNOSIS.--In adults we can make the diagnosis certain by the aid of the laryngoscope. This can be done in a certain number of cases in childhood, it is true, but not with the same ease as in those who have reached more mature years. Ulcerations, benign and malignant growths, and foreign bodies may each or all produce spasm, but the existence of such causes is revealed by the mirror, and excludes such cases from the group under consideration.

TREATMENT.--This does not differ in any essential respect from that suggested in spasm of the larynx in children. Attention to the condition which has been instrumental in the production of the affection, the use of antispasmodics, such as bromides, chloral, myrrh, musk, camphor, ether, chloroform, etc., will meet the urgent symptoms, while the use of tonics, such as vegetable bitters, quinine, iron, cod-liver oil, with attention to a proper hygiene, constitutes the general treatment.

The question of tracheotomy in spasm of the larynx should be considered. It is sometimes stated that there is never in simple spasm a justification for this operation, and that the other means at our control are always adequate to meet the indication. Krishaber, Thaon, and others are of this opinion. Gougenheim and Schnitzler think it is sometimes required. While in a very large majority of cases of uncomplicated spasm of the larynx the spasm will yield to the measures recommended, it is nevertheless true that there are cases in which this result is not realized. The slowness of the action of some of the drugs, the difficulty in securing their introduction into the system, their absence at the time of the attack, and the delay in their administration,--all these facts may render it absolutely necessary to resort to an operation for the purpose of saving the life of the patient. It is, however, rare that this necessity will occur. In one case recently in my own practice I think a life was lost for want of the operation. The trouble was, as I thought, of hysterical origin, and at the time of the consultation did not threaten life. There was free movement of the vocal cords, and the vestibule of the larynx was not obstructed. Spasm of the constrictors occurred at night, and did not continue for a great length of time. There was certainly not paralysis of the abductors of the glottis. I directed an antispasmodic, and advised that if the spasm returned the next night a physician in the neighborhood should be sent for. The spasm did recur, and the physician was called, but before he reached the house the patient was dead. No post-mortem was held, and {76} the question of the morbid anatomy could not be determined with any degree of certainty. From the fact that there had not been spasm till the night previous to the consultation, that she was an adult female previously in good health, with no organic disease, no tumor, no ulceration, no paralysis, and with a perfectly healthy condition of all the parts of the organ as revealed by the mirror, I am led to believe that the cause of death was simple spasm of the larynx. It is possible that this was one of those cases described by Krishaber and Charcot under the name of ictus laryngé or laryngeal vertigo, and that the death was due to some central disease; but the description given by the attendants was that of true spasm of the muscles of the larynx, and it is more probable that, as in Cohen's case, there was impaction of the epiglottis in the vestibule. The question of the operation should be considered in severe spasm which does not readily yield to the ordinary means. It is certain, I think, that life may sometimes be saved by a timely opening of the trachea.

E. F. Ingals suggests tubage of the larynx in cases of spasm threatening death. If the physician is present at the time of the dangerous symptoms, this may be attempted. A large-sized catheter or one of Schrötter's dilators may be used with no danger to the patient, and possibly with the result of saving life.

Chorea of the Larynx.

There is a kind of disturbance of the motor function of the larynx which has been described as chorea. The derangements of phonation and of respiration are such as we should naturally expect from want of co-ordination of the muscles concerned in speaking and breathing. There may be a true chorea of the laryngeal muscles when there is no other indication of the disease. Lefferts, in the first volume of the Transactions of the American Laryngological Association, reports three cases which he designates chorea of the larynx. They were all characterized by spasm of the muscles concerned in phonation. It is to be observed, however, that all three were women in early life, and that there were no other choreic troubles mentioned. There were, so far as the histories indicate, no hysterical phenomena present, if we assume that the laryngeal trouble was not of that character. In the recital of these cases the author seems to think that the evidence that the patients were not simulating is a sufficient proof that the troubles were not hysterical. This will not, I think, be accepted as adequate proof of the absence of hysteria. It is certainly possible that the patients were all three really choreic, but there is at least in the fact of the sex, the absence of other manifestations of this disease, and, so far as the author informs us, no antecedent history of rheumatism or other morbid conditions so frequently preceding chorea, a doubt as to the nature of the affection. Chorea affecting the muscles of the throat and of respiration is, I think, not unfrequently met with, but there is in these cases, so far as I know, such well-marked symptoms of the origin and nature of the trouble as to leave no reasonable room for doubt.

Cases of unmistakable chorea limited to the laryngeal muscles have been seen by Knight, Roe, and others. Chorea or spasm of the expiratory muscles alone may occur. I have the records of one such case, an adult male. I was unable to say certainly that the larynx was the only part involved. After a full inspiration there followed a series of short, jerky, expiratory acts till the movable air in the thorax was all expelled. For a few breaths the respiration was regular and full, when the same phenomena were repeated. There was no organic disease. There was forcible closing of the glottis during the {77} spasmodic expiratory efforts. The patient recovered under treatment by arsenic.[8]

[Footnote 8: It may not be easy in all cases to distinguish between the true choreic cases and the hysterical affections. Knight of Boston has given special study to choreic troubles of the larynx. He recognizes three varieties: The first includes those cases in which the adductor and expiratory muscles each side of the larynx are involved; second, in which the laryngeal muscles alone are involved; third, in which the expiratory muscles alone are involved.]

TREATMENT.--This should be the same as for other forms of chorea.

Nervous Cough.

Besides this ataxic condition we have hysterical disturbances of the motor functions, which are of various kinds according to the muscles involved. A constant effort to clear the throat, as it is called, is sometimes met with--a scraping of the throat, by which there is produced a rough, harsh sound similar to that which is heard in some of the inflammations of the organ. At other times the form is that of cough--a cough which is almost constant, and which is not associated with disease of the mucous surfaces of the thoracic viscera. This cough is sometimes almost continuous for days, and months even. It occurs at intervals of a minute or more, with the same character of hoarseness and roughness, without any interruption, except during sleep, when the breathing is free and easy. I saw a few years ago a little patient who had a cough of this nature which lasted several weeks, when it was replaced by the peculiar rasping, scraping effort mentioned above. The patient was a girl of fourteen years and had not developed. The moral effect of a severe case of typhoid fever in a younger sister, followed by the confinement of the mother, effected a cure. It is not at all uncommon to find that certain patients suffering from uterine troubles are also affected with laryngeal derangement of this character. A lady was seen by the writer a few months ago who had a rough, harsh cough, with attacks of asthma. There was no evidence of thoracic disease, and I learned that she had had this cough from the time of her last confinement. I advised her to consult a gynæcologist, who found that she had a laceration of the cervix uteri. For this she was operated upon, and from the time that she recovered from the immediate effects of the operation she had no more asthma or cough. It had been purely hysterical.

Cohen reports in his work On Disease of the Throat (p. 627) an epidemic of hysterical cough in a school for girls near Philadelphia. The cough was peculiar in character. The neighbors called them the barking girls. Cough of this character may be dependent upon other conditions than hysteria. Irritations reflected from other parts, as the ear and naso-pharynx, have been noticed.[9]

[Footnote 9: Cohen, p. 636.]

E. F. Ingals reports a case of an adult female whose voice had been abnormal for several years. It had been preceded by measles. Upon laryngoscopic examination the ventricular bands were seen to be approximated during the effort of phonation, while the true or vocal bands were, when last seen, moderately separated. The voice was not extinct, but hoarse, low in pitch. The true cords could not be seen during phonation on account of the closure of the false cords. This could hardly be considered as chorea, but there must have been an irregularity of muscular action, something between chorea and hysterical ataxia. There were no other abnormal movements of the larynx.

TREATMENT.--For these hysterical forms of trouble the treatment should be such as to correct, if possible, the morbid conditions upon which they {78} depend. Under the subjects of Anæsthesia, Hyperæsthesia, and Paralysis this has been sufficiently discussed.

PARALYSIS AND PARESIS OF THE MUSCLES OF THE LARYNX.

The function of the muscular apparatus concerned in respiration and phonation depends mainly upon the action of the recurrent nerves, as stated in the paragraph devoted to the Anatomico-physiological Facts. Disease of the centres in or near the floor of the fourth ventricle, where, in close proximity, the pneumogastric fibres of the accessory and the glosso-pharyngeal nerves take their origin, may be the sole cause of a paralysis of these muscles. Disease along the course of the nerves anywhere between this centre and the termination of the nerves may give rise to the same result. Change in the structure or function of the nerves at the point of their contact with the muscles in some instances may possibly be the sole cause of the paralysis. Alteration of the muscles themselves, such as atrophy or degeneration, produces a like effect. In certain cases both the nerves and muscles are involved in the morbid processes, but in some instances, even where there are undoubted changes in the muscles, these changes are secondary, the result of the long inactivity of the muscles. It is possible to group these morbid conditions with reference to the nerves involved; but it frequently happens that several different conditions are present at the same time, and groups of muscles supplied by different nerves are simultaneously involved. It is therefore difficult to classify these troubles with reference to the nerves by which the parts are supplied. The further fact that of individual muscles or parts of muscles supplied by the same nerve-trunk some are affected, while others are intact, renders this effort to make a physiological classification still more unsatisfactory. As a rule, however, we may state in general terms that diseases of the superior laryngeal nerves produce paralysis or paresis of the external tensors of the vocal cords, the crico-thyroids, and, to a certain extent, of the constrictors of the larynx. Diseases of the recurrent nerves produce paralysis or paresis of the other muscles of the organ. If the disease of the nerve is of one side only, we have, as a rule admitting of only a very few exceptions, a unilateral impairment of the motor functions of the parts. In the case of the loss of power of individual muscles or parts of muscles it is by no means easy to find a satisfactory explanation. It seems probable that in some instances the reason is to be sought in the centres, but in a great majority of cases the muscles are degenerated or the nervous filaments of the particular parts are in a morbid condition.

Notwithstanding this difficulty of classification, the troubles of respiration and phonation due to the complete or partial paralysis of the muscular apparatus are, for the convenience of study, divided into groups. These groups are based either upon the seat of the primary lesion or upon the kind of disturbance or the symptoms of the case. Neither method of grouping is satisfactory. We must content ourselves with a provisional arrangement. With the single exception of the arytenoideus, the muscles are double and symmetrical; paralysis may therefore be general or partial, unilateral or bilateral.

The causes, symptoms, or terminations vary with this general or partial, double or single, character of the affection. We propose, therefore, to consider these motor derangements under the following heads, which in the main follow the classification of Mackenzie and most other writers upon the subject:

1. Paralysis of the whole larynx--of one-half of the larynx; {79}

2. Paralysis of the constrictors of the larynx;

3. Paralysis of the adductors of the vocal cords: (a) unilateral, (b) bilateral, (c) central;

4. Paralysis of the tensors of the vocal cords: (a) internal, (b) external, (c) unilateral, (d) bilateral;

5. Paralysis of the abductors of the vocal cords, openers of the glottis: (a) unilateral, (b) bilateral.

Paralysis of the Whole Larynx.

Paralysis of all of the muscles of the larynx gives rise to a position of the parts which has, as before stated, been called the cadaveric condition. The vocal cords are neither abducted nor adducted. The opening of the glottis is sufficiently wide to admit of easy respiration, but the cords are so far apart as to make phonation impossible. The effort to articulate is not attended with any change in the position of the vocal bands. In respiration there is no additional widening of the glottic chink. The superior portion of the larynx is also in a peculiar condition. The epiglottis is erect, standing against the dorsum of the tongue; the vestibule of the larynx is widely open; deglutition is difficult.

ETIOLOGY.--So far as we know, the causes are to be found either in central disease or hysteria. When the cause is in the centres, there is almost of necessity functional lesion of other parts of the muscular apparatus, especially of the parts supplied by the glosso-pharyngeal nerve. There will, therefore, be dysphagia. It is possible that the central lesion may be very circumscribed; in such cases we may have paralysis of individual laryngeal muscles or parts of muscles. These cases are probably very rare, and the indication of more general paralysis is, in fact, the point upon which the diagnosis of central disease depends. Tumor or other disease along the track of the spinal accessory before it unites with the pneumogastric may produce the same effect. When the affection is upon one side only the paralysis is also unilateral. There are, as before noted, exceptions to this statement. In these instances it is probable that the innervation of the affected part or side is supplied by branches from the opposite trunk. Such cases have been reported by George Johnson, Lefferts, and others. It has also been found that injury or paralysis of one recurrent nerve is sometimes followed by bilateral paralysis. Schnitzler reports a case in the Wiener Med. Report for 1882. The left recurrent was compressed by aneurism of the arch of the aorta; the right was normal. There was, however, bilateral paralysis. Experiment by Tourgues[10] demonstrated the fact that powerful excitation and consequent exhaustion of one of the pneumogastrics may result in paralysis of the other. This result is in accordance with facts seen occasionally in traumatism of one of the pneumogastrics.

[Footnote 10: Reported in the Gazette de Montpellier, Nos. 35 and 36, 1882.]

A pure, uncomplicated paralysis, in which all of the muscles of the larynx are implicated, and in which no other muscles are concerned, will almost always be found to depend upon some lesion of the pneumogastrics or the spinal accessories after they leave their point of origin. Whether the paralysis is dependent upon the lesion at one point or another, the symptoms are the same so far as the larynx is concerned. The vocal cords are in a state of absolute rest between abduction and adduction; the effort at phonation gives rise to no contraction of the tensors; the arytenoids leave the cartilages slightly separated; and the state of the organ is that of muscular death.

When the lesion upon which a paralysis of the muscles of the larynx depends is below the point at which the superior laryngeal nerves leave the {80} pneumogastrics, the paralysis is limited to the phonators and respirators. The muscular bands and fibres by which the glottis is constricted are, in part at least, still capable of being thrown into contraction. This condition of recurrent paralysis may be due to a disease of the nerve-trunks, tumor pressing upon the nerves, cicatricial tissue by which the nerves are compressed, aneurism of the arch of the aorta or right subclavian artery, disease of the apex of the lung, especially of the right side, pleuritic adhesions, or, in fact, any injury or lesion along the trunks of the recurrents or pneumogastrics. The paralysis may of course be partial or complete.

The SYMPTOMS vary according to the extent of the muscular disability. In case of complete paralysis of one side there may be aphonia, but not dyspnoea. The glottis admits a sufficiency of air, but does not close so as to allow of the vibration of the cords. Where there is complete paralysis on one side only, the voice is not necessarily entirely suppressed, but it is changed in its quality; it becomes rough, weak, and in its use gives rise to great fatigue. In long-continued cases there is in part a compensation for the want of motion of one of the vocal bands. The muscles of the sound side act with increased vigor, so as to carry the sound cord at its posterior extremity beyond the median line. The result is, that the two cords are brought so near each other that phonation is possible. The arytenoid of the non-paralyzed side is drawn forward beyond its fellow. The cord upon the affected side is less tense than that on the healthy side. The vibrations are therefore not equal; the pitch is different; the voice is therefore unnatural, rattling, uncertain.

As we proceed to discuss the lesions in individual muscles or sets of muscles we shall have occasion to refer to these etiological considerations, as well as to some of the symptoms noted with partial or complete loss of power of the whole group of muscles of the organ.

Paralysis of the Constrictors.

Complete paralysis of the muscles, by which the vestibule of the larynx is closed, is rare. The partial paralysis of these muscles is, however, by no means uncommon. As we have already endeavored to show, it is probable that the motor functions of the muscular fibres in the ary-epiglottic folds--the superior constrictors--are mixed. Probably both the superior and inferior laryngeal nerves are concerned in their movements. It is not, therefore, easy to group these disorders according to the nerves involved, as has been done by Von Ziemssen, Mackenzie, and others.

Partial paralysis of the constrictors may be due to deficient power of one or both of the laryngeal nerves, superior or inferior. The parts involved are the arytenoids, transverse and oblique, and the muscular fibres in the folds going from the arytenoid and from the thyroid cartilages to the epiglottis.

The ETIOLOGY of this form of paralysis associates itself with that of anæsthesia of the parts--namely, the arrest of motor impression in the centre, obstruction along the course of the nerve, disease in the nerve itself, in its trunk or termination, or, lastly, myopathic changes rendering the muscle incapable of responding to the nervous influences. Disease in the centres may possibly affect only these muscles; the disorders of motion may be well defined and local in extent, but usually, in case of central disease, there is a complication of external manifestations and we have a wider range of disturbances. The most common cause of this loss of power is diphtheria.

SYMPTOMS.--The symptoms of paralysis of the constrictors of the larynx are for the most part mechanical. The failure to close the vestibule of the organ in the act of swallowing allows food or drink to pass into the larynx, {81} and, as there is usually anæsthesia of the parts also, the invasion of the larynx is not perceived; no reflex irritation is produced, no cough for the extrusion of the offending matter, which may descend into the trachea, and, reaching the bronchi, may become the agent in the development of a bronchitis or a broncho-pneumonia. The secretions of the mouth overflow the borders of the laryngeal opening and fall into the tube below. Fluids are swallowed with greater difficulty than solids. The voice is not altered except in cases where the crico-thyroids, one or both, are involved, as in complete paralysis of the superior laryngeal nerve. The effort to close the glottis, as in the preliminary act of coughing, is accomplished with difficulty. The sound of the cough is somewhat altered. This is for want of the reinforcement to the adductors furnished by the closure of the vestibule of the larynx. Upon laryngoscopic examination the epiglottis is seen to stand erect against the dorsum of the tongue. The ary-epiglottic folds are lax or wide apart. With this is loss or diminished sensibility of the surfaces. There is little or no change in the color of the membranes. The secretions are normal in quality, and only slightly in excess in quantity.

The course of the disease is in cases of diphtheritic origin like that of anæsthesia from the same cause. The termination, except in rare instances, is recovery. In cases of central origin the local symptoms in the larynx are almost necessarily associated with disorders of other parts. The progress and termination will depend upon the nature and extent of the central lesion.

The PATHOLOGY of this form of paralysis is probably multiple. When of diphtheritic origin it has been believed to consist in a change of the nerves along the trunk or in their distribution, or an alternation of nutrition due to the local changes in the larynx or pharynx during the progress of diphtheria, or to both of them. It is also probable that it is in many cases as much a myopathic as a neuropathic trouble. In other words, during the progress of the diphtheria the muscles, as well as the nerves, have undergone a change in their nutrition; and this local change in the peripheral portions of the nerves, along with this degeneration of the muscles, goes to make up the pathological anatomy and constitutes the essential local morbid condition.

There is, however, abundant reason to think that in some cases at least the influence of the diphtheria in the production of paralysis reaches far beyond the parts which are the seat of the local manifestations of the trouble, or even the centres from which these nerves are derived. It is well known that the extremities may be affected, and that other muscles become involved which can have no direct and immediate relation to the tissues which have been attacked with the diphtheria. It seems therefore evident that there must, at least in certain cases, be a general derangement of the centres, or that there must be some other explanation for the impairment of the muscular power than that which ascribes its loss solely to the local and poisonous action of the morbid deposit or to the defective nutrition of the parts. It is probable that there is in these cases a widespread influence, a constitutional trouble, which, like the disease itself, is general and not local except as to its manifestations.

Paralysis of the Adductors.

A pure, uncomplicated paralysis of the adductors of the vocal cords is extremely rare. When present it is marked by symptoms and signs which are easily recognized. A partial paralysis of an hysterical nature is, however, not unfrequently encountered. The etiology of paralysis of the lateral crico-arytenoid muscles is in most instances the same as that of the other muscles of the larynx. There may be a morbid condition of the centres in the fourth {82} ventricle, from which the spinal accessory takes its origin. It is certainly possible in theory that certain fibres ultimately distributed to these muscles may alone become diseased in their course along the trunk of the nerve. There may be change in the final distributions by which the function of the nerve is arrested. There may be myopathic change in the muscle itself, rendering it non-responsive even to normal nerve-impressions. All of these causes are theoretically possible. In fact, however, we know but little of the real causes which operate in any given case. Mackenzie, Von Ziemssen, and others ascribe it in some instances to catarrh from exposure to cold. There is developed a hyperæmia of the mucous surfaces of the supraglottic space. The structures beneath are involved in the tumefaction as a result. The voice is impaired or lost; the aphonia, which was at first due to the mechanical difficulties in the way, persists after the local inflammation has subsided. The vocal cords remain permanently apart, even though there is no swelling to prevent the arytenoids from approaching each other. Gerhardt attributes this form of paralysis in certain cases to a rheumatic inflammation affecting either the articulations or the muscles themselves. Trichina have been found in one or both muscles, producing a paresis. Syphilis, central or laryngeal, may account for a number of cases. When the loss of power is due to local syphilitic trouble, there is, however, usually a recognizable change in structure, something more than a simple paralysis.

It would seem strange to find a rheumatism so localized as this hypothesis implies. Mackenzie has met with a case in which the paralysis was unilateral and toxic, due to lead-poisoning. He thinks there may be other cases of similar origin, and suggests arsenic also as a possible cause. In his case he compares this paralysis of the lateral crico-arytenoids to the loss of power in the extensors of the forearm in well-marked cases of lead-poisoning. The affection was limited to the adductor muscles. Seifert and Lublinsk in Berlin. klin. Woch. also report cases. The adductors only were affected. The very few cases in which this form of paralysis has been carefully noted do not supply us with the material for a more exact opinion as to the causes of the trouble.

SYMPTOMS.--The symptoms of this form of paralysis are for the most part such as depend upon the mechanical relation of the parts. There is no pain; there is no dyspnoea, except in cases in which there is a catarrh of the larynx; there is no cough. There is however, complete aphonia. There may be an exception to this statement when the paralysis is unilateral. It is possible that where one cord comes to the median line, and the other is affected only with paresis, in the course of time the cord on the sound side may pass beyond the median line and render phonation possible. In such cases, however, the voice is not normal in quality.

Upon inspection with the laryngoscope the glottis is seen to be widely open. The cords approximate the lateral walls of the supraglottic space. Upon an effort to phonate the cords remain immobile. If the constrictors are unaffected, the act of laughing is still possible, from the fact that a partial occlusion of the lumen of the tube is accomplished by the action of the borders of the laryngeal opening and by the approximation of the false cords. In case of unilateral paralysis of course there is motion of the cord upon the sound side, leaving one-half of the glottis open. It has been stated by Von Ziemssen that there is sometimes an anæmic condition of the mucous surfaces. When present, this is probably only a contingent phenomenon, the evidence of a slight alteration of the circulation in the tissues. It is true that the permanent immobility of the parts ought to diminish the activity of the circulation in the muscles, and perhaps also in the neighboring structures. On the other hand, the surfaces have been found hyperæmic. Probably no importance should be attached to the surface condition as a means of diagnosis.

{83} The course, duration, and termination of this form of paralysis must depend largely upon the cause. When the disorder depends upon a catarrh, we may expect that the trouble will disappear, or at least be mitigated, as the local affection is relieved. If of syphilitic or rheumatic origin, it should disappear pari passu with the primary disease. So far as we know, there is no danger to life, the loss of voice being the only important result.

The DIAGNOSIS is easy. The laryngoscope will enable the observer to differentiate it from all other affections by which the voice is destroyed. It is possible that disease affecting the articulation of the arytenoids, and thus preventing their movement, might give rise to a doubt. A careful examination in such cases will, however, generally reveal the fact of tumefaction or other evidence of structural change.

Closely allied to the paralyses which we have just been considering are the affections of the glottis of hysterical origin.

