An examination of the lungs should be made in all cases of adductor paralysis, as this functional condition may be met with in early pulmonary tuberculosis.
Dysphagia.—Pain on swallowing, due to causes originating in the larynx, is usually associated with ulceration of the mucous membrane covering the epiglottis, ary-epiglottic folds, or arytenoid cartilages, that is, in connection with those parts with which the food is brought into direct contact.
The most frequent causes of such ulceration are tuberculosis, syphilis, and malignant disease. The differential diagnosis is often difficult from local inspection alone. The Wasserman test, the previous history, the state of the lungs and sputum, and the results of anti-syphilitic treatment may clear it up.
The treatment of dysphagia, apart from that of the disease associated with it, resolves itself into the use of local sedative applications, such as a weak cocain or eucain spray before meals, insufflations of acetate of morphin and boracic acid, and the use of a menthol spray. One of the best anæsthetic applications is orthoform powder, introduced by means of the ordinary laryngeal insufflator. Its action is more prolonged than that of any of the others, often lasting for from twenty-four to forty-eight hours.
Injection of the superior laryngeal nerve with a 60 per cent. solution of alcohol has been found satisfactory where other means have failed.
Interference with Respiration.—It is only necessary here to refer to such causes of interference with respiration as may call for surgical treatment.
The chief forms of laryngitis to be considered in connection with the production of dyspnœa, are membranous or diphtheritic laryngitis and acute inflammatory œdema.
Diphtheria of the larynx is described on p. 110, Volume I.
Acute Œdema of the Larynx.—Œdema of the larynx may be inflammatory or non-inflammatory in origin. The former is the more common, and may arise in connection with disease of the larynx, such as tuberculosis or syphilis, or it may be secondary to acute infective conditions at the base of the tongue, or in the fauces or pharynx; more rarely it results from infective conditions of the cellular tissue or glands of the neck. The non-inflammatory form may be a local dropsy in renal or cardiac disease, may be induced by pressure on the large cervical veins, and in some cases it appears to follow the administration of potassium iodide in the treatment of laryngeal affections.
The œdema consists of an exudation into the loose submucous areolar tissue, which may be of a simple serous character or may become sero-purulent. The situations mainly involved are the glosso-epiglottic fossæ between the base of the tongue and the epiglottis, the ary-epiglottic folds ([Fig. 287]), and the false cords. If the infective process commences in front of the epiglottis this structure becomes swollen and rigid, and often livid in colour—points which are readily discerned on examination with the mirror, or even without its aid in some cases. The patient complains of great pain on swallowing, and has the sensation of a foreign body in the throat. Should the œdema spread to the ary-epiglottic folds, either from the interior of the larynx or from the fauces and pharynx, dyspnœa becomes a prominent and grave symptom. The patient may rapidly become cyanosed, the inspirations assume a noisy, stridulous character, and great distress and imminent suffocation supervene. If laryngoscopic examination is possible, the ary-epiglottic folds may be found greatly swollen and the upper aperture of the larynx partly occluded. Digital examination may reveal the swollen condition of the parts. The urine should be examined for albumin and tube casts.