RECORD OF MEDICAL SCIENCE.
PATHOLOGY AND PRACTICE OF MEDICINE.
Clinical Lecture on Laryngeal and Throat Affections, delivered at
King's College Hospital. By Robert B. Todd, M. D. F. K. S., Phy-
sician to the Hospital.
Gentlemen,—You have lately had the opportunity of observing two
cases, of the disease of the larynx, the other of an affection of the mu-
cous membrane of the fauces, which will enable me to bring these sub-
jects under your notice to-day.
Let me first remark, with respect to laryngeal diseases in general,
whether it be acute or chronic, that it is very much influenced by diathe-
sis, both in its origin and in its duration. This is very manifest in the
case of the strumous as well as of the gouty diathesis. Persons of
either of these forms of constitution, when once they have been attacked
with laryngeal inflammation, find it very difficult, sometimes, indeed, im-
possible, to shake off the disease.
One of the most formidable of the acute affections of the larynx, hap-
pily less frequently met with now than formerly, is the inflammatory
or membranous croup,—a disease which is characterised by the rapid
formation of a layer of coagulable lymph, forming a false membrane,
that moulds itself to the interior of the larynx, and will extend down
the trachea, whence it is sometimes called “ cynanche trachealis,” even
into the bronchial tubes. The pathology of this disease is not as yet by
any means settled; but it may, I think, be said, that the true mem-
branous croup is, of all laryngeal diseases, the least associated with pe-
culiarity of diathesis. Why it is in so marked a manner a disease of
childhood has received no explanation. We have in adult life a dis-
ease somewhat analogous to it, although affecting the pharyngeal rather
than the laryngeal membrane. I mean that disease which is accompanied
by a membranous exudation on the mucuous membrane of the velum
and back of the pharynx, which the French have designated diplitherite
—a malady in close alliance with erysipelas. Can it be that the cause
and the pathology of diplitherite and of croup are alike ? This subject
is one which demands careful investigation, and the more so as the re-
sults of our ordinary means of treating croup are far from being satis-
factory.
One of the most common forms of laryngeal disease is that which is
connected with the strumous or tubercular diathesis—this is also known
as laryngeal phthisis—it is usually associated .with tubercular deposits
iu the lungs. That form of cachexia which is induced by the syphilitic
poison will also often give rise to laryngeal disease, generally chronic,
but sometimes exhibiting very acute and urgent symptoms. These two
forms of chronic laryngeal disease may be confounded the one with the
other.
Erysipelas may affect the larynx, and give rise to the most serious
consequences. It is well known that the erysipelatous poison is very
prone to attack the mucous membrane of the fauces. From that the
erysipelas may spread either forwards through the nostrils to the face
and head, or backwards and downwards to the larynx. Erysipelas of the
larynx is apt to induce a rapidly cedematous condition of the submucous
areolar tissue, giving rise to that fearful malady, acute oedema of the
glottis, by which the chink, so important to life, is very quickly en-
croached upon, and the difficulties of a severe and rapid dyspnoea, super-
added to the depressing influence of the erysipelatous poison, speedily
destroy life.
To these affections I may add an inflammatory condition of a chronic
form, not destructive to life, nor to the tissues of the larynx. It is
a chronic inflammation of the mucous membrane, very often described
as a relaxed condition, with considerable enlargement of the mucous
follicles. This affection is often connected with the lythic or gouty dia-
thesis, and it likewise frequently occurs in debilitated states of the sys-
tem from various causes. It is sometimes associated with a peculiar
state of the nervous system, a form of hypochondriasis. That condi-
tion of throat which is so apt to occur in clergymen is of this kind.
I shall illustrate to-day the tubercular affection of the larynx, and
that relaxed condition of its mucous membrane to which I have last re-
ferred.
The first case which I shall bring under your notice affords a good
example of disease of the larynx occurring in the tubercular diathesis.
The subject of this affection was a girl of the name of Reynolds, in
Lonsdale Ward, (Vol. xxxiv., p. 160;) she was 18 years of age, and
of delicate health. The history of her case afforded abundant evidence
of the existence of phthsis in her family, as she had lost her mother and
one sister by this disease.