If the cases of true paralysis of the lateral crico-arytenoid muscles are rare, it is equally true that a partial arrest of the action of these muscles, and temporary for the most part in duration, is not unfrequently met with. The etiology of these cases seems to be much more within our knowledge than that of those of which we have just been speaking; at least the conditions under which they occur are much better known. For the most part they occur in females. They are met with in patients of nervous temperament, generally adults, though I have seen one case in which the subject was still undeveloped. There are very generally the evidences of hysteria in some of its various manifestations. We may therefore assume that the disease is functional in its nature and that it is reflex in origin. It has been said that, as it is not dependent upon any disease of the muscles or nerves of the larynx, so far as we know, it should not be classed among the paralyses. For the same reason it should not be considered as a neurosis of the organ, but of the system in general. But it is a neurosis of the larynx, and therefore ought to be placed here. In addition to this, it is in its symptoms identical with or very similar to the true paralyses dependent upon alteration of the nerves or of the muscles of the part.

The etiology of the affection has already been suggested in the definition. A disturbance of the functions of the uterus, or possibly of other portions of the nervous system, may be so reflected as to materially interfere with the action of the muscles of the larynx. It is possible that the affection may occur in males, as other troubles called hysterical sometimes do. That the uterus is not always the source of the reflex disturbance is certain. I have very recently seen a case in which there was unquestionably an intermittent partial paralysis of the adductors of the muscles in an adult man. It seemed to be dependent upon the condition of the stomach. Whenever there was flatulence or an accumulation of gases in the stomach, the voice became husky, requiring great effort and expenditure of air in phonation, and then extinct. Examination with the laryngoscope showed the cords in the condition of adduction. In the effort to speak there was a very slight approximation of the vocal bands, but not enough to admit of their vibration. With the recovery from the disorder of the stomach this condition disappeared. I have seen one other case similar in character. I think we may therefore assume that the trouble can be produced by any affection which creates a disturbance of the pneumogastrics, and which by reflex action interferes with the proper functions of the spinal accessory.

The disease is always bilateral. Its advent is generally sudden. The symptoms are first and almost solely loss of voice. The aphonia may from the beginning be persistent, or there may be intervals when the patient speaks with ease. In some cases the patient is able to whisper; in others this power is also lost: in the effort to phonate there is absolutely no sound. There is {84} no pain, but there is often cough: this cough is hoarse, like that which has been described under a previous heading. The general health is in some cases apparently perfect, but in a majority of instances there will be found some disturbance of the viscera of the abdomen. Perhaps in all cases this is true, but so slight that we are obliged to look carefully in order to find it. Upon inspection with the laryngoscope the cords are seen to be separated, but not so widely as in complete paralysis of the adductors from other causes. There is no marked morbid condition of the mucous surfaces. The secretions are not affected. It is possible that there may be at the same time a partial paralysis of the pharyngeal muscles, so that there is also dysphagia. In a few instances there is a paræsthesia of the parts above. The dysphonia or aphonia is then associated with a feeling as though there was a foreign body in the throat. In efforts at phonation the cords usually move slightly toward the median line, but not enough to enter into vibration. When this condition of things is observed, and there is no other cause for the explanation of the loss of voice, we may with safety assume that we have to do with an hysterical paralysis of the adductors.

The duration of this form of motor disturbance is uncertain. It may terminate suddenly after a short duration or it may continue indefinitely. It is a cause neither of dyspnoea nor asphyxia. It always ends finally in recovery. This statement is possibly subject to an exception in cases in which there are other diseases present and when these diseases are of themselves dangerous to life.

The pathology and morbid anatomy are dependent upon the length of time during which the muscles have been in a state of inaction. It is possible that the muscles may degenerate or lose their power to act with the normal vigor, or there may be a simple atrophy of the muscles, as in a case reported by Mackenzie. So far as I know, this alteration of the muscles is very seldom found in hysterical paralysis. When degeneration or atrophy does exist, it is probably a result, and not a cause, of the paralysis. So far as we know, there is no antecedent change in the larynx. This must of necessity be the case, since the disease is reflex, and not primarily in the organ of speech. Why the morbid influences are manifested in this organ to the exclusion of others we do not know. In fact, we do not know that this is the case. So far as we can judge from the records of similar cases found in the literature of the subject, we may safely believe that there is in nearly all of the patients some other disorders of motility, but the derangements of speech are so striking that these have masked all minor troubles.

The intimate relation between the organs of expression, of which speech is one of the most important, finds in these cases a striking illustration. The quality of the voice is modified by emotion. The evident relation of the generative functions to this psychical state is well known. This fact explains the association of these troubles so frequently encountered in the study of the morbid conditions of the larynx. It is true that the disturbance is not always limited to the phonators, but it is nevertheless more frequently met with in these muscles than in the muscles of respiration. Emotion and the expression of emotion go together. Their morbid conditions are therefore associated.

Paralysis of the Arytenoideus--Central Adductor.

The function of this muscle is to approximate the arytenoid cartilages. Its paralysis leaves the posterior borders of the cartilages separated, even though the vocal processes are by the action of the lateral crico-arytenoids made to approach the median line. There is left a triangular opening at the base of the cartilages, through which the air escapes in the act of speaking. This, the {85} cartilaginous portion of the glottis, remains patent even though the anterior three-fourths of the space be closed. The result is generally, but not always, a loss of speech. The air whistles through this opening, but phonation is difficult or absent. The causes are to be sought in the derangements resulting in the loss of power of the other muscles. Upon examination with the laryngoscope the triangular opening is readily seen. The ligamentous portion of the glottis is seen to close in the effort to speak, while the cartilaginous portion is widely open. There is no other morbid condition necessarily present. The trouble is frequently associated with paralysis of the adductors of the two sides--that is, the lateral crico-arytenoids. In these cases there is complete separation of the cords throughout the whole length.

The DIAGNOSIS is easy except in instances where there is ankylosis of the articulation of the cartilages. Even in these cases a careful study of the parts, as revealed by the mirror, will enable the observer in most instances to recognize evidence of structural disease on the walls of the larynx. There will also be a history of some antecedent affection, such as syphilis or tuberculosis, or possibly arthritis. The course and termination of this form of paralysis depend largely upon the etiology in any given case.

Paralysis of the Tensors of the Vocal Cords.

It will be remembered that these are in two groups, the internal and external.

The internal are the thyro-arytenoids. While their function is in part still a matter of discussion, it is very generally conceded that they have to do with the form and tension of the cords. Their paralysis produces a very marked derangement of the functions of the larynx as the organ of speech. They act ordinarily along with the crico-thyroids, but from the fact of their separate innervation it would seem very probable that they should be the seat of special functional derangements. In fact, it is true that their paralysis in a limited number of cases is found to be quite independent of any disturbances of the external tensors.

ETIOLOGY.--In addition to the general causes of laryngeal paralysis, the use of the voice in an unnatural or too high a key or the too long-continued use of the organ may result in a temporary or even permanent impairment of the power of these muscles. Their exposure to the causes of inflammation, lying as they do so near the surface of the mucous membranes, subjects them to the morbid influences of the catarrhal troubles to which the glottis is liable. They are probably more frequently affected than the literature of the subject would lead us to suppose, as in many cases the disease is temporary.

SYMPTOMS.--These consist mainly in the alteration of the voice. It is hoarse, the register is lower, the quality is uneven. Occasionally a note is, if not lost, uttered with difficulty; some letters, such as the aspirates, requiring the careful adjustment of the glottis, are articulated with great uncertainty. There is what has been called a rattling of the voice. It is quite impossible to sing or to speak long in a high key; even prolonged ordinary conversation gives rise to fatigue, for the reason that there is so great a waste of air in the effort. The pressure upon the under surface of the cords in their relaxed condition forces its way upward and through the glottis without throwing them into normal vibration.

DIAGNOSIS.--The laryngeal mirror reveals the glottis only partly closed. There is an oblong opening extending from the thyroids to the base of the arytenoid cartilages. The vocal processes even are not brought to the median line, but are so far apart as to leave a noticeable slit between them. It seems from this fact that these muscles are therefore the aids of the lateral {86} crico-arytenoids in the rotation of the cartilages on their bases. In the effort at phonation the cords are seen to move with difficulty. The disease may be unilateral or bilateral.

This form of paralysis in course and termination does not in any essential respect differ from other paralyses of the larynx. The duration is therefore very uncertain, and will depend largely upon the cause of the affection.

Paralysis of the External Tensors of the Cords.

This is a rare disease, but is present in complete paralysis of the superior laryngeal nerve. It is then associated with anæsthesia of the superior portion of the glottis, as well as paresis of the depressors of the epiglottis, and generally of the constrictors of the vestibule of the larynx.

ETIOLOGY.--It may be the result of injury to the external branch of the superior laryngeal in its distribution to the muscles. It may be caused by diphtheria. It is possible that the motor fibres of the superior laryngeal nerve may be alone involved, while the sensitive portion is still normal. Cases of partial paralysis are recorded by Von Ziemssen, Gerhardt, and others.

The SYMPTOMS are such as we should expect in diminished tension of the vocal bands: lowering of the pitch of the voice, with inability to reach the higher notes. There ought to be, therefore, hoarseness. Acute paralysis of this muscle has been known to produce aphonia (Ramon).

DIAGNOSIS.--It is said that this form of paralysis gives rise to a well-recognized condition which may be seen in the laryngeal mirror. The cords are described as wavy, irregular in their relation to each other, like the position of two pieces of ribbon, which, having an attachment at their extremities near to each other, are allowed to fall into folds. This condition, if ever present, is, I am convinced, very rare. It is probable that the descriptions have been given to correspond with what ought to be seen, rather than what is actually seen, in the mirror. There is said to be a slight depression of the vocal processes in the act of inspiration, and a corresponding elevation of them in the act of expiration and phonation. The diminished tension should produce this change in position. The disease may also be recognized by placing the finger upon the edge of the crico-thyroid muscle during the effort to speak. The muscle acts so strongly in the healthy condition that it may be easily felt; in paralysis this contraction is wanting.

The course and duration of the disease must depend upon the cause and complications. When the muscles suffer in common with the sensory apparatus supplied by the superior laryngeal nerve, as in the case of diphtheria, there is reason to expect that it will disappear with the other morbid phenomena.

Paralysis of the Posterior Crico-Arytenoids.

The functions of these muscles render any loss of their power as glottis-openers a matter of importance. It will be remembered that they are so situated that they not only rotate the arytenoids, turning the vocal processes away from each other, but they also serve to fix the cartilages, giving them a firm support as points of attachment for the vocal cords. The outer fibres tend also to draw the body of the arytenoids away from each other, as well as to fix them in a postero-lateral position. They are, more than any other of the muscles of the larynx, organs of respiration. They are also in constant action: with each inspiration they contract, and during expiration they {87} fall into rest. In this respect they resemble the other muscles of respiration and the central organ of the circulation. In some respects they also resemble the muscles of the heart in the degenerative changes to which they are subject. Their antagonists are the lateral crico-arytenoids. When both sets of muscles are paralyzed, the glottis is in what is known as the cadaveric condition; that is, the vocal cords are neither widely separated nor parallel to each other. There is an opening of a triangular shape as in the act of easy inspiration, not sufficiently approximated to admit of speech, but sufficiently open to admit of free inspiration. With this understanding of the physiology of the parts, we can readily appreciate the results of the loss of power of these muscles. As stated by Bosworth, the especial danger is in the integrity of the adductors, tending for the want of antagonism to keep the glottis closed. Of all the muscles of the larynx, these are therefore the most important so far as life is concerned.

The disease is progressive (Lefferts, Semon, Bosworth).

The first symptom which attracts attention is generally inspiratory dyspnoea while taking active exercise. The difficulty continues to increase till there is constant difficulty in the act of inspiration, usually with spasm. The dyspnoea is more marked during sleep than when awake. Death may occur at this period of the disease before the gravity of the trouble has been recognized. As a rule, tracheotomy will be required to prolong life, after which the dangers to the patient are passed.

The ETIOLOGY of this form of paralysis presents some peculiar problems. In all paralyses of the individual muscles we are obliged to invoke nerve-changes in special nerve-cells in the centres from which the individual nerves have their origin--changes along the course of the nerves; or, on the other hand, some myopathic change in the muscles themselves. In the muscles now under consideration we have a special function--namely, respiration--involved. The disorder is usually limited to these muscles alone. If it becomes general, it commences here. The phonators not being involved, it is probable that in a part of the cases reported the essential cause of the paralysis must be ascribed to disease in a centre in the brain, or at least along the course of the nerve near its origin. Other cases are evidently due to pressure on the pneumogastrics or recurrents. This view has been proposed by Bosworth. Von Ziemssen and others have thought that syphilis enters very largely into the pathology of this group of cases. There has been noted, as confirmatory of this proposition, that other symptoms of central disease have been in a few instances observed. Diseases affecting the recurrents have been known to affect these muscles alone: Ingals reports cases. On the other hand, it is quite certain that in a large majority of the cases recorded there has been no satisfactory cause assigned. In nearly all of the post-mortems there has been found a degeneration of the muscles. This is as we should expect to find it where the structures have been for a considerable time in a state of inaction. The histological change may possibly be in any case only the result of the paralysis, and not the cause of it. In a few instances there has been discovered a degeneration of the nerve-trunks by which the parts are supplied. As to the causes by which the muscles may become affected, we can imagine that the exposed position suggested by Mackenzie renders them peculiarly liable to mechanical injuries from hard substances forced down the oesophagus. They are subjected to changes of temperature produced by hot and cold drinks and food. Their relation to the seat of local inflammation of a specific as well as of a non-specific character renders them liable to become involved in morbid processes. The fact that the disease occasionally occurs after diphtheria, as I have in two instances demonstrated, gives additional weight to this hypothesis. The fact probably is that there are several varieties of the affection. The want of more accurate information as to the {88} previous history, as well as to the immediate antecedents of the attack, renders it impossible as yet to differentiate the cases due to one or other of these causes. For the present, then, we may conclude that paralysis of these muscles may depend upon either disease of the centres, disease along the track of the nerves, pneumogastric or recurrent, or to disease of the peripheral branches or fibrils, or to disease of the muscles themselves.

SYMPTOMS.--These are at first so slight that the trouble is usually not recognized till it has reached such a stage that the act of inspiration is either attended with fatigue or there is stridor which annoys the patient or alarms his friends. Soon afterward there begins to be a dyspnoea, a difficulty in breathing, especially during any active exertion and during sleep. The voice in the mean time remains normal. Expiration is free. The general health is usually undisturbed. There may be a catarrhal affection of the mucous surfaces, but if so it is quite accidental. Spasm supervenes. There is at times great difficulty of breathing, and, finally, the effort becomes so great that the patient becomes alarmed. Upon examination with the laryngoscope the vocal cords are seen in close proximity to each other even during the inspiratory effort. In fact, they are, by the pressure of the air upon their upper surfaces, brought closer together during inspiration than during expiration. They seem to act as valves which are closed by the weight of the atmosphere upon their wide, flat upper surfaces, pressing them against each other. Hence the inspiratory stridor and dyspnoea. The act of expiration is a passive one in health, and in this condition the air is easily forced out by pressing the cords away. The order of the movements of the cords is therefore changed--in the normal condition wide in inspiration, narrow in expiration; in this disease narrow in inspiration, and while not wide, at least wider, in expiration than in inspiration. In other respects the parts are normal. There is nothing to suggest the trouble except the closure of the glottis during inspiration.

The course and duration of the disease are in a large majority of cases chronic. Once established, it tends to persist. The cases of diphtheritic origin should be excepted from this statement. In those forms in which the trouble is entirely in the muscles of the part life may, so far as we know, be continued indefinitely. Where the trouble is central it is probable that the cause has a tendency to involve other parts of the brain, and in this way to lead to other, and possibly dangerous, complications. Of this, however, we know but little. The paralysis is not directly the cause of death, except as it closes the glottis. The dangers are therefore mechanical. When the patient has once been placed in a condition of safety by the operation of tracheotomy the local paralysis no longer endangers life.

Mackenzie, Von Ziemssen, Cohen, and in fact almost all writers upon the diseases of the larynx cite and publish cases by the way of illustration of the symptoms, course, and termination of this class of troubles. They are now so numerous that it would seem to be hardly necessary to do more than to give the conclusions which the recorded instances suggest. Fortunately, this form of laryngeal disease is rare, and when present it is easily recognized. The treatment is clearly indicated. In all cases in which the inspiratory difficulty is marked tracheotomy should be performed, even though suffocation does not seem to be imminent. The treatment for the radical cure of the disease must be in the main the same as that required in other forms of laryngeal paralysis.

TREATMENT OF PARALYSIS OF THE LARYNX.--The grouping of these disorders for the purpose of description has, for the reasons already given, been based largely upon symptoms. For the purpose of treatment we may properly divide them with reference to their causes. With these in view, we have, first, those cases in which the cause of the affection is within the {89} cranium--central disease; second, those in which the loss of power is the result of disease or pressure along the course of the nerves outside the cranium and before reaching the larynx; third, those in which there is disease of the structure of the larynx itself, nerves or muscles; fourth, those in which the cause is to be found in some distant part--reflex paralysis; fifth, those of toxic origin. This last includes paralysis after typhoid fever, diphtheria, etc., as well as those produced by lead, arsenic, mercury, and possibly copper and other toxic agents.

Diseases of the base of the brain or medulla are for the most part not 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.

DIAGNOSIS.--It is by no means easy in all cases. When laryngeal diphtheria (membranous croup) happens to be frequent, the most experienced diagnostician will meet with occasional difficulties. The sound of the barking, explosive, tickling cough locates its origin in the larynx, but the affection may be very mild or very severe. Expectoration in small children is not pathognomonic; even when it is copious it is not brought up, but swallowed. Fibrinous expectoration would settle the diagnosis of a croupous process. Depressing the tongue with a spoon or spatula and producing the movements of vomiturition often reveals the presence of a tough, viscid mucus rising from the larynx. It renders the catarrhal nature of the laryngitis positively clear. The frequency or volume of the pulse is of no account in diagnosis; it is too variable. Of more importance is the temperature, at least in children. Uncomplicated sporadic croup has no increase, or very little; catarrhal laryngitis is mostly attended with high fever. In very many cases this symptom has guided me safely, in spite of the statements of the books. The stenosis of catarrhal laryngitis comes on very suddenly, in diphtheritic laryngitis mostly slowly. In the former it is not of long duration; remission sets in soon, and is more complete than in membranous croup. An attack of stenosis occurs mostly in the night, and is apt to return with the same vehemence after a fair remission after twenty-four hours. The frequency of relapses in catarrhal laryngitis in children who have been affected before must, however, not prejudice in favor of the catarrhal nature of an individual case, for not infrequently will those who have had many attacks be taken with membranous croup some other time. In the latter the main symptoms--viz. stenosis, hoarseness (or aphonia), and cough--will mostly develop simultaneously and in equal proportion; the unproportionality of these symptoms--for instance, much stenosis and cough, but little hoarseness, or barking cough and hoarseness with little stenosis--would speak for catarrh. The laryngoscope, when it can be used--viz. in the adult and very docile children--reveals redness of the mucous membrane of the pharynx and all or part of the larynx; also tumefaction of the epiglottis or fossæ Morgagni or ary-epiglottic folds. Sometimes the inferior part of the larynx only is affected; Ziemssen has described a severe form under the name of hypoglottic laryngitis. The vocal cords can be watched easily. Their proportionate and parallel contraction is often interfered with.

Tubercular laryngitis, particularly when there is no pulmonary tuberculosis, is not easily diagnosticated by the local changes only. The long duration of {96} hoarseness and fever, increasing emaciation, and the knowledge of the presence of tuberculosis in the family are more conclusive than local examinations can be.

PROGNOSIS.--The termination of catarrhal laryngitis in the adult is almost always favorable. Still, relapses are frequent, and it may become chronic, with permanent tickling of the mucous membrane and submucous tissue. In children it is mostly favorable; still, it is doubtful, because of the frequency of complication with, or transmutation into, bronchitis, pneumonia, or glottic oedema, and because of the facility with which in a prevailing epidemic the catarrhal laryngitis becomes diphtheritic. The elevation of temperature is not a very significant symptom in regard to prognosis. The danger does not increase with the temperature at all. On the contrary, those cases which set in with a high temperature will, as a rule, terminate soon and favorably. When, however, the temperature rises again after having gone down to the normal or nearly normal standard, complications or extension of the catarrhal or inflammatory process must be expected. Catarrhal secretion from the nasal mucous membrane, which was dry in the beginning, is a favorable symptom; so is the looser and moister character of the cough.

TREATMENT.--Whatever plays an important part in the etiology of the disease ought to be carefully avoided. The feet must be kept warm under all circumstances, nothing being more injurious to health in general, and to that of the respiratory organs in particular, than cold and moist feet. Shoes and stockings must be kept dry, the latter changed when wet, and of slowly-conducting material. No part of the body must be kept uncovered, and the dresses of children made the particular object of care on the part of the family physician. Linen must not be in immediate contact with the skin, cotton--or, still better in all seasons, wool--being required for the undergarment. At the same time, the hygiene of the skin requires attention. Regular washing or bathing need not be mentioned as a requisite, as it is self-understood. What, however, cannot be insisted upon too much is this, that the skin must get accustomed to cold water. The whole body must be exposed once a day to cold water--washing or bathing--and well rubbed off afterward with a thick towel. Young infants and those who are very susceptible to colds begin with tepid water, the temperature being lowered from day to day. Even children of three or four years enjoy, finally, a morning bath at sixty or sixty-five degrees F. in winter. Such as do not get easily warmed up under the succeeding friction may mix alcohol with the water they use for washing and sponging purposes, in the proportion of 1:5-8. Sea-bathing also makes the skin more enduring, to such an extent that exposure to cold air has no longer any damaging influence. In fact, cold air without wind is easily tolerated even by those who have a tendency to respiratory disorders, while wind and draught must be avoided. From this point of view the change of climate sometimes required for such as suffer from catarrhal laryngitis must be instituted. It is not always necessary to select a very warm climate; undoubtedly, many of the winter resorts are badly selected, for the very reason that they are too warm. On the other hand, great elevations are not advisable. The sudden atmospheric changes and fogs of high mountains are injurious.

Patients suffering from catarrhal laryngitis or a tendency in that direction must avoid all irritation of the pharynx and larynx. They must not smoke, or talk too much or too loud. Those few clergymen who suffer from clergymen's sore throat in consequence of speaking only will remember that they can speak just as forcibly when speaking less vehemently. The use of alcoholic beverages, unless greatly diluted, is prohibited. Catarrh of the nares and pharynx must get cured. The former will get well in most cases under the use of salt water. A tepid solution of 1 or ½ per cent. of table-salt {97} in water, snuffed up copiously (a tumblerful) from the hand of an adult patient, or a similar solution in a small quantity injected through each nostril of a child, twice or three times a day for weeks and months in succession, will often remove a laryngeal as well as a pharyngeal catarrh. Care must be taken that the fluid passes the whole length of the nasal canal. It must be applied in the fauces, and will then be ejected through the mouth or a small portion of it swallowed. Many a severe nasal catarrh requires no other treatment. Some chronic ones require the use of a spray of nitrate of silver in a solution of ½-1 per cent. every other day, or of a 2 per cent. solution of alum daily. Where both the pharyngeal and nasal catarrh are complicated with, or kept up by, enlarged or ulcerated tonsils, these organs must be resected. The combination of these two measures, exsection of the tonsils and nasal injections, has proved very beneficial in a great many cases.

The treatment of an acute case requires great care. Avoid injurious influences. The patient must keep silent and quiet in bed. The temperature of the room is to be about 70° F., the air moistened by vapor, which must not be allowed to get cold before it reaches the patient.

