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. 1/3–½, 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 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.
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 they can be easily removed; while the histological condition of both the imbedded and the loose membrane is exactly the same.