The affection from which she was suffering has been badly named
“laryngeal phthsis,” because the name would lead you to suppose that
the disease was limited to the larynx ; whereas, I believe, it never oc-
curs without the presence of tubercles in the lungs, either in the crude
or softened state. In some cases, the laryngeal symptoms are the first
to manifest themselves. A patient having indications of a phthisical
tendency, is found on inquiry, before any symptoms of tubercle had
manifested themselves, to have been the subject of frequent slight affec-
tions of the larynx, accompanied by hoarseness and cough, and attri-
buted to exposure to changes of temperature.
In other cases, the symptoms of phthisis develope themselves before
the laryngeal symptoms commence. In the present instance, however,
the affection of the larynx appeared first, and upon superficial examina-
tion at an early period, the diseases might have been viewed as one of
laryngitis simply.
The patient told us that, in November last, soon after exposure to
the wet and cold, she became troubled with a feeling of soreness about
the throat, which was followed by hoarseness and loss of voice, and, at
the same time, she became affected with a dry, suffocating cough, ac-
companied by severe pain in the region of the larnyx.
Pain referred to the larynx is one of the most constant symptoms of
the disease, and will rarely be found entirely absent. Usually the pain
causes great distress to the patient. The affection of voice varies ac-
cording to the scat of the disease. If the epiglottis and adjacent folds
of membrane only are involved, the voice will probably not suffer much ;
but, if the inflammation extend downwards, the affection of the voice
will vary in severity according to the extent to ■which the ventricles of
the larynx or the vocal cords are involved.
A symptom soon appeared in our patient which must always be re-
garded in a serious light; she became subject to difficulty of deglutition.
The report says, that she was quite unable to swallow any solid food,
and even the passage of liquids produced considerable pain, accompanied
by a choking sensation, and that the food was frequently forcibly ejected
from the mouth in the effort at deglutition, and that much of it passed
through the posterior nostrils.
Now, you may naturally ask, what has the larynx to do with degluti-
tion ; it is true that, in swallowing, provision is made to protect the glot-
tis, but how can disease of the larynx create dysphagia ? A very little
consideration of the close connexion existing between the pharynx and
the larynx, and also of the intimate relations of the nerves which sup-
ply both, will furnish the solution of this problem.
You know that the rima glottidis lies immediately behind and beneath
the root of the tongue, and that the epiglottis stands up between both,
and seems to protect and overhang the glottis. In deglutition, the root
of the tongue and the rima glottidis are forcibly compressed together,
and the epiglottis, lying between them, also suffers compression,
and is made thereby to cover the whole chink of the,glottis. This is
the mechanism by which, in deglutition, food is prevented passing into
the larynx ; this close apposition of the root of the tongue to the rima
glottidis serves to close the latter aperture completely, provided the
epiglottis retain its normal flexible and elastic state. But if the epi-
glottis be swollen or thickened, and rigid, or even simply highly sensitive
and irritable, as from ulcers on its surface, then, by its intervention,
that perfect apposition of the root of the tongue to the glottis is prevented,
on which perfect closure of the glottis, and, consequently, perfect deglu-
tition, depend.
The epiglottis may have been removed, as in Majendie’s experiments
and observations; and, provided no material injury have been done to
the neighboring textures, the apposition to which I allude may be effect-
ed, and the glottis protected. But it rarely happens, after chronic de-
structive disease of the epiglottis, that the neighboring textures have so
far escaped as to allow full play to the lingual and pharyngeal muscles,
so that they may perform freely, and without impediment, the actions
necessary for deglutition.
Disease of the larynx, then, gives rise to difficulty of deglutition, when
the epiglottis, or the arytaeno-epiglottidian folds of mucous membrane,
but especially the former, are involved in the disease. And the degree
of dysphagia is greatest when the epiglottis is swollen or so irritable that
the actions necessary for deglutition are impeded through a mechanical
obstacle, or through extreme sensibility of the surface of the mucous
membrane.