When swelling and dyspnoea are considerable, particularly in those grave cases attended with swelling of the submucous tissue, the application of an ice-bladder or ice-cloths will be found beneficial and agreeable. But the cases in which these applications are indispensable are but few. In most of them the necessity of subduing intense inflammation is less urgent than the advisability of increasing the secretion of the congested larynx. For that purpose warm poultices, but of light weight, act very favorably. Inhalation of warm vapors either constantly or at short intervals, or of muriate of ammonium or spirits of turpentine, will prove beneficial. The latter is evaporated from the surface of boiling water, on which a small quantity, from a teaspoonful to a tablespoonful, may be poured every one or two hours. The hydrochlorate of ammonium is evaporated, 10 or 20 grains (1.0 gramme), every one or two hours by heating it on a hot stove or otherwise. The white cloud penetrates the air of the whole room, and, while not uncomfortable to the well, serves a good purpose in liquefying the viscid and tough secretion of the mucous membrane. The internal administration of liquefying and resolvent remedies may properly accompany the external applications and inhalations. Amongst them I count the alkalies, mainly bicarbonate and chlorate of potassium or sodium and the hydrochlorate of ammonium. A child of two years will take daily a scruple (gramme 1.0-1.5). The iodide of potassium will also have a good effect and counteract many a predisposition to chronicity. A child may take from 8 to 15 grains a day (gramme 0.5-1.0). Hydrochlorate of apomorphine, gr. 1/50-1/30 (0.001-0.002), dissolved in water, a dose to be given every two hours or every hour, is quite sufficient to act as a fair expectorant without being enough to produce emesis. Antimonii et potassii tartras has been used more extensively in former times than at present. An adult would take gr. 1/20-1/15 every two hours. Children ought to be spared the drug, as it is depressing, produces unnecessary vomiting now and then, even in small doses, and, what is still worse, diarrhoea. The other antimonial preparations, such as kermes mineral and the oxysulphuret of antimony, are less depressing and less purging, but also less effective; and there are but few cases where a good substitute could not be found. For the purpose of increasing secretion the hydrochlorate of pilocarpine has been recommended. It certainly has that effect, but its indications become doubtful in many cases where the saving of strength is of paramount importance. I shall return to this subject in my remarks on the therapeutics of membranous laryngitis.

Derivation is of great service when well directed. Local depletion must be avoided. A purgative in the beginning is beneficial--a dose of calomel {98} as good as, or mostly better than, anything else. Diaphoretics and diuretics act quite well; the best of them all are warm beverages of any kind. They need not come from the apothecary's nor be very unpleasant to take--water not too cold, Apollinaris, Selters, or Vichy, hot milk, tepid lemonade in large quantities and very often. Sinapisms have a good effect. When not kept on longer than a few minutes--long enough to give the surface a pink hue--they may be applied every hour or two.

Some urgent symptoms may require symptomatic treatment. When secretion is copious, but too tough, and expectoration insufficient because of both the character of the mucus and the incompetency of the respiratory muscles, ipecac in small doses or camphor is indicated. A child's dose of the latter would be gr. ¼-½(gramme 0.015-0.03) every one or two hours. In these cases the hydrochlorate of ammonium may be combined with the carbonate (ammon. chlorid. drachm ss. (2.0); ammon. carbonat. scruple j (1.25); extr. glycyrrh. pur. scruple ij (2.5); aq. pur. fluidounce iij (grammes 100.0)--teaspoonful every hour). When the difficulty of expectoration is excessive an emetic may be resorted to. It is true that infants and children vomit with less straining and difficulty than adults, but, still, the practice of flinging emetics around is too common. The unpleasantness of getting up in the night because of a pseudo-croup in a distant patient's baby is not a correct indication for encouraging the indiscriminate use of emetics. When they are required, antimonials ought to be excluded from the list. Ipecac, sulphate of zinc, sulphate of copper, turpeth mineral are preferable.

In urgent cases the hydrochlorate of apomorphia may be used hypodermically (six or ten drops of a 1 per cent. solution in water). Cases of such urgency, and so excessive dyspnoea coupled with cyanosis, as to necessitate tracheotomy are but very rare. But once in thirty years and in many more than four hundred tracheotomies have I been compelled to operate for a case of catarrhal laryngitis. Still, a few such cases are on record. The best-known amongst them is that of Scoutetten, who operated successfully on his own daughter six weeks old.

Narcotics prove quite beneficial, particularly in complications with pharyngeal catarrh. A dose of gr. j-jss of Dover's powder (gramme 0.05-0.1) at night will secure rest for several or many hours to a child of two or three years; an adult is welcome to a dose of 10 or 12 grains (0.6-0.75). When the irritation is great during the day, it is advisable to add a narcotic (acid. hydrocyan. dil., min. j; vin opii, min. viij-xij; codeine gr. 1/3-1/2, or extr. hyoscyam. gr. ij-iij--daily) to whatever medicine was given. I am partial to the latter, giving it up to gr. viij-x (0.5-0.6) to adults daily in their mixture, retaining the single dose of opium or morphine to be taken for the night. At that time a single larger dose is rather better than several small ones. Narcotics cannot be dispensed with in all those cases in which--as, for instance, in tubercular laryngitis--deglutition is very painful because of the catarrhal and ulcerous pharyngitis. Bromide of potassium has a fair effect, but frequently fails, and the administration of morphia before each meal is sometimes an absolute necessity.

That complications, such as bronchitis, have their own indications is self-understood. The general rules controlling the treatment of laryngitis are not interfered with by them. Oedema of the glottis, however, when occurring during an attack of laryngitis, has its own indications, and very urgent ones indeed in all acute cases. In chronic cases a causal treatment is required according to the etiology of the affection as specified above. In acute cases it is not permitted because of want of time. The danger of immediate strangulation is often averted only by a deep scarification or the performance of tracheotomy.

Chronic cases require all the preventive measures enumerated above and {99} 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.

{100}

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 {101} 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).

[Footnote 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.

[Footnote 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 {102} 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 {103} 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 {104} 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, {105} particularly in the latter; gr. ¼-½ may be given every half hour or every hour. Tartar emetic is liable to develop so many unfavorable effects that even doses--in combination with calomel--of 1/100 of a grain require great caution. The most reliable mercurial preparation, in my experience, and the least hurtful, is the corrosive chloride. In the stomach it combines with the chloride of sodium, is absorbed without being changed, and transmuted into an albuminate during its circulation in the blood. Babies of tender age bear one-half of a grain and more, daily, many days in succession. Salivation and stomatitis are exceedingly rare after its use. Gastro-intestinal disturbances are not at all frequent; diarrhoea, if observed at all, is very moderate, and can be avoided or removed by the administration of mucilaginous and farinaceous food or a mild dose of an opiate. But the administration of the bichloride requires care in regard to its solution. A fiftieth of a grain may be safely given to a baby a year old every hour, but it must be dissolved in one-half of a tablespoonful or a whole tablespoonful of water. The solution of a grain in a pint of water is about correct. In those very rare cases in which no preparation of mercury is borne internally the inunction of sufficient and frequent doses of the oleate of mercury may take the place of the internal administration or alternate or be combined with it. The blue ointment is not so effective as the oleate. The subcutaneous injection of the corrosive chloride may be added to the modes of administration if no time must be lost in introducing as much as possible of the drug into the system. Now and then, however, the subcutaneous tissue of the child does not tolerate it well in that form, though the solution may be not larger than 2 per cent.[3] The cyanide of mercury, in doses of a hundredth of a grain every hour, has been warmly praised by A. Erichsen and C. G. Rothe.

[Footnote 3: The Medical Record, May 24, 1884.]

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

{109}

DISEASES OF THE LARYNX.

BY LOUIS ELSBERG, M.D.

Inflammation, Erosion, and Ulceration of the Epiglottis.

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

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

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

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

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

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

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

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

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

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

Laryngeal Oedema.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Perichondritis and Chondritis of the Larynx.

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

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

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

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

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

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

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

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

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

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

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

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

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 {120} 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 {121} 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 {122} 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 {123} 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, confesses[6] 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 {124} much hypertrophy has already taken place, the color is often quite light grayish instead of red.

[Footnote 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 {125} 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 {126} 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.

Topical treatment of a more decided character being required, the physician usually chooses between powder and solution. Powders are usually propelled by a puff of air through a properly curved tube, whether from a rubber ball, a reservoir of compressed air, or the mouth. The mouth allows the most delicate and accurate application, but the mouthpiece should be protected by a valve from receiving a return current when the patient coughs. Solutions may be applied by means of pipette, syringe, brush, cotton wad, or sponge, according to indications. A fragment of sponge securely fastened to a properly-bent rod or pair of forceps is the safest and most effectual material for positive contact against a limited surface, and a brush the best for painting larger surfaces. The use of the cotton wad involves a slight risk of leaving a detached shred of fibre in the larynx, but renders the manipulation less unpleasant to the patient than the use of the sponge, and is less irritating to the mucous membrane. Spasm of the larynx is usually excited the first time that a medicinal application is made within it, and even death by suffocation has followed the incautious use of powerful agents. Hence strong solutions should not be used until the tolerance of the parts has been sufficiently tested by weak or innocuous ones. The remedies which have been employed topically for intra-laryngeal medication seem to include every available medicinal agent that could be mentioned, from rose-water to the incandescent cautery. The list of really useful ones is not very long. Those upon which the most reliance is placed by the writer comprise tannic acid (a saturated glycerite), zinc sulphate (thirty grains to the ounce of rose-water), and silver nitrate (forty to sixty grains to the ounce) in obstinate and protracted cases of simple chronic laryngitis; iodine and carbolic acid, singly or in combination (one grain or more to the ounce of glycerin), and chinoline tartrate or salicylate (five or more grains to the ounce), in cases attended with infiltration; iodoform (finely pulverized or in recent saturation in sulphuric ether) in ulcerative or proliferative tuberculosis; and iodoform and acid solution of mercuric nitrate (one part to ten or twelve of water) in progressive ulcerative syphilis resisting appropriate constitutional treatment. Other {127} astringents in the simple varieties; resorcin in the glandular, hypertrophic, polypoid, and tuberculous varieties; chromic acid and incandescent metal in the circumscribed hypertrophic and in the polypoid varieties; and zinc chloride and copper sulphate in the syphilitic varieties,--proffer additional resources. These applications are to be made at intervals of one day or more, according to results. Hyperæsthesia and pain, whether of the larynx or of parts adjacent, can usually be subdued by the local anæsthetic effect of solutions of erythroxyline hydrochloride (2 per cent. or stronger) applied at intervals of a few hours, or even by the fluid extract or a strong aqueous infusion of the erythroxylon-leaves. Before the anæsthetic effect of this drug was known, morphine powder (one-eighth to one-fourth of a grain, alone or associated with tannin or with iodoform) or aqueous solutions of morphine salts and of aconite were employed to relieve pain and obtund sensitiveness. The oleate of morphine (2 to 4 per cent. solution) and the oleate of aconitine (2 per cent. solution) are similarly useful. Morphine, by its constitutional influence, is preferable to erythroxyline in some instances, though less prompt in its effects. Where ulcerative processes at the top of the larynx or thereabouts entail odynphagia, these preparations should be used before administering nourishment. The use of erythroxylon products may be entrusted to the nurse or to the patient with comparative safety. Morphine and aconite should be applied only by a medical attendant or an exceptionally skilled nurse. Before any medicinal curative or reparative agent is applied the parts should be thoroughly cleansed of suppurative and secretory products. This may be done with sprays of alkaline solutions--five or more grains of sodium borate or bicarbonate, for example--dissolved in pure water, in tar-water, or in an emulsion of coal tar. An excellent agent, especially in the presence of pus, is hydrogen dioxide, usually furnished in a 10-volume solution which should be diluted with two or more parts of distilled water. It is likewise disinfectant and gently stimulant to mucous membrane. The manipulations by the physician preparatory and medicatory should be performed laryngoscopically, otherwise the entire procedure must be haphazard.

Neoplasmata and fungous growths may require removal should they interfere with respiration. In the presence of stricture, surgical interference by tracheotomy may become requisite. Elsberg, according to the testimony of his assistant, Schweig, seems to have been particularly favorable to the performance of this operation in obstinate cases of ulcerative laryngitis of whatever character, and even in protracted non-ulcerative cases, for the purpose of securing physiological rest to the parts, although the procedure might not be indicated to relieve any embarrassment in respiration. The writer's experience in tracheotomy as a factor in producing rest has not been favorable, such a result being usually defeated by the cough so frequently following a tracheotomy, no matter how well-adjusted a tube may have been inserted. His recommendation, therefore, is limited to cases of embarrassment to respiration due to stricture or constriction unamenable to intra-laryngeal interference.

Morbid Growths of the Larynx.

DEFINITION.--Neoplastic formations, benign and malign, in the interior of the larynx, in its cartilaginous framework, in its investment-tissues, or upon the exterior of the organ.

ETIOLOGY.--Inflammation of the mucous membrane, local irritation or injury, ulceration, cell-proliferation, and excessive granulation seem to be the exciting causes of benign neoplasms. They follow on laryngitis, whether catarrhal, syphilitic, tuberculous, exanthematic, toxic, or traumatic. They {128} are quite common, so to speak, several thousands of cases being on record, and as many or more probably being unrecorded. Heredity does not seem to play any special part in their production. They are occasionally congenital, and may be developed at any age; but they are encountered the most frequently in subjects between the ages of thirty and sixty years, probably because of the greater exposure to laryngitis attending the activity incidental to the prime of life. Males are affected far more frequently than females, probably on account of greater exposure to sources of laryngitis. Benign growths are sometimes followed by malign growths in recurrence, and are sometimes converted into malignity by irritation, whether physiological, mechanical, or instrumental. Malign growths are attributed to cold, chronic laryngitis, and traumatism as the initial exciting causes. Butlin suggests a cryptogamic origin. They are far more common in males than in females, and occur chiefly between the ages of twenty-five and seventy, but they have been noted as occurring exceptionally much later, and even as early as the first year.

PATHOLOGY AND MORBID ANATOMY.--By far the greater number of laryngeal morbid growths belong histologically to the category of benign neoplasms, but the important location they occupy often renders them clinically malign. By far the greater number of benign growths are papillomas, perhaps fully two-thirds, although Elsberg has reported that but 163 instances were papillomas out of 310 seen in his own practice.[7] This has been an exceptional experience. Then we have fibromas, myxomas, adenomas, lymphomas, angeiomas, cystomas, ecchondromas, lipomas, and composite neoplasms. Laryngeal morbid growths, too, occasionally undergo the fatty, colloid, or amyloid degenerations. Papillomas are frequently multiple, and most frequently sessile, but the other benign neoplasms are most frequently single and are more often pedunculated. All this class of morbid growths affect the anterior half of the larynx more than the posterior. They are most frequent on the vocal bands or very near to them, although they may occupy any portion of the larynx. They vary in size from the smallest protuberance to a bulk sufficient to block up the cavity of the larynx and even project above it. The dimensions of the greater number of papillomas vary from the size of a pea to that of a small mulberry. Other benign neoplasms rarely reach the bulk attained by papillomas.

[Footnote 7: Archives of Laryngology, p. 1, New York, 1880.]

Malign growths are far less common than benign ones. They comprise both sarcomas and carcinomas. Sarcomas occur in the varieties of spindle-celled, round-celled, giant-celled, mixed-celled, fibrosarcoma, lymphosarcoma, and myxosarcoma. Some attain only the size of small beans, and few exceed the size of a pigeon's egg. The majority of them are primary growths. Most of them originate in the interior of the larynx, whence they may extend by contiguous infiltration, even penetrating the laryngeal walls. The vocal band and the ventricular band are the most frequent seat. The epiglottis is a common seat. These growths appear either in irregular, smooth, spheroid masses, or nodulated, mamillated, and dendritic. They are much the more common in males, and occur chiefly in subjects between the ages of twenty-five and fifty. Their growth is slow for a year or more, and then becomes more rapid.

Carcinoma is much more common than sarcoma. It is most frequently primary, and primarily limited to the larynx, but occurs likewise in extension of carcinoma of the tongue, palate, pharynx, oesophagus, or thyroid gland. It rarely extends to the oesophagus or penetrates the laryngeal walls.

Squamous-celled carcinoma or epithelioma is the commonest variety, large spheroidal-celled or encephaloid being much less frequent, and small spheroidal-celled and cylindrical-celled occurring still more rarely. Intrinsic {129} laryngeal carcinoma is usually unilateral at first, and most frequently in the left side. Its most frequent seat is at the vocal band. It rarely occurs below this point, and when it does, as in the five cases analyzed by Butlin,[8] it seems to be at some point just beneath. Extrinsic laryngeal carcinoma usually begins in the epiglottis, and sometimes occupies that structure only. It may begin in a cicatrix in the skin.[9] Carcinoma is the more common in males, chiefly in subjects between the ages of fifty and seventy. It has occurred within the first year, at three years, and as late as at eighty-three years. Carcinoma is liable to extend by infiltration of tissue and destroy all the contiguous and overlying tissues, so that it may extend into the pharynx or even externally; the large spheroidal-celled variety presenting the most frequently progressive ulceration into contiguous tissue, and the squamous-celled, intrinsic ulceration. Hemorrhage is frequent. Perichondritis, abscess, necrosis, and fistula take place in old cases.

[Footnote 8: On Malignant Disease of the Larynx, p. 36, London, 1883.]

[Footnote 9: Cohen, Transactions American Laryngological Association, p. 113, 1883.]

SYMPTOMATOLOGY.--Small growths in localities where they neither provoke cough nor interfere with voice or respiration may run their course for a long time without giving rise to any symptoms at all. Growths of larger size, pedunculated growths, and growths located upon important structures give rise to interference with voice, respiration, or deglutition as may be--to cough, and even to pain. Dysphonia is due to mechanical interference with vibrations of the edges of the vocal bands; aphonia, to mechanical interference with their approximation; diphthonia, to mechanical interference at an acoustic node. These manifestations may be permanent or intermittent. Dysphonia is one of the earliest symptoms of carcinoma, and is usually continuous for a number of months before any other indication. Aphonia in carcinoma is often due to nerve-lesion. Dyspnoea is due to some considerable mechanical occlusion of the respiratory tract, whether by the growth itself or in consequence of oedema or of intercurrent tumefaction. It is inspiratory rather than expiratory, and subject to aggravation at night. As with the dysphonia, it varies with the size, location, and mobility of the growth and the position of the head and neck. It may be intermittent or permanent; be slight or severe; or it may terminate in apnoea by spasm, by mechanical occlusion of the calibre of the larynx, or by impaction of the growth at the chink of the glottis. Marked encroachment on the breathing-space is not accompanied with as marked dyspnoea as in acute processes, the parts seeming to acquire tolerance during the slow growth of neoplasms.

Dysphagia is due to a growth at the top of the larynx or on some portion of its pharyngeal surface. It is quite frequent in carcinoma, preceding dysphonia in the extrinsic varieties. It may be associated with regurgitation of food, drink, or saliva into the larynx, provocative of paroxysms of suffocation. Cough is due to growths which project from the vocal bands or press upon them, or to hemorrhage or accumulation of secretory or suppurative products. Hemorrhage, cough, and expectoration of bloody and fetid masses are indicative of carcinoma. Pain is usually due to intercurrent conditions. Aches in the part and sensations of the presence of a foreign substance are more frequent. Intense pain is exceptional in benign neoplasmata; it is often an early symptom in carcinoma, in which it is apt to radiate toward the ears and along the neck. Epileptic seizures and vertigo are sometimes occasioned by reflex influence. Exceptionally, large growths may produce change in the external configuration of the larynx. The general health is not much involved in benign growths, unless they interfere seriously with important physiological functions. Impaired health is far less manifest in sarcoma than in carcinoma. Emaciation, pyresis, and marasmus eventually occur as constitutional manifestations of malign growths.

{130} DIAGNOSIS.--Laryngoscopic inspection usually reveals the growth and furnishes the best means of diagnosis. Intra-ventricular and subglottic growths may elude detection. Palpation is sometimes available, especially with children. Palpation with probes under laryngoscopic inspection is sometimes requisite to determine the mobility of a growth, its form and seat of attachment, and even its size. It seems, too, to discriminate a neoplasm from an eversion of a ventricle. While the histological character of a growth cannot be definitively decided by laryngoscopic inspection, the varieties present a series of characteristics sufficiently pronounced for approximative discrimination. Papillomata are often multiple, usually sessile, and usually racemose or dendritic. Some are white, but the majority are red, and the tinge varies from one extreme of the tint to the other. Some are as small as the smallest seeds; most of them have a bulk varying from that of a pea to that of a berry; some of them are so extensive as to appear to fill the larynx or even project above its borders. They are far the most frequent in the anterior portion of the larynx, and are often located upon a vocal band. Fibromata are most frequently single, smooth and pedunculated, and red. Some are white or gray. Some are vascular. When fully developed they vary in size from small peas to large nuts. They are more frequent upon a vocal band. Their development is slower than that of papillomata. Myxomata are usually single, smooth, pyriform, and pedunculated. They are usually red or reddish. Their ultimate size varies from that of grains of rice to that of Lima beans. They are most frequent at the commissure of the vocal bands. Angeiomata are usually single, reddish or bluish, vary in size from that of small peas to that of berries, and are most frequent on the vocal bands. Cystomata are usually globular, sessile, translucent, and white or red. They are most frequent in a ventricle or on the epiglottis. Their size varies from that of hempseed to that of peas. Ecchondromata are usually developed in the posterior portion of the larynx. Other benign growths are very rare, and do not seem to present special features for recognition by laryngoscopic inspection. Sarcomata are usually present as sessile, hard, well-circumscribed growths, smooth or lobulated. Some are dendritic on the surface, but not to the extent noticed in papillomata, and their location at the posterior portion of the larynx would suggest their true character, for papillomata rarely occupy this position except in tuberculosis. Superficial ulceration occurs in some cases, but is not extensive. There is no peculiarity in the color of the mucous membrane, which may be paler or redder than is normal. The lymphatic glands are not involved.[10] Carcinomata present first as diffuse tumefactions in circumscribed localities, gradually undergoing transformation into well-formed growths, then nodulation, and then ulceration. Meanwhile, especially in extrinsic varieties, the submaxillary and the cervical lymphatic glands become successively involved and tumefied. Squamous-celled carcinoma becomes pale, wrinkled, and nodulated, and sometimes dendritic. Large spheroidal-celled carcinoma becomes nodulated, dark, and irregularly vascular, and finally ulcerated, perhaps at a number of points. In the ulcerative stage of carcinoma of the epiglottis and of the interior of the larynx discrimination is requisite from syphilis and from tuberculosis. In all cases of doubt as to malignancy, laryngoscopic inspection should be supplemented by microscopic examination of fragments detached for the purpose. The early detection of sarcoma may lead to surgical measures competent to save life--a remark applicable, perhaps, in a far more limited degree to intrinsic carcinoma.

[Footnote 10: Butlin, op. cit., p. 14.]

PROGNOSIS.--The prognosis is usually good in benign growths submitted to proper surgical treatment. Left to themselves or treated medicinally, the prognosis is bad both as to function and to life. Such growths are occasionally expectorated after detachment during cough or emesis. Some {131} occasionally undergo spontaneous absorption. Some remain without change for years. Most of them enlarge and compromise life as well as function. Recurrence occasionally follows thorough removal, and this recurrence is occasionally malign in character. Repullulation frequently follows incomplete removal. The prognosis is favorable in sarcomata, provided thorough eradication can be accomplished by surgical procedure. Incomplete removal is followed by repullulation or recurrence. Unsubmitted to operation, sarcoma will destroy life either mechanically by apnoea or physiologically by asthenia.

The prognosis is unfavorable in carcinoma. Recurrence takes place as the rule despite the best devised resources of surgery. Intrinsic carcinoma offers some hope of success to the surgeon; extrinsic carcinoma, little if any. Life is shortest in the large spheroidal-celled, and longest in the small spheroidal-celled variety, other conditions being equal. Death may take place by apnoea or asthenia, as in sarcoma, or by hemorrhage, collapse, or pyæmia. Submitted to tracheotomy at the proper moment in cases in which death is threatened by occlusive dyspnoea, life is prolonged and suffering mitigated. The fresh lease of life is longest in the squamous-celled variety.

