ACUTE EDEMA OF THE LARYNX, WITH THE 
REPORT OF A CASE RESULTING 
FROM PYEMIA. 
BY 
J. H. BRYAN, M.D., 
OF WASHINGTON, D. C., 
LATE PASSED ASSISTANT SURGEON U. S. NAVY J LECTURER ON DISEASES 
OF THE NOSE AND THROAT IN THE MEDICAL DEPARTMENT 
OF THE COLUMBIAN UNIVERSITY *, SURGEON TO 
THE THROAT DEPARTMENT, GARFIELD 
MEMORIAL HOSPITAL. 
FROM 
THE MEDICAL NEWS, 
February 6, 1892. [Reprinted from The Medical News, February 6, xSg.J 
ACUTE EDEMA OF THE LARYNX, WITH THE 
REPORT OF A CASE RESULTING 
FROM PYEMIA} 
OF WASHINGTON, D. C., 
LATE PASSED ASSISTANT SURGEON U. S. NAVY ; LECTURER ON DISEASES 
OF THE NOSE AND THROAT IN THE MEDICAL DEPARTMENT 
OF THE COLUMBIAN UNIVERSITY ; SURGEON TO 
THE THROAT DEPARTMENT, GARFIELD 
MEMORIAL HOSPITAL. 
J. H. BRYAN, M.D., 
The importance and rarity of acute edema of the 
larynx justifies me in calling attention to an inter- 
esting case of this affection that recently occurred 
in my practice : 
On February 2, 1891, I was called in consultation 
with Dr. C. V. Boarman, of Washington, to see the 
patient, G. S., aged thirty years, a fish-dealer by 
occupation, and a man of strong physique. Upon 
entering his room I found him breathing rapidly 
and with great difficulty, but there was no audible 
stridor. The man’s face was flushed and presented 
an anxious expression ; the voice was husky, with a 
peculiar metallic quality; deglutition was painful 
and difficult. There was some swelling of the neck, 
and over the left thyroid gland there was an en- 
1 Candidate’s thesis presented to and accepted by the Council 
for membership in the American Laryngological Association at 
its Thirteenth Annual Congress, September 13, 1891. 2 
BK YAN, 
largement, about the size of a pigeon’s egg, which 
was very painful on pressure. He expectorated a 
thick purulent secretion, the expulsion of which 
was attended by sharp, lancinating pain. 
On examination of the throat, there was observed 
a slight redness of the posterior wall of the pharynx 
and of the fauces; but the parts could not be said 
to be the seat of active inflammation. By means of 
the laryngeal mirror, I found the epiglottis to be 
enormously swollen and very red, projecting from 
the base of the tongue over the laryngeal cavity, so 
that the interior of this could not be seen. Lying 
on either side of the swollen epiglottis, between it 
and the lateral walls of the pharynx, was thick, 
purulent secretion. 
As the necessity for relief of the impending suffo- 
cation was so urgent, without further questioning 
the patient, I freely scarified the epiglottis with the 
laryngeal lancet. Each incision was followed by a 
discharge of blood and pus, and to encourage the dis- 
charge the patient was directed to gargle with warm 
water. In a short while, he expressed himself as 
feeling very much relieved, although I unable 
to detect any diminution in the swelling of the epi- 
glottis. Ice was applied externally, and the man 
was directed to swallow cracked ice frequently. In 
less than two hours the patient was again seen, and 
found in a state of great excitement, as he felt 
worse, and the dyspnea seemed to be increasing. 
Examination showed the epiglottis still to be 
greatly swollen. I scarified again, making deeper 
incisions than before. The flow of blood was not 
very profuse, but the patient was able to expecto- 
rate more freely, the expectoration still being thick 
and purulent. This gave him more relief than he 
experienced from the first scarification, and the 
swelling was perceptibly lessened. Ice internally ACUTE EDEMA OF THE LARYNX. 
3 
and externally was continued during the night. On 
the following morning, the patient was somewhat 
improved as to breathing and deglutition, but the 
voice was about the same. The epiglottis was found 
to be still very much swollen—so much so that the 
interior of the larynx could still not be seen. Scari- 
fication with deep incisions was again practised. 