The nature of the dysphagia, in cases of this kind, deserves your at-
tention. It is not only often extremely painful, and. the actual effort of
swallowing difficult, but the whole act of deglutition is so deranged, that
the usual safeguards to the larynx below, and to the nares above, are
greatly interfered with. Hence, in many instances, and especially when
the epiglottis is rigid and swollen, the attempt to swallow is followed by
great irritation of the glottis and by a powerful expiratory effort, by
which the food or fluid is forcibly ejected upwards, partly through the
mouth, and partly, and most painfully,through the posterior nares. This
kind of inversion of the act of deglutition, when it frequently occurs,
and is associated with other signs of laryngeal disease, is always an
indication of a diseased state of the epiglottis. This feature, then, of
difficult deglutition necessarily directed our attention very much to the
state of the larynx in our patient.
But to proceed with the history of the case. Since the commence-
ment of her attack, she had lost flesh considerably, and had been trou-
bled with perspirations at night. She has frequently suffered from pain
between her shoulders, and her breath has been gradually becoming
more and more short. She never spat blood. As winter came on the
pain returned j she lost her voice, so that she was only able to speak in
a whisper, and her breathing became stridulous,— a symptom distinctly
pointing to the larynx either as primarily or secondarily diseased. This
symptom never disappeared; and while she was in the hospital, the noise
of her breathing was so loud and peculiar, that, upon coming into the
ward, your attention could not fail to be arrested by it. At the same
time she suffered from a troublesome hacking cough, accompanied with
the expectoration of a greenish muco purulent matter; her deglutition
became worse, and she was unable to swallow even very small quantities
of liquids or solids without considerable difficulty and pain.
The first question which proposed itself for our consideration, was
whether the laryngeal symptoms arose from the occurrence of certain
morbid changes in the larynx itself,—in fact, were dependent upon dis-
ease of the larynx,—or whether they were caused by the pressure of
some intrathoracic tumor on the left recurrent nerve. That pressure on
the recurrent is quite sufficient to give rise to such symptoms, has been
abundantly proved by cases of thoracic aneurism. The aneurisms which
usually produce such pressure are small, globular dilatations of the ves-
sel, occurring about the bifurcation of the trachea.
Some years ago, I recollect meeting with a case of this kind which
exhibited all the more prominent symptoms of chronic laryngitis. The
patient was brought into the ward just as I was leaving it after my
visit, and I had no opportunity of making a sufficiently minute exami-
nation of her at that time. There were great emaciation, stridulous
breathing, dyspnoea, with chronic cough, hoarseness, and pain referred to
the larynx. Unfortunately, the patient died very soon after her admis-
sion, and probably in consequence of exhaustion brought on by moving
her. At the post-mortem examination, we found an aneurism situated
just at the bifurcation of the trachea, and pressing upon the left recur-
rent nerve so forcibly as to cause complete obliteration of the nerve tu-
bercles ; hence there was complete paralysis of the muscles of the larynx
supplied by the nerve of this side, and they were found small, ill-nour-
ished, and shrivelled.
Some months ago we had a remarkable case in Rose Ward, as to the
precise nature of which we had some doubt. The man suffered from
symptoms clearly referrible to the trachea and larynx. He was troubled
with violent irritative cough, and the expectoration was tinged with
blood; but the voice was slightly affected, and the breathing was not
stridulous. The diagnosis lay between ulcerative disease of the trachea
and the existence of a small aneurism pressing on the recurrent nerve.
The patient died suddenly by haemorrhage; and a little above the bifur-
cation of the trachea we found a small perforating ulcer, which had in-
cidently been caused by the pressure of an aneurism of the arch of the
aorta against the trachea.
How, then, are we to make the diagnosis between actual laryngeal
disease and that deranged state of the larynx which stimulates inherent
disease of the organ, but which really depends upon the existence of an
irritating or paralysing cause at a distance from the larynx ?