TREATMENT.--The essential treatment is surgical, and to surgical works the reader must be referred for details. Suffice it to say that when a benign growth is small and does not embarrass respiration, it need not be attacked at all, unless its interference with the voice deprives the patient of his means of livelihood. The majority of benign growths are accessible to instruments passed through the mouth. Some require external incision into the larynx, whether partial or complete. The intra-laryngeal procedures in vogue include cauterization, both chemical and by incandescence, incision, abscission, crushing, brushing, scraping, and evulsion. According to the character and location of the growth, direct access from the exterior is practised by infra-hyoid pharyngotomy, by partial or complete thyroid laryngotomy, mesochondric laryngotomy, cricoid laryngotomy, complete laryngotomy, laryngo-tracheotomy, or tracheotomy, as may be indicated.

The thorough eradication of sarcomata usually requires a direct access by section of the thyroid cartilage or even of the entire larynx. This procedure failing or appearing insufficient, partial or even complete laryngectomy may be necessary. Temporizing is of no avail.

The treatment of carcinoma is palliative, unless it be decided advisable to attempt eradication, which may offer some chance of success in intrinsic carcinoma still confined to the larynx. Laryngectomy may be unilateral in some instances, and must be bilateral in others. Unilateral laryngectomy is the more hopeful. Eradication proffers no hope in cases of extrinsic carcinoma in which the growth has passed the boundaries of the larynx. After recovery from the laryngectomy an artificial appliance may be adjusted to the parts for the purpose of supplying a mechanical method of producing sound in the larynx for speaking purposes. Should no radical procedures be instituted, treatment is relegated to general principles, with prophylactic performance of tracheotomy in the presence of dangerous occlusion of the larynx. The voice should be used but little. All sources of laryngitis should be avoided. Ergot or hamamelis may be given to restrain hemorrhage, and morphine to relieve pain and secure sleep. Sprays can be used to keep the parts free from morbid products. Erythroxyline may be applied to produce local anæsthesia as required. Semi-detached portions of growth may be removed from time to time. Nourishment may be given by the bowel when necessary, and so on as in other diseases of the larynx in which the functions of respiration and deglutition are seriously impaired. Medicinally, arsenic may be given in the early stages, as that drug is conceded to possess some slight retarding influence on the growth of carcinoma.

{132} Lupus of the Larynx.

Lupus is rare in the larynx. It usually occupies the structures above the vocal bands. It is most frequent in females, and usually associated with cutaneous lupus.

ETIOLOGY.--Scrofulosis and syphilis seem to be the predisposing causes. Climate may have some influence. The reason of the special proclivity of the female is undetermined. Of 9 reported cases, records of which are before the writer, 8 were in females.

PATHOLOGY AND MORBID ANATOMY.--Laryngeal lupus is usually an extension of the disease from the upper lip or the nose, extending along the nasal passages, pharynx, and palate. Destructive ulceration takes place, with irregular cicatrization and the formation of hard nodules of hyperplastic tissue of irregular conformation, varying from the size of hempseeds to that of small peas, similar to the cutaneous buccal and pharyngeal nodules.

SYMPTOMS.--These include dysphonia, dyspnoea, dysphagia, and cough. Pain is exceptional.

DIAGNOSIS.--Laryngoscopic inspection reveals the characteristic nodulation, the nature of which is inferred from the coexistence of external lupus. The disease may be confounded with lepra, syphilis, tuberculosis, or carcinoma. Discrimination from syphilis is the most difficult, and is predicated chiefly on its slow progress and on the absence of constitutional manifestations.

PROGNOSIS.--This is unfavorable. The reported cures seem to have occurred only under the influence of antisyphilitic treatment.

TREATMENT.--The prolonged use of cod-liver oil and of potassium iodide seems to be more beneficial than any other systemic treatment. Destruction of the nodules and ulcerated tissues is indicated when the diseased structures are sufficiently circumscribed and accessible. This may be done with the sharp spoon or with the electric cautery. Silver nitrate and iodine have been lauded as topical remedies.

Lepra of the Larynx.

Lepra is rare in the larynx.

ETIOLOGY.--Its cause seems to be climatic. In Europe it is most frequent in Norway and Sweden, and in America in Cuba and the West Indies.

PATHOLOGY AND MORBID ANATOMY.--It is always associated with cutaneous lepra, and usually with lepra of the nasal passages and the pharynx. According to Schroetter's observations, laryngeal lepra occurs as small connective-tissue nodules on the epiglottis or in the interior of the larynx, or as uniform thickenings, general or circumscribed. These may lead to stricture. Extensive ulceration may ensue.

SYMPTOMS.--Dysphonia, aphonia, dyspnoea, cough, and local anæsthesia are the main symptoms. Pain is infrequent.

DIAGNOSIS.--This depends upon the external manifestations of lepra and the laryngoscopic detection of the characteristic thickenings and nodulations.

PROGNOSIS.--This is unfavorable.

TREATMENT.--This must be conducted on general principles. Elsberg commended iodoform topically and gurgun oil internally.

{133}

DISEASES OF THE TRACHEA.

BY LOUIS ELSBERG, A.M., M.D.

Disease originating in or confined to the trachea is rare. It hardly ever follows tracheotomy unless the shape of the canula or its relation to the windpipe be improper; the normal tracheal mucous membrane probably resists cadaveric disintegration longer than any other mucous membrane of the body. But morbid processes of the larynx often extend downward, and those of the bronchial tubes still more frequently upward, so that the trachea is found affected in connection with both. Indeed, in what is ordinarily simply called bronchitis (see article on BRONCHITIS) the windpipe is seldom free from the inflammatory condition.

We shall here consider Inflammation, Ulceration, Morbid Growths, Stenosis, and Dilatation (hernia, fistula). Tracheotomy may have to be performed in any of these diseases to prevent impending suffocation, and in some to gain access to the part for further treatment. (See article on TRACHEOTOMY.)

INFLAMMATION.

Tracheitis is either simple or complicated, and acute or chronic.

Simple Tracheitis.

DEFINITION.--Inflammation of the windpipe limited to the mucous membrane.

SYNONYMS.--Catarrhal tracheitis, Tracheal catarrh.

Its ETIOLOGY may be gathered from the corresponding sections on Catarrhal Laryngitis and Bronchitis.

SYMPTOMATOLOGY.--In acute catarrhal tracheitis local irritation is complained of, varying according to the severity of the case from a mere tickling sensation to soreness and pain. This morbid sensation is increased by pressure on the part, and with it there is cough and expectoration--the former either brassy and hacking, or paroxysmal and violent; the latter at first scanty, but very soon more copious than when the larynx alone is affected, although much less so than when the inflammation involves the bronchial tubes at the same time. The sero-mucous secretion gradually becomes muco-purulent or even purulent. When inflammation is confined to the trachea there is no alteration of the voice, and, except in children, in whom the calibre of the windpipe is proportionately small, usually no or only very slight dyspnoea. In mild cases there are no constitutional disturbances. Severe cases are accompanied by {134} the febrile symptoms of a bad cold. The disease runs its course in from a few days to a week or two.

Uncured or too frequently repeated attacks of acute catarrh of the windpipe lead to chronic tracheitis, occasionally with considerable hypertrophy of the mucous membrane. In mild cases the cough and expectoration are less than in the acute disease, but persist, with exacerbations in cold, damp weather; in other cases the cough is more frequent, and the expectoration either thick, glutinous, and scanty, or else thin, frothy, or glairy, semi-transparent, and abundant. The separation by forcible paroxysmal coughing of accumulated adherent tough secretion from the tracheal mucous membrane has been observed to cause not only slight dyspnoea, but even the dangerous suffocating attacks of foreign bodies in the larynx. In color the sputa vary from gray to green and yellow; occasionally they are streaked with blood; sometimes they are without taste or odor; sometimes they are nauseous and fetid. Frequently patients with chronic tracheitis complain of "a sort of tightness at the root of the neck." In some cases a sense of dryness in the region of the trachea is the principal or the only symptom complained of, and this may alternate with, or even actually coexist with, occasional hypersecretion of tracheal or bronchial mucus.

In chronic bronchitis and senile pulmonary emphysema mucorrhrea and cough usually depend to some extent upon the chronic tracheitis that is present.

PATHOLOGY AND MORBID ANATOMY.--The pathological characteristics of simple tracheitis are hyperæmia, active or passive, swelling, and increased secretion of mucus. There is no fibrinous exudation.

Acute inflammation causes the mucous membrane to become softened, swollen and red, either uniformly or in points or patches, frequently with ecchymoses and catarrhal erosions, more perceptible in the lower than in the upper portions of the trachea. Scanty secretion sometimes lies upon the surface in pearl-like drops, which might be mistaken for solid elevations only that they can be wiped off.

In chronic inflammation the redness is more dull, reddish-blue or grayish; the secretion, sometimes more scanty and sometimes more abundant, is puriform and usually spread out over larger portions of the surface; and the glands are enlarged and prominent, with their ducts so dilated that their mouths are readily visible, sometimes, to the naked eye, and always with a low-power lens, and the rest of the tissue is hypertrophied, especially at the back wall of the trachea. Catarrhal tracheal ulcers are exceedingly rare, superficial, and of but slight extent, but they do occur, and are usually situated on the intercartilaginous membrane.

DIAGNOSIS.--Tracheoscopy, a modification of laryngoscopy, can alone determine with certainty whether, and to what extent, the trachea is inflamed. Unfortunately, very few practitioners have as yet mastered this method of examination, which, though really not more difficult than laryngoscopy, requires greater illumination (necessitating under some circumstances a mirror of longer focal distance) and different relative position of patient and operator. (See article by Seiler.) Figs. 25 and 26 show the tracheoscopical images of a case in which there was intense acute tracheitis. The anterior wall is seen in Fig. 25, and the posterior in Fig. 26; on both, but especially the latter, clumps of phlegm and ramifying injected blood-vessels are distinctly seen. In many cases, by means of the stethoscope, either dry sonorous or mucous râles may be heard over the windpipe; at other times we may be aided in coming to a conclusion by the presence of dysphagia--increased when the chin is raised and diminished when the chin is pressed on the chest, as pointed out by Hyde Salter--and by the morbid sensations, increased by pressure, in the region of the windpipe when there is cough and expectoration.

{135} [Illustration: FIG. 25. Acute Tracheitis: anterior wall.]

PROGNOSIS.--Simple tracheitis, though occasionally not without danger in extremely young and very old patients, rarely if ever destroys life. Under good hygienic circumstances it frequently gets well of itself, and it does not usually produce sufficient swelling or hypertrophy to cause stenosis. It is, however, when severe, an annoying disease, apt to recur, and, unless properly managed, difficult to eradicate.

TREATMENT.--Tracheitis is treated very much like bronchitis confined to the larger tubes, only that local measures are more prominently applicable, especially in chronic cases. Frequently, when acute, the disease may be arrested by a Dover's powder, a warm bath, and a diaphoretic drink at night, with hygienic attention, regulation of systemic functions, and soothing applications, such as inhaling simply vapor of water or medicated water, or using warm-water poultices externally. Expectorant mixtures, containing ipecacuanha, sanguinaria, squills, or senega, may be given, according to the age and condition of the patient, with matico and the like, when the secretion is abundant, and with ammonium acetate or sodium bromide (potassium carbonate or ammonium carbonate where there is depression) or tincture of aconite (especially when fever is present), or a very minute quantity of tincture of veratrum viride, when there is much dryness. Inhaling the steam arising from a pint of hot water (160-170° F.) containing 10 grs. of extract of conium, 1 drachm of compound tincture of benzoin, and half a drachm of ammonium sesquicarbonate, or inhaling nebulized solution of potassium bromide, 10 to 20 grains to the ounce, or fumes of evolving ammonium chloride or of nitre-paper, is very serviceable, as well as placing a mustard plaster or a hot poultice on the upper part of the chest (not directly over the windpipe) and on the back of the neck or between the shoulders. Some patients require for several days to take daily from 8 to 10 grains of quinia sulphate, then a smaller quantity, care being taken not to discontinue the remedy suddenly. Smoking eucalyptus-leaves, with much inhalation of the smoke, is useful in protracted cases. In chronic as well as acute tracheitis not only balsamic, anodyne, and astringent inhalations either of vapors, or of liquids nebulized by the various spray-producers are in vogue, but also insufflations of powders, injections of liquids, and touchings with the sponge or cotton-wad probang or tracheal applicator. Powders should never or only rarely (as, e.g., morphia, 1/16-1/8 of a grain, when the cough is troublesome, etc.) be blown into the trachea; injections and touchings should be made use of only after the operator has acquired the necessary skill to apply them by means of the mirror. A few drops of a solution of silver nitrate, varying in strength inversely as the chronicity of the case from 5 grains to 60 to the ounce of water, thus accurately applied at proper intervals of time, have proved successful in otherwise intractable cases. In chronic tracheitis general tonic treatment must be combined with the local, and attention be paid to possible coexistent cardiac and {136} broncho-pulmonary affections or other morbid conditions. In some cases it is advisable to administer potassium iodide; in rheumatism, sodium salicylate; in gout, colchicum. The utility of producing alkalinity of the blood (as by giving alkaline mineral waters to drink, etc.) has received a new and direct support by Rossbach's recent observations of diminution of the blood-supply and of the secretion in the tracheal mucous membrane of cats whose blood was made alkaline by injecting sodium carbonate into the femoral vein.

Patients subject to tracheitis should observe all the precautionary measures of so-called bronchitics as to sponging, bathing, and friction of the body, wearing a respirator, clothing, exercise, habits, etc.

Complicated Tracheitis.

Under this heading are here classed together all inflammatory conditions of the windpipe differing from simple or catarrhal tracheitis. In these, other tissues may be affected as well as the mucous membrane. In exanthematous, erysipelatous, and exudative tracheitis the mucous membrane is prominently involved; in oedematous and phlegmonous tracheitis, the submucous connective tissue; and in perichondritic and chondritic tracheitis, the cartilages and their investing membrane. The latter forms are connected with suppurative and ulcerative processes, and, unless traumatic, almost never occur, except in phthisical and syphilitic tracheitis. I shall speak of them under the head of Ulceration.

The tracheitis of measles and scarlatina consists in an acute catarrh, with sometimes considerable desquamation of epithelium, erosion, and capillary hemorrhage. In cases of small-pox in which the larynx is affected, the same disease may extend into the trachea, varying in severity from a congestion of the mucous membrane to an intense pustular process. Erysipelas of the larynx may also involve the windpipe, and when it does is exceedingly dangerous. More than half a century ago Gibson observed in an epidemic of erysipelas that when it spread to the trachea it generally proved fatal.[1] Tracheal oedema is extremely rare even when the larynx is oedematous. Phlegmonous inflammation and abscess have been observed in a few instances. Tracheal diphtheria is usually an extension of diphtherial disease of the larynx. Without entering into a discussion of the nature and cause of diphtheria, as either a local or general disease, it is here sufficient to refer to the fact that while in simple inflammation of mucous membrane no fibrinous exudation takes place, certain poisonous irritations lead to the exudation of lymph which infiltrates the tissue and may form a pseudo-membranous deposit upon it: experiments have proved that ammonia, chlorine, and, certainly, bacteria, are able to produce this. In laryngo-tracheal diphtheria or croup the disease most frequently commences in the pharynx, occasionally in the larynx, and much more rarely in the trachea.

[Footnote 1: Transactions of the Edinburgh Medico-Chirurgical Society, vol. iii., 1828.]

The treatment of each of these forms of complicated tracheitis is the same as the treatment of the corresponding form of laryngitis.

ULCERATION.

Tracheal ulcers are just as multiform as laryngeal ulcers, but far more rare. Like inflammation, they may occur by extension from above or below, {137} and only those following localized morbid conditions are certain to have arisen in the trachea. Under the head of Inflammation it has been stated that simple catarrhal ulceration does occasionally occur; of this there is really no doubt, but some writers have denied it and thrown the whole subject into great confusion. It is true, however, that a tracheal ulcer has usually a so-called dyscratic base, and either is diphtherial or phthisical (tuberculous) or syphilitic or lupoid or leprous or carcinomatous, or else comes from extraneous causes; as, for instance, from traumatic ulceration or extension or perforation from neighboring abscess, etc. There are two kinds of ulcers--viz. one in which the molecular death of tissue proceeds from the surface inward, and another in which it proceeds from within to the surface. Catarrhal ulcers, as well as ulcers from decubitus after tracheotomy, from pressure of the canula, belong to the first kind; when involving only the epithelium or the epithelium and the layer immediately underneath it the name erosions is given them; and if it were true that catarrhal erosions never penetrate to the deeper structures, it would be justifiable to say that there are no catarrhal ulcers, but only erosions: they do, however, penetrate, and sometimes to great depths. In the second kind of ulcers the epithelium is at first normal or intact, and the loss of substance of underlying tissue in consequence of inflammatory processes in the mucosa, submucosa, or perichondrium affects the epithelium secondarily. This occurs whenever, from any cause, there is primarily caries of cartilage or suppuration of submucous tissue, especially in typhoid conditions, in phthisis, and in syphilis.

{138} [Illustration: FIG. 30. Same case as Fig. 29: post-mortem appearance.]

The seat of tracheal ulcers is usually the posterior wall and the lower portion, unless the upper portion is affected by extension from the larynx or by pressure from a tracheotomy-tube. They are found also in other portions, and sometimes are so numerous that they give to the membrane a sieve-like appearance. Occasionally they denude some of the tracheal rings. In shape they vary, being mostly irregularly circular or oval, and excavated or scooped out; in size they vary from that of a pin's head to that of a marble. In tuberculosis they are generally small and numerous, have a pale background, and are occasionally confluent, while in syphilis they are usually isolated and large, very destructive, and apt to cause contractions or other deformities by {139} partial or extensive cicatrization. Such contracting ray-like cicatrices have more than once produced fatal stenosis.

The SYMPTOMS are frequently obscure, but local pain and irritation are usually, purulent or muco-purulent sputa are sometimes, present. The diagnosis is difficult unless tracheoscopic examination reveals the condition. Fig. 27 shows the tracheoscopical image, and Fig. 28 the post-mortem appearance, of a case of tuberculous tracheal ulceration on the upper portion of the front wall, while Figs. 29 and 30 show the image during life and the appearance after death of a case of syphilitic ulceration. In Fig. 30 the posterior wall is seen with the ulcers, and below them a star-shaped cicatrix.

The PROGNOSIS generally depends upon the underlying disease, and is grave because the latter is. Perforation may take place, as well as cicatrization and hypertrophy, and either process may lead to a fatal issue. In a number of instances post-mortem examination has shown that tracheal ulceration may produce surprisingly great ravages before destroying life.

TREATMENT, like the prognosis, depends somewhat upon the disease underlying the ulceration. Pain is relieved by anodyne, and cicatrization promoted by alterative inhalations, as of nebulized glycerated solutions of morphine, ethereal solution of iodoform, iodinic preparations, oil of solidago, citronella oil, etc. Catarrhal ulcers heal without special treatment with the subsidence of the catarrhal inflammation. In syphilitic ulceration, stenosis from cicatrization is to be dreaded, and specific constitutional treatment is the main reliance. The internal administration of cod-liver oil has been found of service in nearly all cases of tracheal ulceration, especially in phthisis, lupus, etc. Appropriate general treatment must be combined with the local.

MORBID GROWTHS.

DEFINITION.--Tumors, benign or malignant, growing from the wall and projecting into the interior of the windpipe. Inversion of the mucous membrane forming a protrusion into the interior will be spoken of under the head of Stenosis; and tumors of other organs extending into the trachea, such as cancer of the oesophagus, lymphatic glands, thyroid body, etc., are excluded from consideration under the present head.

FREQUENCY OF OCCURRENCE.--Aside from post-tracheotomic granulation-tumors, which with careless tracheotomy or after-treatment occur often, the disproportion in the frequency of laryngeal and tracheal morbid growths is even greater than that of other laryngeal and tracheal affections. I have met with only eight instances of tracheal morbid growths, strictly so called, in a special practice during more than twenty-five years. This is exclusive of post-tracheotomic vegetations and tumors from contiguity.

ETIOLOGY.--Local irritations and chronic inflammatory conditions seem often, if not always, to be the forerunners of tracheal tumors, but the real cause of the latter is unknown. Recently it has been suggested (see the article on LARYNGEAL TUMORS) that the ever-present bacilli play a rôle in the production of morbid growths as well as in that of other diseases. As it is known that some parasitical organisms on plants use up their nidus very slowly, with the formation of peculiar excrescences, while others very rapidly destroy the tissue of their host, it would be easy to suppose that some such difference in the micro-organism causing the tumor determines its benign or malignant character.

Post-tracheotomic vegetations may arise from the irritating pressure of a {140} tracheotomy-tube, especially from the use of a fenestrated tube or a tube ill fitted to the patient. Some observers are of opinion that such tumors existed before the performance of the operation, and, indeed, led to it, even though the supposed reason may have been laryngeal or some other tracheal disease. While it cannot be denied that such may have been the case sometimes, there is no doubt that in other instances--and not only in those in which the vegetations "always grow from the cicatrix" (Petel)--they are truly caused by the operation, or by the wearing of the tube, especially if it be in any way unsuitable as to size, form, etc.

SYMPTOMATOLOGY.--The symptoms of tracheal tumors are local irritation; tickling or other morbid sensation, sometimes inducing and sometimes not inducing cough; and encroachment upon the breathing-space--dyspnoea--depending on their precise seat, size, and rapidity of growth. It is usually difficult for the patient to specify the beginning of his trouble, because, on account of the large size of the windpipe, dyspnoea generally comes on very gradually. An accidental catarrhal condition of the tracheal mucous membrane from a cold usually first arrests the patient's attention. The very great diminution of the calibre of the tube that the patient can bear when the tumor enlarges slowly is sometimes astonishing. Unless the tumor is pedunculated (so that expiratory efforts can throw it up into the larynx), which is generally not the case, expiration and inspiration are equally affected, both becoming gradually more and more labored and noisy. Sometimes the act of swallowing large morsels brings on an increased dyspnoea; sometimes respiration is accompanied by a sort of valvular sound. Cough is frequently, but not always, present, and depends, together with expectoration, upon either coincidental catarrhal condition or irritation from the tumor: in the latter case it is essential, dry, and persistent, and may vary with the position of the patient. Sputum may be bloody and even contain shreds of the tumor, as in similar cases of laryngeal growth. With increase of the tumor the voice becomes weak and suffers in extent of range, as in other cases of tracheal stenosis; the same is true of the diminished rising and falling of the larynx. The course and duration of the disease vary considerably with its nature. I have observed a tracheal fibroma to remain stationary for eight years, when the patient died from other causes and the diagnosis was confirmed post-mortem; and, on the other hand, a cancer to grow so rapidly that the patient died from suffocation within five months of its first causing the slightest symptom. If not relieved, suffocatory paroxysms, with or without consequent bronchitis and pneumonia, lead to a fatal termination.

PATHOLOGY.--As in the larynx, so in the trachea, the pathological character of neoplasmata is generally that of papilloma. Of my eight cases, all observed during life, four were papillomatous (two examined microscopically after successful extirpation, one post-mortem, and one in situ macroscopically only), one was a fibroma, microscopically examined, one an osteo-chondroma, one a sarcoma, and one a carcinoma, the three last having been examined post-mortem.

