in strength, and occasionally there is complete aphonia. Frequently these symptoms, after having continued for a short time, gradually subside; if not, the mucous membrane, particularly in the upper part of the larynx, becomes thickened and considerably softened in texture, with effusion of serous fluid in the subjacent cellular tissue, and apparently in the substance of the membrane itself. In consequence of such effusion, the difficulty of breathing is much increased. Occasionally lymph is effused on the surface of the membrane; but this is seldom met with, and when it does take place, is generally confined to the upper part of the larynx. The larynx and trachea of an old lady of seventy years is here shown, with very extensive false membranes blocking up the bronchi; a large portion besides was coughed up. The specimen, a rare one, is in my collection.
The effusion of serum is often abundant, causing protrusion of the mucous membrane, and narrowing of the canal; and when it is limited to the upper part of the larynx, as frequently happens, the disease is termed Œdema Glottidis. In this affection, the majority of the symptoms, which have been already enumerated as attendant on laryngitis, are all present, and in an aggravated form. Inspiration is extremely difficult and sibilant, and occasionally the patient experiences a sensation, as if a foreign body were lodged in the passage, and had changed its position on the muscles of the part being put in motion. The symptoms of œdema come on gradually in some cases, in others with alarming rapidity. They often follow ulcerations of the soft palate, and of the root of the tongue, as shown in treating of diseases of that organ, occurring on the patient being exposed to cold or moisture, or supervening rapidly when discharge from the ulcerations is by any accident suddenly suppressed. The difficult breathing, with cough and violent attempts at expectoration, takes place in paroxysms, and often to so alarming a degree as to threaten immediate suffocation, especially during the night. The patient, if he has fallen asleep, often starts up suddenly, and catches at the nearest object, having dreamed probably of drowning or strangulation. Deglutition is seriously impeded, the strength is exhausted, the body is emaciated, the features become contracted, and evince great anxiety. As already stated, the serous effusion is chiefly situated in the upper part of the larynx, particularly on the lips of the glottis, and on the inferior surface of the epiglottis; and on introducing the finger, a soft swelling can be felt beneath this cartilage. Perhaps the following sketch exhibits the most complete instance of œdematous swelling of the rima glottidis to be found in collections of morbid anatomy. The patient was brought to the Royal Infirmary labouring under all the symptoms of the disease in
a very aggravated form. Tracheotomy was performed without delay, and with instant relief. The patient fell into a quiet and profound sleep, which lasted for six or seven hours. He started up suddenly and fell down dead; probably the end of the tube had become obstructed by mucus. It is scarcely to be supposed that the patient could have breathed at all with such a state of parts at the top of the air-tube, as here represented. Could any of the swelling have come on in the interval betwixt the performance of the operation and his sudden death? In some instances, the disease rapidly proceeds to a fatal termination, the glottis being speedily and entirely shut by the swelling; in others, the patient lingers for weeks, or even months.
Depletion, local and general, especially the former, if employed on the first appearance of the inflammatory symptoms, will often arrest their progress; but if practised at a more advanced period, it can be productive of no benefit, and if any advantage does follow, it is merely temporary. Sometimes considerable benefit will be derived from the use of blisters, or from the unguentum tartritis antimonii being rubbed on the sides of the neck and over the larynx, so as to produce an eruption of numerous pustules. When all hopes of procuring resolution have passed, and when the urgent symptoms occasionally threatening suffocation supervene, tracheotomy should be performed without delay; and it ought to be borne in mind, that the more early this operation is resorted to, the greater is the chance of success. It has been repeatedly stated, that the disease is confined to the larynx, and, in most instances, to the upper part of it; so that, by making an opening in the windpipe below the thyroid gland, the disease is situated above the incision, the patient breathes through a canal which is in its healthy state, the affected parts are set at rest, and from their remaining comparatively motionless the disease often subsides spontaneously; if not, the various applications to the parts can be employed much more successfully than before; for when the parts remain subject to constant irritation from the movements necessary for respiration and nutrition, all medicines and all topical applications are generally productive of little or no benefit. But if the incision be made into the crico-thyroid membrane, we shall, in most instances, cut into the very middle of the disease; at any rate, the affected parts can be at no great distance from the incision, and the irritation of the tube will be a sufficient cause to excite inflammatory action in parts contiguous to the original disease, and already disposed to assume a similar action; thus the disease may be extended. I have performed tracheotomy on a very considerable number of patients afflicted with œdema glottidis, and I may say, with almost uniform success. The disease was speedily subdued, and in most of them there was no great difficulty in closing the artificial aperture, and restoring natural respiration. The relief afforded by the operation is almost instantaneous; the performance of it, if skilful, is attended with no danger; and want of success will generally be found to proceed from its having been too long delayed.