To determine affirmatively the existence of inherent disease of the
larynx, you must not trust solely to the symptoms. Those symptoms
you will find to be impaired voice, breathing difficult and stridulous, and
the dyspnoea, although constant within certain limits, yet becoming
much exacerbated from time to time, pain referred to the larynx, and
more or less difficulty of swallowing. Now, all of those symptoms may
be caused by the pressure of an aneurism or other intrathoracic tumor
on the recurrent nerve.
You must add, therefore, to the examination of symptoms, inspection'
with the finger, which alone will often enable you to decide.—
With the forefinger of the right hand you will generally be able to reach
the epiglottis with great ease, and you may often feel its laryngeal sur-
face; the finger may be passed along the arytceno-epiglottidian folds,
and any thickened or roughened state of the mucous membrane covering
these parts can be readily felt. When the epiglottis is much thickened,
you will find it more or less rigid, with edges rounded, or it may be so
swollen as to appear like a small globular tumor between the tongue and
the larynx. If the mucous membrane covering the epiglottis be dis-
eased, the surface will feel uneven or rough, or it may be hollowed out
into small depressions, with irregular and perhaps callous edges. Gene-
rally, when the mucous membrane of the larynx is affected with chronic
inflammation, that of the fauces is often found to sympathize with it;
hence, upon looking into the mouth, you will often notice an injected
state of the mucous membrane covering the back of the mouth and
throat. When ulcers exist in the larynx there will usually be found a
certain amount of purulent expectoration, which may in part, however,
come from the lungs, if, as usually happens in cases of laryngeal phthisis,
these organs are also affected with tubercular deposit. On the other
hand, if the lungs be found perfectly healthy, it may be inferred that all
the secretion is derived from ulcers in the larynx, which is the case in
syphilitic ulceration uncomplicated with other disease. In tubercular
disease, expectoration is only met with in cases where the tubercles are
being softened and broken down. In the crude state, before the tuber-
cular deposit has undergone disintegration, there is no expectoration
whatever from the lungs.
If the laryngeal symptoms are caused by an intra-thoracic tumor,
there can be no difficulty in the diagnosis when there is a bulging or
prominence to be found in any part of the chest; but if the tumor be
small, and situated near the bifurcation of the trachea, considerable dif-
ficulty will often be experienced before any conclusion can be arrived at,
and in such cases the diagnosis will rest in a great degree upon negative
evidence. The absence of pain referred to the larynx, and the absence
of purulent secretion, will to a certain extent direct the attention to the
interior of the thorax for an explanation. The degree and kind of dys-
phagia will sometimes help you. Generally speaking, the dysphagia is
not nearly so great nor so prominent a symptom where there is intra-
thoracic tumor, as in cases of laryngeal disease; and it differs also in
kind. In the latter, the dysphagia is evidently obstructive, so to speak,
and the food is apt to go the wrong way; it sputters back into the
mouth and into the posterior nares; but in tumor cases there is a feeble-
ness and difficulty in using the pharyngeal muscles while the passage is
quite free and unobstructed.
The respiratory movements in aneurismal cases are more hurried and
otherwise impaired than when the larynx only is affected, although air
passes freely into the lungs, or the greater part of them. In laryngeal
cases the respiratory affection depends upon the amount of obstruction
which exists to the passage of air into the lungs, from the diminution
of the size of the glottis; and, in these cases, the dyspnoea arises from
the want of air. In these laryngeal cases, auscultation indicates feeble-
ness of breathing and faintness of respiratory murmur, which are uni-
form if there be no localised tubercular deposit. In intra-thoracic tu-
mor you may have general-rhonchus, accompanying a paroxysm of dysp-
noea ; or, if the tumor press on one bronchus more than another, the
ronchus will be greatest on that side, or the sounds of breathing most
feeble; it will be plain that less air gets into that lung than into its fel-
low. In the present case we had no difficulty in coming to a conclusion,
the tubercular diathesis being well marked both in the patient’s history, and
also by the presence of physical signs; moreover, the patient’s age was
against the presence of aneurism, and this is a point which will often
prove of valuable assistance to you in pronouncing an opinion, for
aneurism very seldom occurs before the age of thirty.