Of non-malignant tracheal tumors observed by others, the large majority were papillomata; next in number come fibromata. Aside from these two kinds of tracheal tumor, the cases recorded in literature are the following: Rokitansky more than thirty years ago described tracheal enchondromata found after death; and Cohen discovered in the corpse of a phthisical patient a number of small enchondromata on the central portions of the tracheal cartilages. Steudener, Demme, Wilks, Chiara, and Eppinger have observed, post-mortem, tracheal osteomata. Gibbs has described a tracheal cystic tumor[2] seen with the laryngoscope; Müller, under the guidance of Gerhardt, a myxo-adenoma observed tracheoscopically and carefully studied {141} during life and after death; and Eppinger has recorded a case of post-mortem tracheal adenomata and cysts, Simon having previously found three similar tumors on dissecting a new-born tigress. Virchow speaks of the occurrence of retro-tracheal retention-cysts, and Gruber has observed several; but there can be no doubt that at least some of the tumors thus described are nothing but circumscribed dilatations of the tracheal mucous membrane--practically, dilated mucous glands. As to malignant tumors, in addition to my two cases Schrötter has reported two cases of sarcoma, and Labus one of fibro-sarcoma, while Rokitansky, Klebs, Koch, Schrötter, Langhans, and Mackenzie have described cases of carcinoma.

[Footnote 2: Cohen questions whether this was a cyst or an abscess. It burst spontaneously.]

Cases of cancer of the oesophagus, which involve the trachea--excluded, as before stated, from present consideration--are, comparatively speaking, by no means rare, and are apt to establish a fistulous communication between the two tubes.

DIAGNOSIS.--The symptoms mentioned are those common to nearly all cases of tracheal stenosis, and will be referred to again under that head. Tracheoscopy alone makes the diagnosis certain; unless when the seat of the disease is ascertainable without, its nature is shown by the expectoration of portions of the tumor. The first case of tracheal tumor ever diagnosed during the patient's life was observed by means of the mirror by Tuerck in 1861; but it is very difficult in the mirror to estimate distances as to depth, and unless the number of tracheal rings above a tumor can distinctly be counted, a growth in the lower cavity of the larynx may readily be mistaken for one in the trachea, and vice versâ. Catheterism of the trachea shows the distance at which the tumor is situated, sometimes very accurately, but it is dangerous unless performed under the guidance of the mirror, and even then requires great care. The introduction without the mirror of a probe or sound for the same purpose is still more dangerous and unjustifiable, while with the mirror it is perfectly safe in proper hands. Localized protrusion of the mucous membrane into the interior is the condition which most simulates tracheal tumor. (Compare Fig. 32.)

The pathological nature of a tracheal tumor can sometimes be determined in situ with more or less probability. Without microscopical examination it is not always possible to say whether a growth is benign or malignant unless the mass has advanced to ulceration, and then specific disease must be excluded by the history and concomitant symptoms. Papillomata have a peculiarly uneven surface; fibromata are usually more smooth. With equally good illumination, tumors of the trachea resemble tumors of the larynx, and may be similarly differentiated. The former are almost always non-pedunculated, or at least none of those hitherto observed have had a long pedicle. Their seat is generally the posterior wall, or the cicatrix of the anterior wall after tracheotomy. In Fig. 31 is seen the tracheoscopic appearance of one of my cases of tracheal papilloma.

PROGNOSIS.--The prognosis is always unfavorable in malignant cases, and also in non-malignant when the tumor grows rapidly or has already attained a large size. The introduction of the laryngoscope has bettered the prognosis, inasmuch as in many cases early recognition enables us, by performing tracheotomy, to prevent sudden death from suffocation, and also because by the aid of the mirror removal has been accomplished through the natural passages.

TREATMENT.--Removal of a tracheal tumor through the natural passages {142} by means of either cutting or cautery instruments requires so much special ability on the part of the operator that it need not be described in detail in a work designed for general medical practitioners. When the tumor is situated above a point at which tracheotomy can be judiciously performed, no physician worthy of the name should hesitate to lay open the trachea in any case in which suffocation is impending. Removal of the tumor by surgical operation after opening the windpipe may be attempted or not according to circumstances, but in all cases palliative measures by sedative inhalation and otherwise may be resorted to, and the patient's general health, especially in malignant cases, must be kept up as much and as long as possible.

STENOSIS.

DEFINITION AND PROXIMATE ETIOLOGY.--Stenosis is narrowing or more or less occlusion of the windpipe. It is either stricture or constriction from within, or compression from without, or both combined. Constriction within the trachea is due to swelling or thickening or cicatricial displacement of the mucous membrane or other tissue, inversion of its walls, or morbid growth or foreign body in its interior. Compression from without is due to goitre (which has in some cases prevented viability) or other disease of the thyroid body; aneurism; abscess; enlarged bronchial glands or cervical lymphatics; disease of the sternum, clavicle, or vertebræ; mediastinal tumor; cystic, emphysematous, or other tumor of neighboring tissue; or foreign body. According to Rose's observations of goitre,[3] compression of the trachea leads to fatty degeneration of the cartilages and their subsequent softening and absorption; after which, the windpipe having become membranous throughout and no longer patulous, death can easily--in some positions or flexion of the body, etc.--take place.

[Footnote 3: Der Kropftod und die Radicalcur der Kröpfe, Berlin, 1878.]

In acute tracheitis, though there is swelling of the mucous membrane, the large size of the tube usually obviates stenotic symptoms, while chronic tracheitis does occasionally lead to sufficient contraction to interfere with respiration; but generally stenosis is the result of syphilis, and frequently follows ulceration and cicatrization. In a case recorded in the Bullétin des Sciences médicales for January, 1829, the lumen of the trachea was reduced to two lines.

SYMPTOMS AND DIAGNOSIS.--The main symptom is the peculiar, gradually increasing dyspnoea; once observed, it is recognized without much difficulty. There may also be mucous râles; cough rough and sibilant; attempts at clearing the throat without expectoration, or occasionally with some expectoration, which is at first light-colored, then streaked with blood, and at last purulent, but never abundant (unless accidentally complicated by catarrh), and always difficult to eject; perhaps occasional pain, but constant disagreeable sensation (tightness) in the trachea just above the sternum. Tracheoscopy settles the diagnosis. The tracheal rings are seen either as diminished circles or arcs--sometimes concentrically placed, sometimes in two different directions, as shown in a case of tracheal stenosis from {143} compression causing protrusion of the mucous membrane into the interior, represented in Fig. 32, or else constricting bands are visible.

As to the dyspnoea, both inspiration and expiration are affected--frequently, however, the former more than the latter, as is shown by pneumatometry. The head is thrown forward and the chin up; the larynx moves up and down less energetically than in health (while the respiratory movements of the larynx are abnormally increased in laryngeal dyspnoea); the thorax is less expanded than normally, especially its upper portions.

As to catheterization and probing, see the remarks under the head of Morbid Growths.

PATHOLOGY.--The pathological changes in cases of stenosis vary with its cause. In the great majority of cases of stricture from within, syphilis--antecedent ulceration followed by cicatrization--has produced the stenosis; in compression thyroid disease, and next often aneurism, is the cause. The stenosis is most frequently situated in the lower, next in the upper, and least in the middle, portion; more often than the latter alone the whole tube is affected.

PROGNOSIS.--This is rather favorable with timely and proper treatment unless a continuing active cause be irremovable; without treatment, however, the cases almost invariably terminate fatally from pneumonia, tracheal spasm, apnoea as before explained, etc.

TREATMENT.--When the symptoms are urgent and the stenosis is not too low down, tracheotomy must be performed. Sometimes a very long and flexible tube may be introduced with success in case of very low stenosis, but more often tracheotomy is disappointing on account of the stenosis extending too low down even when its beginning is higher up.

Stricture, especially when the symptoms are not very urgent, may be relieved by dilatation through the natural passages, with, or if possible without, previous tracheotomy. The cure of compression implies removal of the compressing tumor or disease. Soothing inhalations, such as of hops, benzoin, etc., diminish irritation and give temporary relief.

DILATATION (HERNIA, FISTULE).

Dilatation of the trachea is either confined to the tube (when the synonym tracheaectasy is applied to it) or is diverticular. In the former case it may involve only a part or else the whole extent of the windpipe. Whenever free respiration, especially expiration, is chronically impeded, some portion of the air-tract below the obstruction is apt to become dilated; thus, a bottle-shaped dilatation is sometimes found immediately below an annular contraction. On the other hand, tracheaectasy may extend upward from bronchiectasy. It has been observed post-mortem to a slight extent in public criers, trumpeters, etc., and in old coughers from laryngeal disease, chronic bronchitis, pulmonary emphysema, etc., but without giving rise to distinct symptoms during life.

Diverticular dilatation forms an air-containing tumor which either looks into the oesophagus or is discernible on the outside of the neck. Though rarely met with, it ought to be thought of in all appropriate cases, and when pointing externally ought always to be recognized by the careful practitioner. It is either hernial, glandular, or fistular--three pathological conditions which have hitherto been confounded. On account of the construction and position of the trachea there can be but little protrusion outward without previous {144} dilatation. Unless there be a deficiency of the cartilaginous rings, only the posterior wall, which is always unsupported, and to a slight extent also the intercartilaginous membranous portions, are liable to tracheal hernia. This is properly called tracheocele; but the various terms aërial goitre, aërial bronchocele, pneumatocele, tracheal air-cyst, tracheal retention-cyst, internal tracheal fistule, subcutaneous or incomplete fistule of the trachea, have been indiscriminately used as synonyms of tracheocele, and have added all the more to the confusion, as some of them originated, no doubt, as correct appellations of the particular cases to which they were applied. Aside from the occasional occurrence, both congenital and acquired, of tracheo-cutaneous fistule, complete and incomplete, and the still more rare occurrence of hernia of entire portions of the mucous membrane, the cases of diverticular dilatation of the trachea--or saccular tracheaectasy, as it may be called--are glandular, as found by Rokitansky more than fifty years ago. Virchow seems to regard all such glandular dilatations as retention-cysts (see Morbid Growths), but although retro-tracheal retention-cysts doubtless do occur (Gruber has reported two unquestionable instances), and although the tumors now under consideration do in fact sometimes contain a little mucus in addition to air, they do not constitute cysts or adenomatous new growths, but are simply distended portions of the tracheal mucous membrane, respiratory glands, whether the dilatation be caused, as Rokitansky thought, by traction (Zerrung) and hypertrophy of the mucous glands, or, as Eppinger suggests--and which is more likely--mainly by increased intra-tracheal air-pressure. There must, however, I think, coexist some deficiency or weakness of the cartilaginous or other tissue, either congenital or acquired.

When the dilatation is retro-tracheal only, the symptoms are very obscure, and diagnosis during life is at best uncertain. In one such case under my care, confirmed (death having occurred from another cause) by post-mortem examination, there was some dysphagia and slight alteration of the voice. In all other cases the characteristic and unmistakable sign of the disease is the peculiar intermittent, or, at all events variable, aërial cervical tumor. It increases and diminishes with forcible expiration and inspiration, and attains its largest size during violent coughing, hawking, blowing of the nose, or other expiratory effort. Occasionally the voice is considerably affected. The tumor, especially by the manner in which it can be made to temporarily disappear and reappear, can usually be easily differentiated from subcutaneous emphysema and goitre, the only two conditions with which it might be confounded. In the fistular variety the opening into the trachea can sometimes be seen by means of tracheoscopy.

Aside from the deformity which the tumor may cause, it sometimes induces laryngeal spasm and dyspnoea; otherwise it is of no gravity.

As to TREATMENT, methodical and continued compression by applications of astringent collodion or by mechanical means is the only palliative measure applicable; when suffocatory attacks call for it, tracheotomy must be performed.

{145}

TRACHEOTOMY.

BY GEORGE M. LEFFERTS, A.M., M.D.

The operation of tracheotomy, or the artificial opening of the air-passage--using the term in its modern acceptation as including all of the five incisions that are both anatomically and surgically possible, either singly or in combination, between the lower border of the thyroid cartilage and the upper edge of the sternum (incisura jugularis sterni), and reserving the term laryngotomy to denote the division of the thyroid cartilage alone--fulfils two important and usually urgent indications: First, in allowing the respiratory current free access to the lungs in cases where the laryngeal obstruction is of such a sudden or of so progressive a character as to either immediately or remotely threaten the life of the patient; and, secondly, in affording a ready means of direct access to those portions of the air-tract which lie below the level of the glottis, and thus permit not only of the direct extraction of such foreign bodies as may accidentally have found their way within the air-passage, but of neoplasms here located and of occluding diphtheritic membranes. Catheterization and aspiration of the trachea are likewise both rendered not only possible, but easy of execution. Both general indications mentioned often coexist, and are met by the operation in a large class of cases; the first alone plays its important life-saving rôle in many.

The disease or accident which renders the operation necessary varies greatly, and upon this variation depends not only the surgeon's decision as to the precise time at which the opening into the air-tube must be made, but also the precise point at which the operation should be performed. These general questions I treat of in detail. The special indications may conveniently, but somewhat arbitrarily, be arranged as follows, in groups, which I have attempted to make complete, although some of the conditions, being purely surgical, do not strictly come within the compass of this essay:

A. Acute inflammatory diseases of the larynx and trachea: 1. Acute oedema of the larynx. 2. Erysipelatous and exanthematous laryngitis. 3. Acute perichondritis, with abscess. 4. Diphtheritic croup.

B. Chronic affections of the larynx and trachea: 1. Syphilitic laryngitis. 2. Phthisical laryngitis. 3. Chorditis vocalis inferior hypertrophica. 4. Carcinoma of the larynx or trachea. 5. Non-malignant growths of the larynx or trachea. 6. Tumors overlying the superior aperture of the larynx. 7. External compression of the trachea by tumors of the neck or chest. 8. Strictures of the larynx or trachea.

C. Neurotic diseases: 1. Paralysis of the abductors of the vocal cords. 2. Spasm of the adductors of the vocal cords. {146}

D. Traumatic conditions: 1. Foreign bodies in the larynx or trachea. 2. Impaction of foreign bodies in the pharynx or oesophagus. 3. Fracture of the larynx. Rupture of the trachea. 4. Scalds and burns of the larynx. 5. Incised and gunshot wounds of the throat. 6. Poisonous bites inflicted by certain insects about the mouth or neck. 7. Suffocation from the passage of blood, fluids, etc. into the air-passages (tracheotomy, with aspiration of the windpipe and artificial respiration). 8. Suffocation from the acute collection of either mucus or serum in the bronchia (ditto). 9. Suffocation from the inhalation or development of poisonous gases (tracheotomy, with artificial respiration).

Finally, although it pertains alone to the province of the surgeon, I may allude to the temporary tracheotomy and "tamponing of the trachea" which has been recommended--and certainly found efficient--in preventing the entrance of blood to a dangerous degree into the lower trachea and lungs during the performance of certain operations in the neighborhood of or upon the air-passages, such as resection of the upper jaw, the extirpation of large nasal and naso-pharyngeal polypi, removal of the tongue, subhyoidean pharyngotomy, laryngotomy, and extirpation of the larynx.[1]

[Footnote 1: For the details of this procedure consult Schüller, Die Tracheotomie, etc., Stuttgart, 1880.]

All-important as a preliminary to the operation itself is a thorough knowledge of the surgical anatomy of the region upon which it is proposed to operate; and this not alone in the adult, but especially in the child, where essential differences often exist. Possible anomalies also are not to be forgotten.[2] The assurance of the surgeon depends upon this knowledge: mere, manual skill will not compensate for its want; the success, both immediate and remote, of the operation is in great measure the reward of its possession.

[Footnote 2: See Pilcher, "The Anatomy of the Anterior Median Region of the Neck," Ann. of Anat. and Surgery, Brooklyn, April, 1881.]

It will be remembered that the trachea commences at the inferior border of the cricoid cartilage, directly opposite to the lower edge of the fifth cervical vertebra, and reaches thence downward, in the median line of the neck, until it bifurcates opposite to the third dorsal vertebra. In its upper part it is nearly subcutaneous, and is surmounted by the prominent ring of the cricoid cartilage (easily identified, even in the young child), above which, in turn, lies a slight depression (the crico-thyroid space) between the cricoid and thyroid cartilages. As the trachea descends in the neck it recedes gradually, lying at the episternal notch about one and three-eighths of an inch from the surface. Throughout the whole of this course it is in relation with important structures. In its cervical portion it is covered by the sterno-hyoid and sterno-thyroid muscles, and in the median space, which is usually distinct between them, by layers of the deep cervical fascia. It is also crossed by the isthmus of the thyroid gland, which lies between the second and fourth tracheal rings; by the arteria-thyroidea ima, when present, and below by the plexus formed of inferior thyroid veins with their tributary and communicating branches. In the latter region, but more superficially, are some communicating branches between the anterior jugular veins. The innominate and left carotid arteries are also anterior to it in the episternal notch as they diverge from their origin. Laterally, the trachea is in relation with the common carotid artery, the lateral lobes of the thyroid body, the inferior thyroid veins, and the recurrent laryngeal nerves. The thoracic portion of the trachea is covered by the manubrium sterni, with the origins of the sterno-hyoid and {147} sterno-thyroid muscles, by the left innominate vein, and by the commencement of the innominate and left carotid arteries. Still lower, the transverse portion of the arch of the aorta crosses, and the deep cardiac plexus of nerves lies in front of it. Posteriorly, throughout its length, it rests upon the oesophagus.

In performing, then, either the superior or inferior operation of tracheotomy, after cutting through the skin and superficial cervical fascia--which is really loose areolar tissue containing fat--the superficial layer of the deep cervical fascia is reached, and immediately below it more or less adipose tissue and the two anterior jugular veins lying in an inferior tracheotomy to either side of the wound, which is always made in the median line. As a matter of fact, these various layers are rarely demonstrable, and the surgeon proceeds irrespective of them until he reaches this point in his operation--viz. the muscles which overlie the trachea. These may overlap in the median line, and have to be retracted after having been separated; or, again, a thin line of connective tissue marks a slight interval between their inner edges, and is readily seen and dissected through if the operator has kept his incision vertical and strictly in the median line of the neck--a matter so important to the success of his operation that I do not hesitate to again allude to it. The muscles separated and gently retracted, together with the overlying tissues, toward the sides of the wound, the upper edge of the isthmus of the thyroid gland overlying the second and third, perhaps fourth, rings of the trachea, is always seen in a superior tracheotomy--its lower edge very frequently in the inferior operation. The isthmus is adherent to the trachea and to the larynx through the deep layer of the deep cervical fascia, but is capable of being slightly displaced or pushed upward or downward as the case may be, and thus kept from obscuring the operative field. This being done, the deep layer of the deep cervical fascia is seen covering and strongly adherent to the tracheal wall together with the thyroid veins. A few touches of the knife, carefully avoiding the blood-vessels, serve to clear it away, and the tracheal rings are clearly exposed.

In carrying out this dissection, which has been described as occurring in an ordinary and uncomplicated adult case, several matters must be borne in mind; and especially is this true if the operation concerns infants. In them, for instance, the thymus gland rises half an inch above the level of the sternum, and is frequently to be found as late as the sixth or seventh year. In both adults and children the innominate artery occasionally comes into view in an inferior tracheotomy, obliquely crossing the lower portion of the right half of the trachea. It is relatively higher in the child than in the adult. The left innominate vein is also often observed when the trachea is opened low down.

Certain abnormalities of the blood-vessels have been alluded to above. The commonest consists in the existence of a thyroidea ima artery, which when present usually arises from the innominate trunk, but sometimes from the right common carotid or the aorta: it passes to the thyroid body directly in the median line of the neck and close to the trachea; again, the place of the anterior jugular veins may be taken by a single central vessel, almost sure to be wounded during the operation if it exist (Mackenzie).

In performing the operation through the thyro-cricoid membrane (thyro-cricotomy) or through the cricoid cartilage alone (cricotomy), the same tissues are met with, and the same dissection is necessary in the earlier stage of the operation, as have been described in the operation of superior or inferior tracheotomy; but the parts are more superficial, adipose and cellular tissue less abundant, blood-vessels much less numerous, and the operation very much simpler. The thyroid gland of course does not come into view, {148} and the crico-thyroid artery, a very small vessel, needs no attention in the dissection.

I have here and elsewhere included under the general term tracheotomy five distinct operations, having for their object the opening of the air-passages, which are surgically possible between the lower border of the thyroid cartilage and the upper edge of the sternum. In this classification I have followed that of Schüller, and its simplicity, but exactness, and the avoidance of the old confusion of different terms which results from the use of one intelligently employed, seem to me to commend it. These five operations are--1. Thyro-cricotomy, or the opening made through the crico-thyroid membrane alone. 2. Cricotomy, or the division of the cricoid cartilage alone. 3. Superior tracheotomy, the incision being made above the point where the isthmus of the thyroid gland crosses the trachea and below the cricoid cartilage. 4. Median tracheotomy, when, the isthmus being displaced or torn through, the trachea is opened immediately below its site. And 5. Inferior tracheotomy, the incision being made below the point of crossing of the isthmus of the thyroid gland, and at varying distances, dependent mainly upon the age of the patient and size of the parts, above the sternal notch.

Rarely, I am bound to admit, is the field of all of these operations as distinctly limited in practice as is here indicated, and one, perhaps two, are rarely selected. Thyro-cricotomy (old term laryngotomy) is often indicated, and cricotomy and median tracheotomy are sometimes performed as here described. Superior tracheotomy is commonly a combination of at least two of the methods--viz. the division of the upper rings of the trachea and the cricoid cartilage as well. It may even, probably frequently does, trench also upon the thyro-cricoid membrane (thyro-cricotomy) and upon the field of a median tracheotomy, the isthmus being pushed downward or even cut or torn through. The latter operation and cricotomy are, I believe, rarely if ever done from choice. Finally, inferior tracheotomy is a common method. As here described, it meets a large number of indications, and, despite its superior difficulties over the higher operations, is therefore necessarily often chosen; not infrequently, however, does it invade the median region, the isthmus of the thyroid being pushed upward.

Which of these operations shall be selected in a given case depends upon the particular conditions which render it necessary, and likewise, to some extent, upon the age of the patient. Durham summarizes the question very fairly. Thyro-cricotomy (old term laryngotomy) is by far the easiest operation to perform, and its execution is attended by least risk; therefore it is the operation to be preferred in any sudden emergency when suffocation threatens, and especially where the surgeon is alone with the patient. Generally, it is not as applicable as the others, especially in early childhood, on account of the limited dimensions of the thyro-cricoid space. It cannot be recommended in cases of acute or extensive diseases or injuries of the larynx, nor is it likely to be of much service if a foreign body is in the trachea or bronchus. On the other hand, it is probably the best operation to adopt in cases in which foreign bodies are impacted in the larynx, in cases of limited chronic disease or contractions of the superior laryngeal parts--usually the result of syphilitic ulceration--and in cases in which respiration is impeded by intra-laryngeal growths which cannot be removed by the natural passages.

Cricotomy, combined with superior tracheotomy (old term laryngo-tracheotomy), is not a difficult operation, and may be advantageously practised, especially in children; in the adult it meets many indications. Holmes recommends it the more urgently, in preference to an inferior tracheotomy, the earlier the age of the subject may be.

Inferior tracheotomy is comparatively difficult to perform, and during its performance dangers may have to be encountered greater and more numerous {149} than those met with in either of the other operations. This is true certainly of children. As regards young children, Holmes states that after the age of five or thereabouts the surgeon can, if he prefer it, open the trachea below the isthmus of the thyroid gland. He himself does not recommend the operation before puberty. In the case, however, of a foreign body loose in the windpipe of a child, where a large opening is required, it can hardly be obtained above the thyroid body and below the cricoid. To cut through the isthmus of the thyroid (median tracheotomy) is, in early life at least, a doubtful proceeding when it is of large size, on account of its vascularity, and the incision must be made below it--in other words, an inferior tracheotomy.