In consequence of laryngitis, or of long-continued irritation in the neighbourhood, the mucous membrane becomes indurated, and subsequently ulcerates; or ulceration may extend from the fauces. In some cases, the ulcers of the larynx are few, and of slight extent; in others, they are more numerous, and of considerable width and depth; and in some there is extensive and uninterrupted destruction of the surface, surrounded by thickened and elevated mucous membrane. This disease is termed Phthisis Laryngea. It is characterised by constant tickling cough with expectoration of purulent matter; by pain in the region of the larynx increased on pressure; by great prostration of strength, with general sinking of the vital powers, and frequently by hectic fever. From extension of the ulceration, the vocal chords, the ventricles of the larynx, and the mucous folds forming the rima glottidis, are more or less injured, and frequently altogether obliterated; partial or complete aphonia is the consequence. In phthisis laryngea, especially when advanced, swelling from serous effusion, to a greater or less degree, almost certainly supervenes, the œdema is found in the upper surface of the epiglottis, beneath the mucous membrane, upper and forepart of the pharynx, and occasionally also in the lips of the glottis,—an effect of the contiguous ulceration,—in the same way as œdema glottidis supervenes on ulceration of the lining membrane of fauces and pharynx; the usual train of symptoms denoting phthisis laryngea may thus be interrupted by those of œdema of the glottis becoming (each paroxysm) more and more urgent, terminating in suffocation or relieved by tracheotomy.
From the reasons which have been already stated, inspiration is performed with difficulty, and accompanied with a wheezing and rattling sound, resembling the passage of air through a narrow aperture lined with viscid fluid. Deglutition is difficult; and, from the inactive state of the muscles which naturally close the glottis during swallowing, and from the greater or less destruction of the epiglottis, a portion of the fluid taken by the mouth escapes into the windpipe, produces violent coughing, and is ejected by the mouth or nostrils. As the disease advances, the lungs become affected, the patient is incapacitated for ordinary exertion by the dyspnœa which ensues, he grows weak and languid, and seems, in fact, to labour under phthisis pulmonalis. Not unfrequently the two diseases are combined; but, in the majority of cases, the affection of the lungs supervenes on that of the larynx. Ulcers with tubercular bases are very frequent about the ventricles of the larynx in subjects dead of pulmonary phthisis. The chordæ vocales are thus often exposed. The affection of the lungs is perhaps attributable to frequent and harassing cough, occasioned by the state of the larynx and ejection of profuse vitiated secretions.
When the ulceration extends deeply, portions of the cartilages sometimes become diseased; the soft parts surrounding them are destroyed, they become necrosed, and are expectorated along with a quantity of highly fetid purulent fluid. In some instances, the expectorated portions are osseous, of loose texture, irregular margins, and dark colour, exhaling an odour intolerably fetid. It sometimes happens that the ulcerations proceed still more deeply, perforating the parietes of the canal, and establishing a communication betwixt the windpipe and gullet; or, if the perforation is anteriorly, the communication is with the cellular tissue on the forepart of the neck, abscess forms which may attain a large size and be productive of much inconvenience and danger.