In our patient, it was a question at first whether the disease of the
larynx was syphilitic or tubercular. There was no history of syphilis
to be obtained from the girl herself, but this, as you may easily con-
ceive, could not be considered as conclusive against the syphilitic origin
of the malady. There were, however, no other marks or symptoms of
syphilis. However, there could be no doubt about the existence of tuber-
cle. Pthisis was traced in her family history, and the upper part of the
left side of chest yielded a dull sound to percussion, both in front and
behind. The breathing in this situation, although very feeble, was dis-
tinctly tubular, and there was, so far as the sign could be depended on in
a case where voice was at a minimum, increased resonance of voice. On
the right side, in the situation of the apex of the lung, there was ron-
chus and some crepitation.
From all these symptoms and signs we set the case down as one of
tubercular disease of the lungs, in which there was a chronic thickening
of the mucous membrane of the larynx and epiglottis, and probably
ulceration in or near the ventricles of the larynx, impending the move-
ments of the chordae vocalcs. Although in laryngeal cases the precise
seat of the disease may generally be most accurately assigned, we can-
not always predicate the particular nature of the affection, which may
sometimes be merely thickening, and sometimes ulceration of the mu-
cous membrane. I know of no definite sign which will enable us to
diagnose with certainty the presence of ulceration, but it exists in a
large number of cases of laryngeal disease connected with pulmonary
pthisis, and, if there be blood and pus in the sputa, it will probably be
always found. In tubercular ulceration, the ulcers appear to be formed
by the irritation and inflammation consequent upon the deposit of tu-
bercular matter in the follicles of the mucous membrane. At the same
time, Louis holds that laryngeal and tracheal ulcerations may be caused
simply by the irritation produced by the contact of the tubercular mat-
ter expectorated from the lungs, and I have more than once observed a
fact which certainly seems to bear out this explanation. I have found
crude tubercles in one lung, and softened tubercles in the opposite lung ;
the bronchus connected with the lung in which the tubercles were soft-
ened, exhibited an ulcerated state of the mucous membrane, while the
bronchus of the opposite side was entirely free from them, which, no
doubt, might be attributed to the passage of sputa along the one, and
not along the other.
In our patient we inferred the existence of crude tubercles in the
left lung, but we thought that in the apex of the right lung softening of
tubercles had taken place, and that possibly a small cavity might have
been formed. I thought that in this case the larynx was very likely af-
fected with aphthous ulcerations, in their nature very similar to those
aphthous ulcers which are so common on the tongue and fauces. The
mucous membrane of the epiglottis felt as if it were considerably
thickened, and no doubt the same condition prevailed in that covering
the lips of the glottis, so that the chink became in this way much nar-
rowed, and a considerable impediment was offered to the free entrance of
free air into the lungs. On the epiglottis I thought I could detect a
number of small ulcerations, more particularly on its laryngeal surface.
Such ulcerations would readily increase the difficulty of deglutition and
the pain which the girl suffered when anything passed over the epi-
glottis. The mucous membrane was so irritable, that when the patient
attempted to swallow liquids, a great quantity was often ejected through
the posterior nares.
The symptoms did not vary much in the further course of the case.
Treatment, as you would expect, was of very little use, and all that
we attempted to do was to uphold the strength with nourishing food,
and to relieve the distressing pain and irritability of the throat,
which prevented her from sleeping, by giving small doses of opium
at night.
Occasionally, to relieve the extreme irritability of the larynx, a
sponge, tied on a probang, and soaked in a strong solution of nitrate of
silver, was passed down to the larynx, so as to apply the solution well
to the epiglottis, and to allow some of it to trickle down into the glot-
tis. This application was always followed by considerable relief, as the
patient always expressed herself as much better after each application,
and her pain was relieved, although only temporarily.
The difficulty of swallowing and the dyspnoea increased in severity,
and the vomiting continued unabated, so that she was unable to take
much nourishment. The exhaustion increased, and, on the 25th, she
was attacked with convulsions, from which she never rallied.