When the operation of tracheotomy shall be performed is a question which the experience and individual views of the surgeon, based on experience, must decide in each case. The doubt always arises in the mind of the inexperienced operator whether the symptoms are sufficiently urgent to render the operation necessary. To him these general rules may be given: The immediate indication for the operation is to be looked for in the thorax. It is the recession of the lower part of the sternum and contiguous ribs and the retraction of the intercostal spaces and clavicular fossæ at each act of inspiration. He must not wait until lividity of the lips and blueness of the fingernails prove that the blood is being imperfectly oxygenated (Mackenzie). Let him remember also that, aside from the immediate and imminent danger of sudden suffocation, a remote one exists and increases the longer he postpones his operation and allows the struggle for air to continue--viz. vascular engorgement and oedema of the lungs, especially in young children; the production of all those conditions which allow, and even predispose, the lung after the operation to fall an easy prey to the inflammatory processes.

The instruments necessary for the performance of the operation of tracheotomy are few and simple, and are such as may ordinarily be found in any small operating-case. A scalpel, a probe and sharp-pointed bistoury, dissecting and artery forceps, a tenaculum, a grooved director, two small retractors, scissors, and a dilator for the tracheal wound, are necessary. To these may be added the needles and thread, waxed ligatures, sponges, and tape. The tracheal tube is elsewhere described. A faradic battery, good suction syringe, and a large flexible catheter may render good and timely service if at hand.

It is true that many other and more or less complicated instruments have been devised for the purpose of facilitating the operation; and other methods, aside from that of the knife, have come of recent years into vogue; but, still, simplest means, as above given, have in the experience of most surgeons been proven to be the best. This statement, undeniably true for all surgical measures, is especially so for the operation under consideration, which is often necessarily undertaken without opportunity for elaborate preparation and under the most adverse and inconvenient circumstances. The more familiar, therefore, the surgeon is with his instruments, the better and more certain will be his work.

Holding this view, it is unnecessary for me to more than briefly mention such instrumental aids as the grooved tenaculum of Chassaignac, the groove serving to guide the operator's knife into the trachea; the sharp double hooks of Langenbeck, which, after being caught in the tracheal walls to either side of the site of the intended incision, are sprung apart after the latter is made, thus dilating the wound and rendering the introduction of the tube easy; the tracheotome of Thompson, a pair of curved cutting forceps, the blades of which are caused to open by a screw after they have been plunged through the tracheal walls; that of Garin, a forceps with curved blades--one, the longest and sharpest-pointed, being made to penetrate the trachea, the instrument then opened, and both blades cut their way to the desired extent of {150} incision; finally, the tracheotome of Maisonneuve, a curved dilating hook with cutting inner edges. Its point is entered between the first and second rings of the trachea and brought out again between the fourth and fifth; the handle is then carried under the chin, so that the blades are made to cut through the trachea and the skin between the points of insertion and exit, after which, upon pushing a spring, the two halves of the hook separate, and the canula is introduced between them (Thornton). And the trachea-stretcher of Marshall Hall, by means of which a portion of the trachea is cut out and the opening kept patent.

None of these instruments have been proven to possess any practical worth; on the contrary, their use, especially that of the latter forms, has in more than one instance been attended with disastrous results.

To obviate the danger of serious hemorrhage during the performance of tracheotomy, both the galvano-cautery knife and the thermo-cautery instrument of Paquelin have been recommended within the past few years, and a number of operations placed upon record. The procedure is the same whichever means be used. The skin and soft parts overlying the trachea are usually alone cut through by means of the cautery-knife, the cartilaginous rings of the tube, when reached, being divided with the ordinary knife. This fact alone speaks against the thoroughness attainable by means of these methods; but, still more important, neither has been found reliable in checking hemorrhage, and in several instances the operator has been obliged in haste to lay aside his cautery apparatus and turn to the ordinary and better-known means to complete his operation. The healing of the tracheal wound made by the cautery is slow: erysipelatous inflammation may attack the wound as the result of the burn, and extensive sloughing of the edges is not unknown, while the resulting cicatrix is large, strong, and contractile, and has caused, in one case at least, a stenosis of the trachea. In the face of these facts he must indeed be an enthusiastic advocate who would recommend the procedure. Mackenzie justly remarks that the use of the thermo-cautery for opening the air-passage merely introduces an unnecessary complication into the operation.

The choice of a proper tube, one suited to meet the special indications in a given case and specially adapted to the age of the patient and the calibre and position of his trachea, is no unimportant matter, and may do much not only to facilitate the immediate success of the operation, but likewise prevent the occurrence of those possible unfortunate results, ulceration, fatal hemorrhage, abscess, pneumonia, and pyæmia, no lack of which are recorded in our literature.

Although the number and variety of mechanical devices and forms of tracheal tubes that have from time to time been devised by the inventive ingenuity of operators is large, the choice practically centres upon one of two forms. The first, and the one most commonly used, is but the original canula of Trousseau, modified by Roger, in that the tracheal portion of the tube is detached from the collar or neck-piece, and moves freely with the movements of the patient; and by Obré, by the important device of an inner tube to prevent clogging of the outer or original tube by mucus. Starting upon this essential basis, the instrument-maker has perfected the instrument of to-day. It is a silver tube, double throughout, the inner tube projecting at the lower or tracheal end beyond the outer--an important point, as it prevents any possible permanent occlusion by mucus or blood-crusts, membranes, and the like at this point, removal of the inner tube at once clearing the end of the outer one. The curve of both tubes should correspond to the arc of a quadrant, and the outer is fastened to a transverse collar or shield by means of two small projections or pins upon its sides which lie under small wire bridges upon the shield after it has passed through an opening in the {151} transverse neck-collar large enough to permit of its free movement during the respiratory movements of the trachea, as well as during the forcible action caused by cough. The ends of this collar or shield curve slightly backward to correspond with the curve of the neck, and are perforated by, preferably, large oval openings, instead of the usual small, inconvenient slit, through which the tapes are passed which hold the tube in position by encircling the neck. To this same shield is fastened, by means of a small turn-screw or a revolving collar, the end of the inner tube, which is thus prevented from being forced out of the outer tube by coughing or any motion of the patient. Upon the upper or convex surface of the outer tube a small ovoid opening is usually made for the purpose of permitting the expiratory current to pass upward (the inner tube being removed) into the larynx and render phonation possible; also, the free opening of the outer tube being closed, to allow of respiration being carried on through the larynx and natural passages--often an important matter, as the case progresses toward recovery, in instances where the operation of tracheotomy has been performed on account of laryngeal obstruction.

A set of these tubes, which can now be readily obtained, should consist of four, with the following diameters: No. 1, one centimeter; No. 2, nine millimeters; No. 3, seven millimeters; No. 4, five millimeters: their length is of course in relative and fixed proportion to these measurements. A tube should always be selected less in diameter than the trachea operated upon: to seek to introduce one of the same calibre is not only unnecessary, but cannot fail to be dangerous. Tubes constructed upon the same principles as that just described (Lüer's) are made of hard rubber instead of silver (Leiter): their lessened cost is their principal recommendation, added to the one that they are more easily kept clean and sweet than the silver tubes. The fact that they are necessarily made much heavier and thicker than the latter is a disadvantage, the lumen of a hard-rubber tube being smaller than that of a silver tube of corresponding external diameter. The objection urged against them, of their great danger of breakage, I have not found borne out by experience. Tracheal tubes are also constructed of platinum, and recommend themselves on the score of lightness.

The main objection to any of the forms of tube just described exists in the nature and shape of their curve, which not infrequently causes the lower or tracheal end to lie in contact with the anterior tracheal wall, or its convexity with the posterior, and irritate, even ulcerate, them. This misfortune is entirely obviated by the canula of Durham, the second of the two forms to which I have called special attention, and which is essentially a right-angled tube, made of four sizes, with a long horizontal portion, varying from 7 to 4 centimeters, and short vertical portion, of from ½ to ¾ of an inch in length and slanting slightly backward. The former portion is capable of being lengthened or shortened in any sized tube by means of a screw arrangement attached to it as it passes through the usual neck-collar or shield; and the vertical tube can thus be correctly adapted to the particular depth at which the trachea naturally lies in a given case from the surface; and not alone this, but also to the condition of the overlying parts, whether thin or fat, swollen or otherwise. Once in position, the vertical portion of the tube remains in the long axis of the trachea, and does not touch its walls to any injurious degree. Owing to its right-angled shape, the angular and descending portions of the inner tube of this canula are necessarily made upon the lobster-tail principle, with joints--a possible disadvantage, as they can become clogged with mucus and may become detached. Other modifications and improvements exist in this Durham canula over the older one first described, which add to its utility, but need not here be dwelt upon. Suffice it to say that the tube is an excellent one for its purpose, and is deservedly highly {152} spoken of and recommended by those who have had experience in its use. Its cost is an objection.

The other forms of tracheal tube need but passing mention. The bivalve canula of Fuller is made in two lateral segments, fastened to a collar and tapering when closed to a point, so that introduction of the apparatus through the tracheal wound is made easy. Once introduced, an inner complete canula is slid into its place, thus separating the two outer halves and rendering the whole round and compact. It has been criticised unfavorably on account of the danger of hemorrhage that it is likely to cause through pressure on the tracheal walls by the sharp edges of the outer canula. In Gendron's canula the same lateral blades are separated after introduction by means of a screw fastened on a transverse bar.

Soft-rubber canulas were introduced to the profession not long since by Morrant Baker for subsequent use after the operation of tracheotomy, the usual tube having been worn meanwhile for a few days. Being soft and flexible, they are certainly safe and comfortable for the patient, but their thickness and the absence of any inner tube are, especially the latter, serious disadvantages. They are not, I believe, generally used. Finally, the long, flexible tracheal tube of König was devised by its author to meet the indications in cases where the trachea is compressed from without by tumors, and where a long canula that is flexible, but at the same time rigid enough to resist pressure, becomes a necessity. It is made in the form of the ordinary tracheal canula, only larger, some three or more inches of the centre of the descending portion of the tube being constructed of spirally-twisted silver wire.

It may not be out of place to remind at this point that a tracheotomy is not infrequently performed, of necessity, very hastily, and in the absence not only of a tracheal tube, but likewise of other and even more essential instruments. The lack of the former need never be a barrier to the prompt performance of the operation, for the ready wit of the true surgeon will show him various ways out of his temporary difficulty. A thick goosequill fastened by threads passed through its outer end makes an efficient improvised canula. A bit of elastic catheter answers the same purpose. Retractors for the edges of the tracheal wound, made of wire--silver if it be at hand, a couple of hairpins if it be not--and connected together by an elastic tape which passes around the neck, will not only answer a good temporary purpose in holding the tracheal wound dilated, but have been recommended by Martin--in a more elegant form, it is true--as a proper method of treatment after opening the trachea. Finally, one or more stitches passed through the cartilaginous edges of the wound, and attached to the soft parts beyond it, will serve to secure its patency, at least temporarily.

If a patient be doomed to wear a tube constantly in his trachea, the instrument described above can be removed at a suitable interval after the operation and its place supplied by a single tube of the same size and form as has been found adapted in the case. In the convexity of this permanent tube an ovoid opening should be made to allow of the passage to the larynx of the respiratory current, in part at least, and to its mouth a pea-valve may be fitted which shall admit air on inspiration, and not allow it to escape on expiration, thus doing away with the necessity of the patient's closing the opening of his tube with his finger each time that he requires to speak. Several forms of these valves have been devised, but practically they are of little use, are annoying to the patients, and, as a rule, not tolerated by them.

How shall the operation of tracheotomy be performed? An answer to this question necessitates a short description of the operative steps of the different procedures that is given in the order in which, I believe, the operations are, as a matter of experience, found to occur in practice--viz. 1st, superior {153} tracheotomy, combined or not with cricotomy; 2d, thyro-cricotomy and, 3d, inferior tracheotomy. Certain preliminaries are common to all.

The patient should be extended upon a table covered with one or two thicknesses of blanket and of suitable height, which has been placed sideways in front of a window if the operation is done by daylight. (At night several candles tied together afford a better and safer light than a kerosene or oil lamp.) The surgeon stands at the right side of his patient and facing the window. Of his two assistants--and the value of trained assistance in this operation is inestimable--one faces him, without obscuring the light, and is prepared to use the sponges, hand the instruments, manipulate the retractors, and render such direct assistance as may be required. The second sits at the head of the table and holds the head of the patient steadily, the neck being well extended and thrown backward over a small round pillow (or, better, a wine-bottle wrapped in a towel) which has been placed beneath it. The head must be held directly in the median line of the patient's body, and even in that of the operating-table. The assistant's attention must never waver from this important duty. In certain cases too great inclination of the head backward serves to increase the urgent dyspnoea, or even to check respiratory efforts. This effect he must watch for, and be prepared to relieve instantly by raising the head. His duties also include the preliminary administration of an anæsthetic, and its use during the operation if required. That such use is safe in this class of operations is now generally admitted, but it is not always necessary. The operation is not an exceedingly painful one, and I have often performed it, with the adult patient's consent, without using any anæsthetic (sometimes freezing the skin over the site of the incision before making it), he submitting rather than undergo any addition to the sense of urgent dyspnoea from which he is already suffering. In children anæsthetics--ether being more commonly employed, although chloroform is often used--are much more necessary, often indispensable. Their effects are speedily manifested when asphyxia is present in any marked degree, and but little of the vapor need be inhaled. The administration, always to be carefully watched and profound anæsthesia avoided, renders breathing easier in many instances, certainly lessens laryngeal spasm, and may be discontinued early in the operation when the air-tube is or has been nearly reached by dissection. Any slight risk attending their use is more than outweighed by the safety and precision which they ensure in the more difficult and delicate steps of the operation (Sands). If the patient be already insensible or if death be imminent, their use, of course, is contraindicated.

The operator having previously decided which operation he will perform, and after carefully identifying the position of the various parts, the larynx especially, marking them with ink upon the skin if he chooses, now steadies the loose skin over the site of his intended incision, and then makes it, freely, firmly, cleanly, and exactly in the median line. If it be for a superior tracheotomy, combined or not with cricotomy, the operation I shall first describe, it must extend from just at the notch of the thyroid cartilage downward for about four inches. A free external incision is very desirable in all cases. The subcutaneous tissue now rapidly dissected through by the careful use of the knife, the veins as met with either being pushed to one side or, if they cross the line of incision, cut if small, then twisted or immediately ligated, or if large doubly ligated and then cut between the ligatures, the interval between the sterno-hyoid muscles is sought for and found, then separated by the blade or handle of the knife and held apart by retractors at the side of the wound. It is important that the faint whitish line of connective tissue which marks the interval between the muscles be recognized, otherwise it happens that the operator passes through the body of one of them, deviates at once from the median line, and approaches the side of the trachea {154} instead of the front. The ring of the cricoid cartilage above and the upper edge of the isthmus of the thyroid gland below can now be either seen or felt by the finger in the wound between them; and about the latter lies more or less connective tissue and numerous small veins. As a rule, careful touches of the point of the knife, or, as some operators prefer at this stage, its handle or the use of a blunt director, serves to dissect up piecemeal or tear through and clear this away, the veins again being pushed out of the way, or if necessary cut and tied, and all parts held aside by removing and replacing freshly the retractors from time to time as the dissection proceeds, until the ring of the cricoid and the upper rings of the trachea come plainly into view; that is, are seen, not alone felt. During this dissection, especially if the handle of the scalpel be used, too much pressure must not be made upon the trachea. More than once I have known it to cause sudden suspension of the respiration, probably by exciting reflex spasm of the larynx. If the isthmus of the thyroid gland extend far upward, it must be pressed downward, its facial attachments to the cricoid and trachea cut or torn through, and may require to be held downward in the lower angle of the wound by an additional retractor. The upper rings of the trachea having been thus well cleared of their overlying parts, the next step of the operation follows. I am in the habit of now removing the retractors and allowing the trachea, which may have become displaced by them, to resume its normal position, the head of the patient being meanwhile readjusted. All this takes but a few seconds. A tenaculum is then implanted in the median line, either just below the edge of the thyroid or the cricoid cartilage, if the latter is not to be severed, and held firmly by the assistant at the head of the table, thus steadying and elevating slightly the trachea and rendering the incision into it certain. The retractors are now reintroduced at the sides of the wound, and the operative field is clear and steady. A glance having shown that all bleeding has ceased, another that the tracheal dilator and tracheotomy-tube lie ready at hand, the operator plunges a straight-pointed bistoury through the tracheal wall at the level of the third or fourth ring in the median line, and cuts quickly upward until the cricoid cartilage is reached, if he proposes, as in the adult can usually be done, to limit his operation to a superior tracheotomy. If not, as in the child, and the cricoid cartilage must be cut through to gain sufficient space for the introduction of the tube, it also is severed by prolonging the incision upward to the thyro-cricoid membrane. A hissing of escaping air, with the bubbling of a little blood and paroxysms of cough, follows the incision and shows that the trachea has been fairly opened. The tracheal dilator is now introduced, the lips of the tracheal wound separated, and the canula slipped neatly into the windpipe (unless in the case of a foreign body), and secured a moment or two later, when respiration is fairly established, by tapes passing around the neck. The tenaculum and retractors are removed at the same moment that the tube is slipped into place.

Many different methods have been recommended for the dilatation of the tracheal wound and to assist the introduction of the canula. The dilator (Trousseau) which has been mentioned surely answers all purposes, and is simple and easily used. An ordinary dressing forceps will likewise do the work if introduced closed and afterward opened. More complicated procedures are unnecessary.

Thyro-cricotomy requires that the superficial incision be so made over the larynx that the thyro-cricoid space shall lie in the centre of one, about two inches long, made in the median line. Following now the dissection just described, the thyro-cricoid membrane is easily reached and quickly seen as soon as the sterno-hyoid muscles are retracted. It should then be divided transversely close below the lower edge of the thyroid cartilage, the wound dilated, and the tracheotomy-tube slipped into place.

{155} Inferior tracheotomy demands that the external incision be free. In children, and in adults with a short neck, it should extend from the cricoid cartilage to just above the sternum. The subsequent steps of the operation are as for superior tracheotomy, with but slight differences. The anterior jugular veins may come into view, but can generally be avoided. If they are joined by a transverse branch, this is necessarily cut through after being doubly ligated. After the thyro-hyoid muscles are separated, the rings of the trachea are much less distinctly felt at first than in superior tracheotomy, being covered by more connective tissue and numerous veins. These inferior thyroid veins, especially if large, are the great obstacle in the way of this operation, and much care is necessary in order to avoid them, which should be done if possible. The lower edge of the isthmus of the thyroid gland, which presents to a variable extent above in the wound, does not, as a rule, offer any obstruction. The thymus gland present in infants is easily pulled downward and out of the way. The trachea at length fairly exposed and all bleeding controlled, the left fore finger of the operator is placed in the lower angle of the wound to securely protect the large blood-vessels here located, and the incision made through some three tracheal rings from below upward.

It may happen that in either a superior or inferior tracheotomy no time will be allowed for careful and slow dissection as here described. In such instances Durham advises that the surgeon grasp the trachea between the fore finger of his left hand on the left side and the thumb on the right, and make uniform, steady, deep pressure, thus firmly securing it and at the same time protecting the large vessels of the neck. The fingers thus placed are not to be moved until the trachea is reached, which is accomplished by rapid incisions confidently made. The pressure of the fingers causes the wound to gape and the trachea to advance. The latter reached, it is caught by the tenaculum and the operation completed as before described.

The operation of median tracheotomy may require a word. As has been stated, that part of the trachea covered by the isthmus of the thyroid gland is very commonly encroached upon in performing either or both superior and inferior tracheotomy, the isthmus being slightly displaced from its site. Other than this the site here mentioned would rarely be selected as the point for opening the trachea. Certain conditions, it is true, might render it necessary, but they would be rare. The danger lies in the hemorrhage which, theoretically at least, is to be expected when the isthmus of the thyroid gland is either torn or cut through; but opinions vary very greatly as regards this danger. With a thin, narrow isthmus in children I have frequently, in performing superior tracheotomy, cut my way through to a sufficient extent to clear a suitable space upon the trachea through which to introduce a tube without difficulty or danger. I should not recommend the procedure, however, were the isthmus to be seen to be, when reached, thick, wide, and exceedingly vascular, but at the same time believe that the danger even here of cutting into it is much overestimated.[3] Roser's recommendation to apply a ligature to the isthmus on either side of the median line previous to its division is not generally applicable. Hueter has shown that the fibrous capsule of the thyroid gland enclosing it and its blood-vessels is firmly attached to the trachea and sides of the larynx, and that from the isthmus this fascia extends upward over the larynx (fascia laryngo-thyroidea), and thus prevents, in a measure, attempts at displacing the gland downward. Bose[4] recommends that this fascia be divided transversely over the anterior convexity of the cricoid cartilage, when a director can be passed behind the isthmus, to lift it from the trachea and depress it far enough to expose three or four of the {156} rings: the capsule of the gland thus remains unbroken and no hemorrhage occurs. The procedure certainly merits trial; twice it has succeeded well in my hands.

[Footnote 3: See Foulis, "Some Points on Tracheotomy," Glasgow Med. Journ., vol. xv. No. 2, p. 123.]

[Footnote 4: Archiv für klin. Chirurgie, vol. xiv. p. 137.]

Cricotomy, the division of the cricoid cartilage alone, is an operation which, as far as I am aware, is rarely ever performed. The objection urged against it, however, that in the adult the elasticity of the cricoid cartilage is so great that a wound through its ring cannot be made to gape sufficiently to allow of the introduction and retention of a canula without discomfort and danger of necrosis of the cartilage, is not borne out by experience. In children the objection cannot of course be urged.

The description of the operative steps which has been given, and which comprises the routine in an ordinary and easy cure, should not mislead. The operation is not always as simple and safe as would appear from what has been said. At times complicated and difficult, at times dangerous in practice from the delay involved, it demands in all, but especially in certain urgent cases, a trained hand and eye, sound anatomical knowledge, coolness, self-reliance and presence of mind on the part of the operator. Despite the greatest caution, and even in apparently favorable cases where time for dissection and deliberation is allowed, certain mishaps may occur which complicate the operation to a serious, dangerous, or even fatal degree. Some of these, as will be seen, are avoidable with care, but others may happen that are not only unavoidable, but totally unforeseen, and from their very suddenness all the more embarrassing.

