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 larynx2 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.
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. 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 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.