In the upper lobe of the right lung, a cavity about the size of a
filbert was found, and was filled with pus. The remainder of the up-
per lobe, of the same lung, was infiltrated with tubercular matter. The
upper lobe of the left lung contained crude tubercles, so that tubercular
disease was not much advanced. We found numerous aphthous ulcera-
tions on the mucous membrane of the ventricles and cordse vocales, and
also upon the laryngeal surface of the epiglottis, and these ulcers you
may now see in the preparation. The mucous membrane covering the
epiglottis and upper part of the larynx was much thickened, and the
glottis very much contracted in size.
In reference to the frequency with which ulceration is met with in
different parts of the air passages, Louis states, that, out of seventy-one
cases, there were found thirty-one in which ulcers were found in the
trachea, twenty-two in which the larynx was similarly affected, and in
eighteen ulcers were found upon the epiglottis.
I shall now notice another case, which is more deserving of your at-
tention than the last, inasmuch as it is an example of a very common
affection of the fauces and larynx, and one which is curable, or at least
very manageable. The patient is a man named Osborne, in Sutherland
Ward. His symptoms area harsh, irritative cough, with slight mucous
expectoration, in quantity not at all proportionate to the violence of the
cough, and also a considerable degree of hoarseness of voice. Upon
looking into his mouth you find the mucous membrane of the faucial
region exhibiting a dusky red blush, and you will observe a number of
red points, as of raised papillae, which are the mucous glands of the
velum and back of the pharynx, in an enlarged and swollen state. The
appearance of the mucous membrane generally, was one of great laxity,
and the uvula was more or less elongated. In some cases the uvula is
so much increased in length that it reaches to the glottis, and excites
irritative cough. The inflammation upon which this state of mucous
membrane depends, never leads to the formation of pus or lymph. It
may, however, run into a slightly cedematous state, but this is rare; and
it is not always limited to the pharynx only, but often extends to the
larynx and trachea, and sometimes into one or more bronchial tubes.
This kind of inflammation is very common in men of gouty diathesis,
and in women of a relaxed habit who do not take proper care of their
health. Such persons you will often find complaining of being very
subject to attacks of hoarseness, and liable to catch cold upon the slightest
exposure, and even without any apparent cause. The hoarseness will
remain after the other symptomps^ of the cold have gone for a con-
siderable period, in spite of various forms of treatment adopted for the
cure, and it is accompanied with a troublesome cough which harasses
the patient very much. Persons laboring under such symptoms as these
are often treated for bronchitis, and take large quantities of expectorant
and other medicines for the relief of the cough. The seat of the irri-
tation upon which the cough depends is thought to be in the bronchial
tubes, and its real position (the fauces) is overlooked. On carefully ex-
amining a patient laboring under this affection, you will find the lungs
quite sound and the bronchial tubes free from irritation. Such being
the case, you next proceed to examine the fauces, and you find
the swollen, red, relaxed condition of membrane which I have de-
scribed.
The character and constituents of the cough will help you to dis-
tinguish this affection. It is a highly irritating cough; the patient
coughs with 'all his might to dislodge something which irritates the
fauces or the larynx and upper part of the trachea. The product of
the cough is very trifling, a little saliva and mucous, or throat and nasal
mucous, which in London is often mixed with sooty matter. The ex-
pectoration is in general infinitely small as compared with the vehemence
of the cough. Exposure to cold air always excites and greatly aggra-
vates the cough. The patient often complains that his cough is parti-
cularly troublesome on his first going to bed j this may be either from
change of temperature from warm to cold, or it may be caused by the
assumption of the horizontal position, when the uvula dropping upon
the glottis may excite cough.
Cases of this kind are most rife during the cold winter months,
and in the early spring, when the cold north or east winds prevail
so much.
With regard to our patient Osborne, he was a hard-working, indus-
trious man, with somewhat of the lithic acid diathesis. Three years ago
he was admitted into hospital with several small, hard tumors in the
tongue, each about the size of a marble, which excited our fears as re-
gards their malignant nature. We were not able to determine any very
satisfactory history of syphilis, but they disappeared very quickly under
iodide of potassium, and he got perfectly well. In the beginning of
this winter, however, he was attacked by cough, which he attributed to
exposure to cold. He had been working hard all day in a close room,
and in the evening was exposed to the cold air on his return home.