Accidents may occur during the dissection of the soft parts overlying the larynx and trachea, and the importance of carefully determining by palpation the location of the various parts prior to making the preliminary incision, and of studiously preserving their relation and location during the dissection, cannot be overestimated. Neglect of this precaution has in more than one instance led to the air-passages being opened through the thyroid cartilage or thyro-hyoid membrane, instead of at the intended point. It should not be forgotten also that the natural laxity of the several layers of connective tissue of the neck is much increased by their division, and that the trachea, being naturally freely movable, is thus very easily displaced from its normal position during the act of dissection; especially will this happen when unskilful attempts are made to hook aside or retract the divided structures during the operation. Thus it may easily occur that the entire trachea is drawn to one side and entirely lost, or, more commonly, is turned upon its vertical axis, and finally opened at the side instead of anteriorly in the median line. It may not be opened at all, either being altogether missed by the surgeon in his dissection, which is continued past it, even down to the vertebral column, or the tracheal tube may be passed into the tissues lying in front of the trachea, under the mistaken idea that the latter has been incised. Persistence in keeping to the median line during dissection--a golden rule in the operation of tracheotomy--will render the first accident impossible; the second may be avoided by hooking up the trachea, as has been described, before incising it. If the opening into the trachea has not been made large enough to receive the tube, as often happens to the young operator, and even to the experienced when he fears to extend his incision on account of the proximity of the thyroid isthmus, no resource remains but to carefully enlarge it, pushing the thyroid isthmus or veins from before the course of the knife. If the opening be small, and be lost both to touch and sight, a second should at once be made, especially in urgent cases, and no time lost in searching for the first. This opening must be made directly in the median line, otherwise the canula will stand awry in the wound and be easily dislodged from its position in the trachea. If the first opening made is faulty in this respect, it is better to at once make a second. It may seem unnecessary to {157} warn the surgeon against thrusting his sharp-pointed bistoury too far inward at the moment of incising the trachea; but as a matter of fact it has been driven through both anterior and posterior walls, and even through the oesophagus, until it has struck the spine. The converse, or a too superficial incision, is an accident more likely to occur, the point of the knife not being made to penetrate the mucous membrane of the trachea, which is probably swollen and thickened. No relief in such cases follows the incision, and an attempt to introduce a tracheal tube may cause it to pass between the mucous membrane and tracheal walls into the submucous tissue, thus stopping up the tube as it progresses. The disastrous result of such an accident can readily be foreseen unless the complication be quickly appreciated as to its nature, the tube withdrawn, and the incision completed. Much more frequently will a somewhat similar accident occur in the operation of tracheotomy for croup or diphtheria. The pseudo-membrane overlying the walls of the air-passage is not penetrated, but pushed before the knife, which has properly incised the walls of the tube; the introduction of the canula now crowds this membrane still farther back toward the posterior tracheal wall, and a complete tracheal stenosis is added to the pre-existing laryngeal one; sudden and urgent dyspnoea follows, and prompt relief alone wards off fatal suffocation. Fortunately, in such instances the forcible efforts at respiration and struggles of the patient are often sufficient to break through the occluding membrane and allow the respiratory current to pass. Violent cough often follows, and more or less of the membrane is forced out through the tube. Should these events not come instantly to pass, the surgeon must not wait for the efforts of the patient, he being often cyanosed and unconscious at this point, but by passing an elastic catheter down through the tracheal tube break through the occluding membrane forcibly. The occurrence of such an accident is always denoted by absence of respiration through the canula and by alarming asphyxia, and its cause needs but little reflection to be appreciated.

Much the same train of events happens if during the introduction of the canula large portions of the false membrane are completely detached and drawn down into the lower trachea by the violent inspiratory efforts of the patient, or stripped up from the mucous membrane and pushed downward into the air-tube. No time should be lost in either case in removing the tracheal tube, dilating the tracheal wound by forceps or otherwise, and in endeavoring to clear the trachea by seizing the obstructing membrane with forceps. If this be unavailing, the suction-syringe must be adapted to the mouth of the canula and the trachea cleared by aspiration. A large elastic catheter may take the place of the canula. Sands recommends in such instances as the foregoing that another opening should be freely made below the first one in the trachea, when respiration will probably be re-established. The success of this procedure of course depends upon the depth to which the false membrane has been drawn in the trachea.

Schüller regards the moment at which the trachea is opened as the most important and most dangerous of the whole operation. Certain of the accidents which may occur at this period have been detailed; others remain to be spoken of, one of which at least--viz. hemorrhage--requires special mention. Even before the tube is cut into it may cause an important question to arise for the surgeon's decision. A bleeding, often copious and persistent, which arises during the course of the operation from the accidental or unavoidable wounding of the thyroid veins, especially when they are large and numerous, the patient unruly, and perhaps with a short fat neck, and the fact that having wounded one the blood flows so over the parts as to obscure and increase the chance of wounding others, constitutes one of the commonest difficulties met with in the operation of tracheotomy. Hemorrhage arising from a wound of the thyroid isthmus is much rarer, and neither, as a rule, need be {158} feared if due care and promptitude be exercised. But should it occur in a case in which the urgency of the dyspnoea allows of no time in which to employ the ordinary methods by ligature, torsion, pressure, or otherwise of checking it, shall the incision be made and the risk boldly incurred of blood passing to a dangerous degree into the trachea, and this in the face of the oft-repeated advice--the, in some quarters, absolutely given rule--that the trachea is never to be opened until all hemorrhage has ceased? I hold that it unquestionably should be, and that he who waits in many instances until the former moment will have to wait until his patient is dead. Durham truly says that it is useless to let the patient die from suffocation while attempting to prevent death from loss of blood; and yet this has been done.

In any case, then, where there is great venous congestion, marked venous bleeding, and little time, the patient being on the point of suffocation, the surgeon should carefully but boldly proceed and complete his operation in spite of the hemorrhage, opening the trachea and introducing the canula even though the entire field of his operation be obscured by blood. The tracheal opening once made under such circumstances, the patient, if the blood which enters the windpipe be not coughed up again, may be turned upon his face, so that the blood will gravitate toward the tracheal opening and the lips of the latter compressed about the rigid tube; or the blood may be aspirated from the trachea by means of the suction-syringe through an elastic catheter in the wound or the tracheotomy-tube by the operator's mouth, according to the urgency of the case. These measures answer for the slighter cases, but where the patient has suffered from urgent impending suffocation before the opening of the trachea, the entrance of the blood and its suction downward by the first inspiration may make it complete, and the danger is great. Still, the choice lies between the two evils, and the advice given above holds good. To the treatment there recommended will now have probably to be added artificial respiration and faradization. Comfort in any case may be taken in the fact that the re-establishment of respiration through the tracheotomy wound quickly relieves the pulmonary capillaries and the right heart of their distension, the venous circulation resumes its natural course, and the venous bleeding, perhaps alarmingly free, ceases almost immediately or is readily checked by pressure.

Where time is afforded and despatch in the operation is not a necessity, the trachea should not be opened until all hemorrhage has ceased. This, as a rule, is readily controlled by the usual measures, and in a large percentage of operations is not excessive. A direct fatal hemorrhage is very rare; likewise an arterial hemorrhage of any extent, especially if the possible anomalous position of certain arteries, such as the thyroidea ima, be borne in mind and care in making the incision exercised. Nothing but gross carelessness on the part of the surgeon and entire loss of presence of mind can account for the opening of the carotid or innominate arteries, as has been done. During the performance of the low operation of tracheotomy the finger of the operator must more or less frequently be pressed into the lower angle of the wound, and his anatomical sense constantly on the alert.

The entrance of air into a vein during the operation is a possible accident, especially when it is much enlarged and imbedded in dense tissue, as sometimes occurs in malignant disease of the throat or when large tumors of the parts exist. Should such an unfortunate complication occur, the proper treatment, according to Erichsen, should be compression of the wounded vein with the finger and its immediate ligation if possible; compression of the axillary and femoral arteries and a recumbent position for the patient to favor cerebral circulation; and, lastly, artificial respiration.

At the moment of opening the windpipe two conditions may suddenly {159} supervene, both of which need, as may usually be easily done, differentiation from the asphyxia produced by the entrance of blood into the trachea. The first of these is the apnoea which not unfrequently arises in children suffering from urgent dyspnoea the moment that a free opening is made and the air-stream rushes unimpeded into the lungs. The condition lasts but a moment or two, and need excite no alarm. The second is based upon the fact that the operation itself not seldom excites an alarming asphyxia, probably by provoking laryngeal spasm. The introduction of the tube serves to promptly relieve it.

Finally, I may refer to those rare but unfortunate and unpreventable cases where the introduction of a tracheotomy-tube after a carefully conducted operation fails to give relief. Such instances are reported by several authors, and depend upon the existence of some unascertained pathological lesion, such as the presence of a stricture of the trachea below the site of the operation, compression of this tube from without or a tumor within, stricture of the primary bronchi, or some similar condition. A careful preliminary examination and study of the case will in the majority of instances do much to fix the indications for the operation and perhaps account for the surgeon's failure.

The operation itself having been practically completed with the introduction of the canula, the after-treatment of the case now becomes the important consideration. This naturally varies in accordance with the accident or disease which has rendered the opening of the trachea necessary. In the instance of a foreign body lodged in either larynx or trachea the tube may at once be removed as soon as the former is removed or expelled. Indeed, the introduction of the tube is often unnecessary, as the offending article flies out through the wound as soon as the trachea is opened. The only contraindication would be to this rule when the foreign body is of a sharp and irritating character, and has been impacted in the larynx, especially of a child, and consequent inflammation and swelling of the parts may confidently be looked for. Should the operation have been called for on account of laryngeal or tracheal obstruction due to syphilis, both constitutional and local treatment are indicated, the latter varying with the special conditions presented, and being fully described in the section of this work treating of that subject. The patient not infrequently is obliged to wear the tracheal tube permanently. In croup and diphtheria the first efforts of the surgeon after introduction of the tube should be directed toward the removal of such shreds of the membrane as present through the tube or may be reached by forceps introduced through it into the air-passage. Large quantities may thus often be gotten away, to the manifest relief of the patient. A pseudo-membrane covering the vocal cords and causing glottic stenosis has thus also more than once been removed through the wound. A feather carefully passed through the tube into the trachea, by exciting cough and through its mechanical effects, is of assistance in promoting the expulsion of membrane lodged in the trachea below the wound. The use of an elastic catheter and aspirating syringe for the same purpose is advised by Roux and Hueter. In any case, constitutional treatment as well is indicated, and other measures--viz. the inhalation of steam, direct local applications, and the like--such as may meet the views of the particular operator.

Granted that the operation has been performed to meet the indication in cases of sudden and urgent dyspnoea arising from the passage of blood into the trachea or the accumulation of serous fluids in the lower air-passages, as well as in cases of dangerous intoxication from the effects of poisonous gases and narcotics, aspiration of the trachea in the former instances, followed by artificial respiration in all, and perhaps the catheterization of the trachea in the latter, as advised by several recent writers, will tax the surgeon's energies as the primary consideration after his operation. The catheter may be first used for the purpose of aspiration in the former cases, if {160} necessary, then for the injection of air, it here taking the place of the natural upper air-passages.

In cases of acute laryngeal oedema, certain chronic inflammatory processes, neoplasms in the larynx or trachea, and injuries or wounds of the air-passages, the proper treatment, aside from that of the necessary tracheotomy, will suggest itself on ordinary surgical principles, or is elsewhere specially treated of in this work in connection with the subjects themselves.

Aside from these special indications for after-treatment, which must be met as they arise, there are certain general rules for the management of any case after the tracheotomy-tube has once been inserted: they relate mainly to the care of the patient, the dressing of the wound, and the care of the canula.

A variable period of intense and exhausting suffering from dyspnoea having probably preceded the operation, the sooner the patient is allowed to seek refreshing sleep the better; and this may be allowed if there be no danger of hemorrhage. Nourishment of a fluid character and stimulants, if necessary, are to be allowed in quantities and at times dictated by good judgment. The patient's first attempts at swallowing must be watched and directed, as the fluids frequently pass in part for a short time into the larynx, and may appear at the tracheal wound. If the condition persist, it may be, no other apparent cause existing, because the tracheal tube is too long and presses on the posterior wall of the trachea, thus interfering with deglutition. For the first day or two at least a competent nurse must be in attendance, and the care of the tube entrusted, after explicit directions, to her. For the first twenty-four hours the secretions usually need to be constantly cleared from the mouth of the inner tube as they are coughed up by the patient, and the tube itself occasionally removed and thoroughly cleaned in carbolized water (or water to which a little borax or potash has been added) by means of a bristle brush, such as is used for cleaning pipes. As the case progresses, the secretions are not as profuse or annoying, and the patient learns to assist himself, in caring for his tube and to remove and replace the inner one. Attempts at using the voice are to be abstained from, and a slate or pencil and paper used until, if the case progress favorably, the third day, when he may be shown how to produce it by closing the outer fenestrated tube (the inner being removed) with the finger. The outer tube does not require usually to be removed, except in diphtheria, for cleansing until the third or the fourth day, prior to this it being done by means of a feather. The removal of the tube should always be done by the surgeon himself, and the occasional danger of its difficult reintroduction, caused by the swelling of the parts, not forgotten. At the same date, the wound sutures may be cut and removed. After its first removal the outer tube is taken out, cleansed, and replaced at each daily dressing, which consists in the washing of the wound with carbolized solutions, the application of adhesive strips, if necessary, across it after the sutures have been removed, and the insertion between the neck-plate or collar of the tracheotomy-tube and the skin, upon which it presses, of a layer of sheet lint covered by a little simple cerate or like dressing. The tapes attached to the canula for fastening it about the neck need changing, and care must be taken to regulate each day their degree of tension about the neck in proportion to the amount of inflammatory swelling attendant upon the wound through the soft parts overlying the trachea.

The patient, during, especially, the first few days after the opening into the trachea has been made, should be kept in a well-ventilated room with a uniform temperature. There is rarely any occasion, except in cases of croup and diphtheria, when it may be advisable, to envelop him in steam. Some surgeons place a small wad, two or three layers of gauze, wrung out frequently in hot water, over the mouth of the tube for the first day or two. A {161} large, coarse sponge answers the same purpose; and the precaution seems to me to be a good one, preventing, as it does, air of a low temperature from entering the lungs, and rendering it moist and free from adventitious particles. The difficulty is in keeping it in place.

The question as to the final removal of the canula is a difficult one to answer here, depending as it does upon the various causes for which the operation was originally performed. In certain cases, as will be seen from what has been said, its sojourn in the trachea will only be from a few moments to a few hours; while, on the other hand, in cases, for instance, of severe syphilitic disease of the larynx, with cicatricial stenosis of its cavity, the tube, once introduced, has to be worn during the lifetime of the patient. Between these extreme limits the period varies greatly. As a general rule--perhaps from the fourth or fifth day to the end of the first week--an attempt to cause the patient to breathe through the natural passages, the outer end of the outer fenestrated tracheal tube being closed, will partially succeed. Each day will now make success greater; the voice in part returns, and a period is soon reached when the outer tube may be closed with a cork (at first during the daytime only) and respiration carried on entirely through the larynx. The speedy removal of the tube and the closure of the tracheal wound then follow as a matter of course. I have never found it necessary to employ any of the various forms of after-treatment canulas, and believe them to be unnecessary. The original tube, preferably a fenestrated one, as heretofore described, is to be worn until convalescence is established, then permanently withdrawn.

The tube should be removed at the earliest safe and practicable moment. Its lengthened sojourn is not devoid of danger, as will be shown; and an atrophy of the laryngeal muscles, especially the abductors of the vocal cords, may follow their prolonged disuse, or at least inactivity, thus giving rise to a narrowing of the glottic opening perhaps inconsistent with respiration.

The wound, covered by granulation-tissue if the tracheotomy-tube has been worn for any length of time, quickly closes, when the latter is removed, and needs to ensure this but a few narrow strips of adhesive plaster to be passed across it and attached to the side of the neck, to prevent the air being forced out through it during the first day or two when the patient coughs or attempts to speak.

In cases where the tube has been worn for a long period, and the edges of the opening have firmly cicatrized, their freshening by the knife or scissors is a necessary preliminary to their being brought together by means of a suture or two.

The wound in the trachea closes not by the formation of a cartilaginous, but rather of a dense connective tissue, and the cicatrix is so smooth and small as to be with difficulty discernible. The cicatrix remaining externally upon the neck need be but slight and linear, and cause no disfigurement, especially if the wound have been properly treated and watched during the healing process.

Among the complications and accidents which may occur after a tracheotomy successfully performed,[5] none is commoner, and none, perhaps, is more to be feared, than the broncho-pneumonia which may develop at any time within the first three or four days, and especially in those cases where the operation has been rendered necessary by a diphtheritic inflammation of the throat or air-passages. Bronchitis is common when much blood has escaped into the trachea during the operation. The periodical and careful auscultation of the chest is therefore desirable, in order that the earliest physical signs of these morbid conditions may be detected.

[Footnote 5: See Parker, "On Some Complications of Tracheotomy, with Illustrative Cases," Lancet, Jan. 24, Jan. 31, and Feb. 7, 1885.]

{162} Secondary hemorrhage is rare: should it occur, the wound must be opened, enlarged if necessary, and the bleeding vessel sought for and secured. A slight hemorrhage may be checked by pressing the parts firmly about the tracheal tube and the use of styptics locally.

When the pathological condition of the parts has demanded that the canula be worn for a long time, and in cases where sufficient care has not been taken to select one suited to the age of the patient or to the particular form of operation that has been chosen, perhaps to the needs of the special case, an ulceration of the anterior or posterior wall of the trachea, the result of the pressure of the lower edge of the tube or of its upper posterior and convex side, may occur. Usually, it happens on the anterior wall, rarely on both, and the main trouble to which they give rise lies in the repeated hemorrhages that proceed from the laceration of granulation-tissue, in changing the canula, for instance, and the descent of the blood into the trachea and lungs. Cases of extensive ulceration, with erosion of the large vessels at the root of the neck, and fatal hemorrhage, have been reported. Considerable care should then be exercised in so adapting a canula to a special case that it will lie as free as possible within the lumen of the trachea. Ulceration of the tracheal walls, it is claimed, never occurs with the right-angled canula of Durham. Occasional change of form in the canula or the use of canulas with rounded extremities (perforated with numerous slits) is often advisable when the tube is worn for a length of time.

Another complication following the prolonged sojourn of a tracheal tube--rare, it is true--is the development of a mass of granulation-tissue, a veritable tumor, which may occlude the lumen of the trachea and lead to serious disturbances of respiration. The growth usually occurs about the inner edges of the tracheal wound, extending thence inward and upward or downward, as the case may be, and is most frequently met with, perhaps, after tracheotomies undertaken for diphtheria, although it may occur as a result of the ulcerations mentioned above, and develop even from the cicatrix in an old and perfectly-closed tracheotomy wound. The size of the mass, its location, and the amount and manner of its interference with the respiratory current vary much, but the condition must ever be regarded as a troublesome, even dangerous, one, and may always be suspected when attempts at the removal of the canula temporarily or permanently are followed by sudden and urgent dyspnoea.

The exuberant granulation-tissue which forms about the outer edges of even a recent tracheotomy wound, and occasionally renders the reintroduction of the tube difficult, as well as closing the wound while it is out, is a much simpler matter, and is easily remedied by cutting it away with the scissors or checking its formation by caustic applications.

A subcutaneous emphysema not infrequently occurs as the result of poor surgery and delay at the time of introducing the tube into the windpipe, or may come on later when the tube fits the tracheal wound incompletely. In either case it need excite no apprehension, and usually quickly subsides. Cervical cellulitis is a more serious matter, but is fortunately rare if unconnected with disease of the cartilages of larynx or trachea. It probably depends upon injury to the tissues and a too extensive opening up of the intermuscular strata at the time of the operation. Should the complication arise, the tendency to the burrowing of pus must be prevented by free drainage and, if necessary, incisions. The other surgical indications are to be treated on general principles.

When the incision necessary for the introduction of a tracheotomy-tube has been made through healthy tissue, necrosis of the cartilage in contact with the tube belongs to the rarest of the complications of the operation. The simple traumatic perichondritis set up by the operation shows no tendency to {163} eventuate in death of the parts. Equally rare is cicatricial contraction of the trachea as the direct result of the operation. That it may follow the healing of the extensive defects sometimes left by the syphilitic and other processes can readily be understood; and the same defects, involving as they occasionally do the loss of large amounts of tissue and destruction of important parts, may eventuate in the formation of an aërial fistula during or after the healing process is completed. The occurrence of such a fistulous opening as the result of a simple and uncomplicated tracheotomy wound could only be regarded as the evidence of unskilful surgery and after-treatment. The various plastic operations undertaken for the repair of such defects are described in the works on general surgery, notably in the able monograph of Schüller. Dislodgment of the canula out of the trachea as the result of an insufficiently long tube, or of neglect to fasten the tapes which hold it properly about the neck, so that it slips during coughing or the movements of the patient, is an accident which may not for the moment attract the attention of an inexperienced surgeon unless laryngeal dyspnoea is urgent. The patient breathes quietly, the air passing by the sides of the tube, which apparently is correctly placed. The simple test of ascertaining whether air be passing through the canula or not, or of making a trial whether the patient breathe as well when the finger closes the opening of the outer tube, as he will do if the tube is out of the trachea, will decide the question. Should the tube have slipped, it is of course at once to be replaced.

The breaking off of a portion of the inner canula, and the terminal piece falling down the trachea--several instances of which have been reported during recent years--is more apt to happen with the right-angled canula of Durham, the inner tube of which is necessarily made up of segments held by small rivets: these become in time loosened and the piece that they held detached. The outer tube of the hard-rubber canula also has become detached from its collar and dropped into the trachea. An occasional inspection of the condition of the tube is therefore desirable.

{164}

DISEASES OF THE BRONCHI.

BRONCHITIS, ACUTE AND CHRONIC; CATARRHAL; MECHANICAL; CAPILLARY; AND PSEUDO-MEMBRANOUS.

BY N. S. DAVIS, M.D., LL.D.

DEFINITION.--Inflammation of some part or of the whole of the mucous membrane lining the bronchial tubes between the bifurcation of the trachea and the alveoli or air-cells of the lungs. The inflammation may vary in grade from simple hyperæmia, with increased irritability, to the most intense engorgement, exudation, and tumefaction of the membrane, and in activity from the most acute and rapidly-progressive to the most chronic and protracted in duration.

SYNONYMS.--By the earlier writers the disease was called Peri-pneumonia notha, Angina bronchialis, and sometimes Erysipelas pulmonis. More recently it has been called Catarrhus suffocativus, Catarrhus pituitosus, Catarrhus bronchialis, Bronchial catarrh, and Bronchitis; Fr. Bronchite; Ger. Bronchialentzundung. Adopting the simple name of bronchitis, acute and chronic, in the further consideration of the subject I shall group the cases as they occur in general practice under the heads of Catarrhal, Mechanical, Capillary, and Pseudo-membranous Bronchitis.

HISTORY.--During all the earlier periods of medical history bronchitis was generally confounded with inflammation of the membrane lining the larynx and trachea on the one side, and with pneumonia and pulmonary phthisis on the other. Among the earliest writers who gave more accurate descriptions of bronchitis as a distinct disease were Badham, J. P. Frank, and Broussais, in the latter part of the eighteenth century. Full and accurate descriptions of the disease, differentiating it from inflammation of other parts of the respiratory organs, were not given, however, until the discovery of auscultation by Laennec, and its practical application aided by percussion to the physical examination of the chest. This important addition to the previous means for studying the exact location and extent of all diseases within the chest, and the largely increased attention given about the same time to the study of morbid anatomy, soon led to as accurate an appreciation of the existence and extent of disease in any part of the organs of respiration and circulation as in any of the structures of the human body.