This soon brought on irritative cough, which was very obstinate, and
did not yield to the usual remedies. On carefully examining the chest,
we found no indications of bronchial irritation, but the fauces presented
the injected, swollen, relaxed condition of mucous membrane, with en-
larged mucous glands, which I have already described.
I treated him with the local application of the solution of ni-
trate of silver (£ss. to the 5j.) by means of a probang, which W’as
thrust behind the epiglottis, down to the glottis, on the plan of Dr.
Horace Green, of New York. The patient can always tell whether the
sponge enters the larynx or not, from the great irritation it excites when
it passes into the glottis; and in the withdrawal of it the operator
feels a certain resistance, caused by the sponge being grasped by the
muscles of the larynx, which resistance is not felt when it simply passes
into the oesophagus. To pass the sponge into the larynx requires a
good deal of steadiness and expertness on the part of the operator.
While I fully admit the feasibility of the operation, I nevertheless sus-
pect that the sponge may often pass simply into the oesophagus when it
is thought to enter the larynx.
The application was continued every morning for three weeks, either
to the glottis or to the neighboring mucous membrane; and partly, no
doubt, from this cause, and partly from his avoiding exposure to the
cold air, he left the hospital very much relieved, at the expiration of
that period.
This case affords a good example of that particular form of affection
of the mucous membrane of the throat and larynx which is not bene-
fitted by the administration of any drug whatever, but which almost
always is relieved by the local application of nitrate of silver, sulphate
of copper, or even of simply astringent substances.
This plan of treating affections of this kind has long been familiar
to practical men in this country, and was long ago practised very exten
sively by the late Mr. Vance, of this city. Dr. Green, of New York,
had the boldness to pass the sponge into the larynx, and to show that
such an operation was a less formidable one than was previously sup-
posed. It is, however, an operation not wholly free from danger, and
which is not attended with proportionately gcod results. I do not hesi-
tate to state this from considerable experience of it. In the vast ma-
jority of cases, quite as good effects may be obtained from applying the
solution to the neighboring mucous membrane. Pass the probang down
to the glottis, and swab well about its neighborhood, and you will do as
much good as if you passed the sponge into the rima glottidis; and
sometimes you will do more good and cause less irritation.
For some years past I have been in the habit of applying the solid
nitrate of silver to the mucous membrane of the fauces, the velum,
uvula, and the pillars of the palate; and it may be brought very near
to the laryngeal membrane by sliding the caustic along the posterior
pillars of the palate, some way down. By this treatment you may ob-
tain results quite as satisfactory as by pushing the probang into the glot-
tis, and in many instances more so; and the plan is, I think, on the
whole, safer and more manageable.
I have been supplied by Mr. Matthews, the surgical instrument-
maker of Portugal street, with a modification of the ordinary porte-caus-
tique, which is very useful for applying nitrate of silver to the throat.
The caustic is placed in a case made of platina; this moves on a ball-
and-socket joint, and may, by that means, be fixed at any angle. Its
handle is constructed in telescope fashion, and may be drawn out to any
length that can be required; so that, by its aid, you may apply the
caustic very low down.
But in the application of nitrate of silver a great deal of caution is
necessary. You must take great care not to apply it too freely, else you
may cause too much inflammation and ulceration. In some cases, in-
deed, it is impossible to avoid these consequences; but, with due care,
you need never find them so much as to be troublesome, and very often
they are salutary. I always make the patient use the precaution of
gargling his throat very frequently with the coldest water—iced water
if it can be had—for some hours after the application of the caustic;
and by these means inflammation is limited, and the parts strength-
ened.
If time permitted, I could tell you of numerous instances of coughs
of the most troublesome kind, and of long duration, which had resisted
all the ordinary cough medicines, and yielded to three or four applica-
tions of nitrate of silver.—Lon. Med. Times and Gaz.