ETIOLOGY.--The causes of bronchitis, like those of all other acute diseases, may be divided into two classes--namely, predisposing and exciting. The first embraces all those influences that are capable of rendering the mucous membrane of the air-passages more susceptible to impressions, whether by direct increase of the irritability of the structure or indirectly by altering the quality of the blood and the tone of the smaller blood-vessels. The second embraces such influences only as are capable of exciting a direct increase of irritability of the lining membrane of the bronchial tubes, with congestion of {165} blood in its capillaries. Among the most common predisposing causes may be mentioned age, sex, occupation or modes of life, and climatic influences. As a general rule, the several grades of bronchitis are more prevalent during childhood and old age than during the active period of adult life. The British Registrar-General's Report for 1868 contained 33,258 deaths attributed to bronchitis, being 1344 for every million of inhabitants. Of the whole number, 10,550 died during the first three years of life, and 18,485 over forty-five years of age, leaving only 4223 to occur between the ages of three and forty-five years. This, however, is very far from indicating correctly the relative prevalence of the disease at the different periods of life, for the reason that the disease is far more fatal both in early life and in old age than in the early and middle periods of adult life.[1] During the months of February, March, and April, 1882, in San Francisco, there were 65 deaths reported from bronchitis, of which 37 were of children under five years of age, 25 adults over forty years, and only 3 persons between five and forty years. During the same months there were reported 154 deaths from bronchitis in the city of Chicago, with about the same ratio in regard to age. In the city of Philadelphia, during the seven years from 1862 to 1869, the deaths from bronchitis at all periods of life aggregated 969, of which 495 were of children under five years of age, 14 over five and under fifteen years, and 460 of persons over fifteen years of age.[2] These and similar mortuary statistics have led to the very general adoption of the opinion that early childhood and old age are pre-eminently susceptible to attacks of bronchitis. Yet my own clinical observations and records relating to the time and number of acute and subacute cases of bronchitis coming under my own care lead to a very different conclusion. By reference to those records I find a larger number of cases occurring between the ages of ten and thirty years than at any other period of life. Thus, during the first six months of the present year (1882) I recorded 59 cases of primary bronchitis; that is, cases not arising secondarily as complications of other diseases. Of this number, only 5 were children under ten years of age, 38 between ten and thirty years, and 16 over forty. It is probable that similar results will be obtained by all who will take the trouble to record the whole number of cases, instead of simply the number of deaths. The statistics of mortality in relation to this disease are deceptive, not only in regard to relative susceptibility of the human system to attacks at the different periods of life, but also in regard to the ratio of mortality of the disease itself. It is generally conceded that the chief mortality from this disease occurs during infancy or early childhood and in old age, cases rarely terminating fatally in youth or the more active period of adult life. Careful examination of cases will show that this fatality at the extremes of life is owing mainly to the greater tendency of the inflammation at those periods to extend directly from the bronchioles into the lobules of the lungs, thereby complicating the bronchitis with lobular pneumonia; and in more than half the cases reported under the head of bronchitis the fatal result was caused by the pneumonia instead of the bronchitis.

[Footnote 1: See Reynolds's System of Medicine, Amer. ed., vol. ii. p. 318.]

[Footnote 2: See A Practical Treatise on the Diseases of Children, by J. F. Meigs, M.D., and William Pepper, M.D., 4th ed., p. 189.]

Neither recorded facts nor my own clinical observations show any decided difference in the susceptibility of the sexes to attacks of bronchial inflammation.

Those occupations which confine the parties pursuing them much indoors, and at a temperature either too warm or too cold, strongly predispose to attacks of inflammation of the membrane lining the respiratory passages. Habitual exposure to a warm, confined air invites free exhalation from both the bronchial and cutaneous surfaces, with increased susceptibility, and {166} consequently renders the individual more susceptible to all external impressions. Habitual passive exposure indoors to a low temperature represses the exhalations and causes the retention of some of the products of tissue-change which by their presence in the blood render the individual more liable to attacks of inflammation on the supervention of any exciting cause. For the same reasons the habitual wearing of too much warm clothing on the one hand, or too little on the other, predisposes to attacks of bronchial disease. Another error of importance is the unequal adjustment of clothing to different parts of the cutaneous surface. In children especially we often see an abundance of warm clothing over the whole body, while the legs and feet and neck have but a single covering, and sometimes none. And even adult women often go out loaded with warm clothing, while their feet and ankles are protected only by thin shoes and stockings. All those occupations that surround the workmen with an atmosphere filled with irritating gases, floating particles of stone, metal, or charcoal, or with the dust from grain and many vegetable substances, increase the liability of such workmen to attacks of all grades of bronchial inflammation.

It is universally conceded that bronchitis, as well as inflammation of all other parts of the mucous membrane lining the air-passages, prevails most in such countries as are characterized by a cold, damp, and variable climate. This can be well illustrated by comparing the prevalence of this class of diseases in that belt of our own country lying north of the fortieth parallel of latitude and east of the Rocky Mountains with the prevalence of the same class in the belt south of the thirty-third parallel and bordering upon the Atlantic and Gulf of Mexico. In the former the summers are comparatively short, with brief periods of high temperature, the winters cold, and the transition seasons, spring and autumn, long and exceedingly variable, with a predominance of cold and dampness. In the latter all the conditions just mentioned are substantially reversed. Perhaps the earliest reliable statistics we have bearing upon this subject are those collected by Samuel Forrey from the several military posts occupied by the United States Army, and given in a series of articles in the American Journal of Medical Science, and subsequently in an octavo volume, on the climate of the United States and its influence over the prevalence of diseases. The valuable facts presented by Forrey were added to by Daniel Drake, and given in full in his large work on the topography and diseases of the great interior valley of this continent. From these sources we learn that the average annual number of attacks of inflammation of the mucous membrane of the respiratory passages in every 1000 soldiers at Fort Snelling, in Minnesota, latitude 44° 53' N., was 600. At Fort King, fifty miles from the Gulf of Mexico, latitude 28° 58' N., the annual number of attacks average only 101.2 in every 1000 persons. Again, at Madison Barracks, near Sackett's Harbor, New York, the average number of attacks for every 1000 persons was 637.2, while at Key West, Florida, the average number of attacks was 208.9, and at Baton Rouge, Louisiana, only 207.2. Lest it should be thought that these five posts had been selected for the purpose of showing the most extreme contrasts, it may be added that Drake, after a laborious comparison of the statistics at all the military posts in the great interior valley from Fort Snelling at the north to Fort Jessup in Louisiana, the most southern, makes the "ratio of decrease in bronchial inflammations" as we pass from the north to the south as 31.5 for each degree of latitude.[3] A similar comparison of the statistics of all the posts on the Atlantic Slope from Madison Barracks to Key West gives nearly the same results. The general inference here drawn concerning the much greater prevalence of bronchitis in the colder and more variable climate of the northern belt of our country {167} than in the southern is fully corroborated by all the facts to be gathered from observations in civil life.

[Footnote 3: See A Systematic Treatise on the Principal Diseases of the Interior Valley of North America, etc., etc., 2d Series, pp. 795, 796.]

A study of these same military statistics, representing the mean ratio of the prevalence of diseases of the respiratory passages for a period of ten years at nearly all the posts, will justify some other inferences of interest besides the one just stated. According to this general inference or rule, which is assented to by all the authors within my reach, the three important factors in the climates most favorable for producing bronchial inflammation are cold, variableness, and dampness, the latter being emphasized by most writers as of predominating influence. Yet the tables before us show that the highest ratio of prevalence of inflammatory attacks of the mucous membrane of the respiratory passages in the northern part of the interior valley was at Fort Snelling, in the immediate vicinity of St. Paul, Minnesota, being 600 attacks for every 1000 soldiers, while the lowest ratio was at Fort Dearborn, on the site now occupied by the city of Chicago, being only 102 for every 1000 soldiers. Looking at the posts in the eastern part of the northern belt of country, Madison Barracks, at Sackett's Harbor, at the eastern end of Lake Ontario, gives a ratio of 637 attacks for every 1000 soldiers, while Fort Niagara, at the mouth of the Niagara River, near the western end of the same lake, gives a ratio of only 355. Again turning to the posts in the southern belt of country, the tables show at Fort Jessup, in the interior of Western Louisiana, a ratio of 432.8, while at Fort Jackson the ratio was only 47.5 and at Fort King 101.2. As Fort Snelling is on the high rolling prairie of the interior of Minnesota, noted for its cold and dry air, and Fort Jessup on the elevated arid plateau between the head-waters of the Sabine and the Red River, they cannot be noted for a high degree of atmospheric moisture. On the other hand, Fort Dearborn was located on the south-west shore of Lake Michigan, on the borders of a low and wet prairie with a substratum of impervious clay, giving all the conditions favorable for the prevalence of a high degree of atmospheric moisture. And Forts Jackson and King are both on low alluvial lands only fifty miles from the Gulf. Again, Fort Niagara is surrounded by all the conditions favoring a high degree of atmospheric moisture, certainly equal to those surrounding Madison Barracks in nearly the same latitude, and yet the ratio of attacks in the latter was nearly double those in the former. It is evident, therefore, that there exists some important factor in the climatic relations of the inflammatory affections of the respiratory passages besides temperature, humidity, and changeableness. A glance at the topography of the whole country will show that each of the posts giving a high ratio of attacks--namely, Madison Barracks and Forts Snelling and Jessup, to which may be added Forts Gratiot, Crawford, and Wood--are so located as to be exposed to the prevalence of unusually severe winds or atmospheric currents either from the north-east or the north-west and west, with certain relations either to high mountain-ranges or ocean-currents. For instance, from Madison Barracks the open valley of the St. Lawrence River extends in a north-easterly direction to the Atlantic Ocean, where the cold ocean-current is from the north, favoring the pressure of cold atmospheric currents directly up the valley from the north-east, reaching its termination at the eastern end of Lake Ontario with but little diminution of force. The mountains of Northern New York, Vermont, and New Hampshire seem to prevent the deflection of these currents to the south, and help to keep them directly in the line of the valley. That the high ratio of attacks of bronchial and catarrhal affections at Madison Barracks is largely due to the influences here described is corroborated by the fact that the same class of diseases are much more prevalent in the province of Quebec, through which the valley of the St. Lawrence extends, than in the province of Ontario, as shown by the Registrar-General's Report in reference to the several {168} military posts in the Canadas. Turning to Forts Snelling and Crawford at the north and Jessup at the south, we find them so situated in relation to the great mountain-chains to the west as to be fully exposed to the cold and strong atmospheric currents that sweep over the Plains from the north-west and west with such force as to justify the popular title of blizzards. Without consuming more time in details, it may be said that the force and direction of atmospheric currents have quite as much to do with the development of inflammations of the air-passages, including all grades of bronchitis, as either temperature or humidity.

As might be inferred from what has already been said in relation to the influence of climatic conditions, season of the year is also found to exert a marked influence over the prevalence of bronchial affections. Those parts of the year characterized by a low temperature, high winds, and frequent thermometric changes are accompanied by the highest ratio of prevalence of inflammations of the respiratory passages. Thus, the statistics compiled from the records of all the military posts by Drake show an average ratio for the four quarters of the calendar year of 119.8 for the first quarter, 72.7 for the second, 48.7 for the third, and 99.6 for the fourth.[4] This corresponds closely with the results of clinical records kept under my own observation through a series of years.

[Footnote 4: See Drake on the Principal Diseases of the Interior Valley of North America, p. 792.]

That tubercular deposits in the lungs, cancerous growths, emphysema, and previous attacks of bronchitis, all strongly predispose the patient to further attacks of the last-named disease, is proved by universal clinical experience.

EXCITING CAUSES.--Exposure to sudden and extreme changes in atmospheric temperature from warm to cold is almost universally regarded as the chief exciting cause of inflammation of the bronchial as of all other parts of the mucous membrane of the air-passages. More accurate and detailed observations, however, show that such changes of temperature are seldom productive of diseases of this class unless accompanied by coincident high winds and humidity. My own studies concerning the relations between special meteorological conditions and the prevalence of particular diseases have led me to the following conclusions in regard to bronchitis and inflammation of the mucous membrane of the air-passages generally:

First. Many sporadic cases are caused, at any and all seasons of the year, by exposure of limited portions of the cutaneous surface to cool or cold currents of air while the rest of the body is well protected. Females going out with thin shoes and stockings or sitting before open windows with low-necked dresses, and children out on cold days with naked legs from short trousers and defective stockings, afford many and familiar examples of bronchitis from this cause.

Second. The sudden transition from a protracted period of intense dry cold to a higher temperature with increased atmospheric humidity. Almost every winter season, in the northern belt of the United States, east of the Rocky Mountains, is characterized by several periods of steady dry, cold air, varying from one to three weeks in duration, during which the mercury in the thermometer often descends more than 20° C. (8-10° F.) below zero, and which generally ends in a sudden change in the direction of the winds and a marked elevation of temperature, constituting what is popularly called a thaw. Such changes are very uniformly accompanied by a general prevalence of catarrhal affections of the air-passages, including many cases of bronchitis. This class of cases occur principally in the months of December, January, and February.

Third. The occurrence of those cold north-east winds that during the latter part of autumn and early part of spring so often sweep over the whole extent of our Atlantic coast and press up the valley of the St. Lawrence to {169} the great interior lakes, and the still more severe currents that come during the same seasons from the north-west and west, over all the wide plains that intervene between the great mountain-chains to the west and the upper lakes and Mississippi River to the east, are also accompanied by a high ratio of prevalence of bronchial affections, as has been already shown from the records of the several military posts. Most of these severe storms of wind are accompanied by either snow or rain and a marked increase of ozone or active oxidizers. In some of the severe snowstorms from the north-east, occurring in the latter part of February and in March, I have found an unusual amount of free ammonia. Whether either the ozone or the ammonia has had anything to do with the production of the bronchitis cannot be determined until the observations and records now being made under the auspices of the American Medical Association have been continued for a few years, by which adequate data will be furnished for reliable deduction.

Besides ordinary meteorological conditions, bronchitis may be produced by inhaling irritating substances, such as steam, irritating gases, steel-dust, or minute particles of other metals or stone in workshops, and the dust encountered in handling grain, etc. The disease has often occurred in epidemic form without the presence of an obvious exciting cause. It also frequently occurs in connection with certain general fevers, more particularly with typhoid, measles, influenza, and pertussis. It also sometimes, though more rarely, accompanies rheumatism, constitutional syphilis, and erysipelas. The presence of tuberculous and cancerous deposits in the lungs almost always provokes more or less bronchial inflammation during some part of their progress.

Acute Bronchitis.

SYMPTOMATOLOGY.--The most common form of acute bronchitis, by many writers styled catarrhal bronchitis, acute bronchial catarrh, etc., presents considerable variety of symptoms, according to the extent of the membrane involved and the intensity of the inflammatory process. As a general rule, the disease commences with slight chilliness or unusual sensitiveness to slight changes of temperature, accompanied by a sense of soreness and oppression behind the sternum and sometimes across the whole chest, with a frequent and rather dry, harsh cough. In many cases there is during the first day or two coincident congestion of the membrane lining the nostrils, fauces, and larynx, causing sneezing, with some feeling of soreness in the throat and hoarseness, also a heavy dull pain in the head, much increased by coughing. By the second day a moderate general fever has supervened, characterized by dryness and moderate heat of the skin, flushed face, slight increased frequency and fulness of the pulse, more sense of oppression and soreness in the chest, with a continuance of harsh, dry cough, which often causes soreness in the epigastrium, radiating laterally in the direction of the attachments of the diaphragm to the inner surface of the ribs. On the second or third day the inflamed membrane begins to be less dry and the paroxysms of coughing bring up a scanty expectoration of a tenacious, somewhat frothy mucus, which gradually increases until about the fourth or fifth day, when it becomes more opaque, sometimes yellowish, and much more easily expectorated. At the same time that the expectoration changes to a more opaque condition, the general febrile symptoms begin gradually to abate, and the cough is accompanied by less sore pain both in the chest and head.

In the milder class of cases, the decline in all the general symptoms is so rapid that by the seventh or ninth day, convalescence is established. But in the more severe cases the more important symptoms may continue through {170} two weeks, and convalescence not be complete until the end of the third week. And in some of the cases the inflammation does not disappear on the subsidence of the febrile symptoms, but degenerates into a chronic form, causing a continuance of cough, with some muco-purulent expectoration and slight soreness in the chest, through an indefinite period of time. The disease is most likely to take this course when it occurs in young persons having a scrofulous diathesis, or in connection with eruptive fevers or pertussis, or in the aged afflicted with rheumatism.

During the active stage of ordinary cases of bronchitis the urinary secretion is diminished in quantity, redder than natural, and deficient in chloride of sodium, and the bowels are inactive. But after the crisis of the disease is passed, as indicated by the character of the expectoration, the renal and intestinal discharges soon return to their normal condition.

The results of auscultation and percussion in ordinary bronchitis, limited to the membrane lining the larger bronchial tubes, are mostly negative. In some instances during the first or dry stage, the respiratory or vesicular murmur may be slightly harsher or more dry than natural, and after the exudation or secretion of mucus, as indicated by expectoration, there may be some coarse, moist râles, which are removed temporarily by coughing, but return again in a little time. These râles are heard much more in cases occurring either in infancy or in old age than in youth or the middle period of adult life. Percussion elicits only the natural degree of resonance throughout the whole course of the disease, except in those rare cases in which complete occlusion of the bronchial tube has taken place, causing exclusion of air from certain lobules of the lungs, and consequently a shade of dulness on percussion over such lobules.

Mechanical Bronchitis.

By mechanical bronchitis is meant those cases in which the inflammation is caused by the direct action of mechanically irritating substances floating in the inspired air, as fine particles of steel and other metals, particles of stone, charcoal, and various vegetable powders and fungi. Such substances, when inhaled, are liable to impinge on the surface of the bronchial membrane and produce direct irritation and inflammation, both acute and chronic.

Cases originating from this class of causes differ from ordinary acute bronchitis chiefly in the mode of beginning and in the greater tendency to continue in the chronic form. Instead of slight rigors, coryza, and early development of moderate general fever, the patient generally complains first, and for several days, of a sense of tickling or fulness in the air-tubes, with occasional paroxysms of violent coughing and little expectoration. Sometimes particles of the foreign substance that is producing the inflammation may be seen mixed with the mucus or matter expectorated. In many of these cases there is much soreness in the chest and considerable dyspnoea, especially during the night, followed by severe coughing in the morning, and a more free discharge of mucus occasionally containing little streaks of blood, but which is never intimately intermixed with the sputa as in pneumonia. If the patient, by change of occupation or otherwise, ceases to be exposed to the further action of the exciting cause, the symptoms soon begin to abate, and a complete recovery may take place in from two to four weeks. If exposure to the further action of the exciting cause is not avoided, the disease will necessarily assume a chronic form, and in many cases produce such changes as to materially shorten the life of the patient.

{171} Capillary Bronchitis.

By this term is meant inflammation in the smaller bronchial tubes, but not necessarily involving the true bronchioles as they terminate in the air-cells. It may arise from all the causes that are capable of exciting inflammation in the larger and medium-sized tubes. It may occur at any period of life, but is most frequent in infancy and early childhood, and next in persons past the middle period of life.

The chief differences in the clinical history of this and ordinary catarrhal bronchitis arise from the greater obstruction to the ingress and egress of air through the inflamed tubes. The same degree of tumefaction of the membrane that occasions but little obstruction in the larger tubes is capable of completely obstructing many of the smaller ones, and thereby causing much dyspnoea and sense of oppression, with frequency of respiration, accompanied at first by an abundance of dry râles in all parts of the chest, followed later by the complete intermixture of dry sounds and moist submucous râles, the latter caused by more or less exudation or secretion of mucus from the inflamed mucous membrane. The addition of the tenacious mucous exudation to the previous tumefaction of the membrane, often so far obstructs the ingress of air to the air-cells of the lungs that the respirations become short, very frequent and noisy, with blueness of the lips, coldness of the extremities, drowsiness, and soon death from suffocation. This result, however, is seldom met with except in quite young children and in persons enfeebled by age or by previous disease.

In cases which do not thus tend to an early fatal result from the direct obstruction of the bronchi the respirations continue frequent, in young children sometimes reaching 50 or 60 respirations per minute, with much dyspnoea and restlessness; the pulse is quick, but not in proportion to the respirations; the expression of countenance is anxious and often slightly bloated, with a leaden hue of the prolabia; the wings of the nose expand and the chest heaves with each inspiration, giving a great variety of dry, whistling sounds generally throughout the whole chest, which after the first two or three days become mixed with sharply-defined submucous râles, and in the later stages give place to the latter entirely. The cough is frequent and inefficient, on account of the difficulty of getting sufficient air to make it satisfactory. The temperature varies from 38° to 39.5° C. (101-103° F.), seldom rising above the latter figure unless complicated with lobular pneumonia. The urine is generally scanty and deficient in the chlorine salts, and the bowels are inactive. The labored efforts of breathing in many cases make the upper and anterior part of the chest appear more prominent than natural, and even more resonant on percussion on account of temporary emphysema from over-distension of the air-cells in those parts, while in some parts of the lower and posterior portions there is less expansion and less resonance than natural from the occlusion of some of the bronchi and the partial obstruction of others leading to those parts of the lungs.

Between the third and fifth days usually the mucous exudation, which up to that time had been scanty and tenacious, becomes more abundant and more opaque, and in two or three days more assumes a distinct muco-purulent character and is much more easily expectorated. As that which comes from the smaller bronchial tubes is less mixed with air, and consequently less frothy than that which comes from the larger tubes, the two qualities of matter may often be recognized in the same mouthful of sputa; and if the whole be placed in water, that from the smaller tubes will drop lower in the water, or sink to the bottom if detached from the other, which floats freely upon the surface.

In acute cases, at the same time that the expectoration becomes more opaque and more easily dislodged by coughing, all the more important {172} symptoms begin slightly to improve, and by the end of the second week convalescence is fairly established. Many cases, however, are less acute, slower in progress, and do not reach convalescence in less than two or four weeks; and many of this class manifest a strong tendency to continue indefinitely in a chronic form, more especially in persons past the middle period of life. In some of the cases that do not continue in a chronic form, the bronchial membrane is left in a condition of such susceptibility that the attack is renewed on the slightest exposure to the exciting causes.

Rheumatic Bronchitis.

Although many systematic writers on practical medicine make no mention of this form of bronchitis except as a complication of general rheumatic fever, yet cases both of acute and chronic inflammation of the bronchi, of unmistakable rheumatic character, have so often come under my observation that I am constrained to recognize it as a distinct form of disease. In regard to the relative frequency of the occurrence of this class of cases, I find in a brief report concerning 965 cases of chronic pulmonary disease, read in the medical section of the American Medical Association by F. H. Davis in 1877,[5] the following classification of the cases:

Chronic catarrhal bronchitis . . . . . . . . . . . . . . . . . . 403 Chronic rheumatic bronchitis . . . . . . . . . . . . . . . . . . 283 Chronic bronchitis accompanied by gastric derangement and spasmodic dyspnoea . . . . . . . . . . . . . . . . . . . . . . 119 Chronic bronchitis, modified by syphilitic disease . . . . . . . 37 Hereditary pulmonary tuberculosis . . . . . . . . . . . . . . . 56 Inflammatory pulmonary phthisis . . . . . . . . . . . . . . . . 67 --- Total . . . . . . . . . . . . . . . . . . . . . . . . . . . 965

It will be seen that, of the 842 cases of chronic bronchitis included in the table, the writer classes 283, or a trifle more than 33 per cent., as of rheumatic character. That the relative proportion of acute cases of a distinct rheumatic character is less than those of a chronic grade I have no doubt, and yet their number is not so small as to be insignificant or unworthy of careful attention.

[Footnote 5: See Transactions of American Medical Association, vol. xxviii. p. 269, 1877.]

They differ in clinical history from ordinary acute bronchitis chiefly in the following particulars: Etiologically, a large proportion of them occur in persons of a rheumatic diathesis, either hereditary or acquired, and at those seasons of the year characterized by a predominance of cold and damp air with frequent changes of temperature.

Symptomatically, they are characterized from the beginning by more continuous dull pain in the chest, often extending to the attachments of the diaphragm, the shoulders, and the dorsal portion of the spine; by more persistent dry, harsh cough, often exhibiting a marked spasmodic character and accompanied by a great aggravation of the pains in different parts of the chest. When the smaller bronchi are involved the stage of dry râles is much more protracted, the dyspnoea and suffocative paroxysms of coughing more uniformly aggravated at night; and when mucous exudation does take place it remains scanty and viscid, rarely presenting a distinct muco-purulent character unless the case is protracted into a chronic form, and sometimes not then. During the active stage the urine is less in quantity and more decidedly acid in reaction than natural, and the bowels generally costive.

Spotted a typo or a problem in this chapter? Tell us

A system of practical medicine. By American authors. Vol. 3 (part 1 of 8)

Cite this passage

MLA

APA

Chicago

Opening