At the Garfield Hospital, whither the patient was 
now sent, the following history was obtained : 
He had had frequent attacks of sore-throat, but 
they were always mild in character, lasting only a 
few days. For the past three years he had led a 
very intemperate life, and on one occasion was con- 
fined in an inebriate-asylum. He had never had 
syphilis, but several years previously he had a small 
venereal ulcer on the prepuce, which healed in a 
few days; no constitutional symptoms have ever 
developed. On the 9th of November, he contracted 
gonorrhea, for which he was treated by internal 
medication; but the discharge, while becoming 
less, never entirely ceased. On January 9th, he 
consulted a prominent surgeon, who, in addition to 
prescribing internal medication, passed a sound for 
the relief of a deep-seated stricture. The sound 
was passed for the second time, January 26th, and 
that night he had a severe chill; feeling ill on the 
following day, he took a Turkish bath, but without 
experiencing any relief. He continued to feel 
somewhat ill, with occasional chilly sensations, until 
February Ist, when he experienced a severe pain in 
the larynx, attended with great difficulty in breath- 
ing. About the same time he noticed that his neck 
was swollen. These symptoms increased in intensity 
until I saw him on the following day, and found the 
condition that I have already described. 
February 3—the day of admission to the hos- 
pital : His temperature was 103° ; pulse, 106 ; respi- 4 
BRYAN, 
rations, 30. There was a slight purulent discharge 
from the urethra. Examination of the urine re- 
vealed nothing abnormal, save a large number of 
pus-cells. I continued ice internally and externally; 
gave y grain of muriate of pilocarpine hypoder- 
matically, and kept water impregnated with the 
compound tincture of benzoin boiling in the room. 
4th, 8 a.m. The temperature was gg%° ; pulse, 963 
respirations, 30. Noon, temperature, 
108 ; respirations, 36. At BP. M., temperature, io3-|-0; 
pulse, 112; respirations, 42. 
The patient was res'less and did not sleep during 
the night; breathing was easier; the voice was not 
so hoarse; he was still expectorating a purulent 
secretion ; the swelling of the neck was subsiding. 
Examination with the mirror showed a marked sub- 
sidence of the swelling of the epiglottis. In the 
evening the man complained of severe pain in the 
epigastric region and at the lower border of the left 
lung. The treatment of the previous day was con- 
tinued, and in addition 3 grains of salol were given 
every three hours. 
sth, 8 a.m. Temperature, io3^°; pulse, 108; 
respirations, 48. Noon, temperature, io3|-0 ; pulse, 
102; respirations, 44. At 8 p.m., the temperature 
was io2|°; pulse, 112; respirations, 48. 
The pain at the lower border of the left lung 
continues. Examination reveals a diminution of 
the respiratory murmur over the lower part of the 
left lung, both anteriorly and posteriorly. No 
rales and no dulness on percussion are detected; 
the patient complains of pain and numbness in the 
left arm. The swelling of the neck has entirely 
disappeared; the swelling of the epiglottis has sub- 
sided, and for the first time the arytenoid cartilages 
and the ary-epiglottic folds are visible. The whole 
larynx is intensely red, the congestion extending as ACUTE EDEMA OF THE LARYNX. 
5 
far down the trachea as can be seen. There is no 
indication of an abscess at the base of the tongue; 
the expectoration has ceased, and there is no pain 
on pressure over the larynx. The salol and ice were 
discontinued, and 3 grains of quinine were given 
every three hours; and the larynx was sprayed with 
a solution of tannin (gr. xx ad )at similar intervals. 
6th, 8 am. Temperature, roif0; pulse, 118; 
respirations, 44. Noon, temperature, io2-|°; pulse, 
116; respirations, 52. 8 p.m., temperature, ioi|-0; 
pulse, 114; respirations, 52. A pronounced jaun- 
dice appeared this morning. The treatment of 
yesterday was continued, with the addition of tr. 
ferri chloridi, gtt. xx, every three hours. 
7th, 8 a.m. Temperature, ioo|°; pulse, 120; 
respirations, 50. Noon, temperature, ro2-|-0; pulse, 
120, respirations, 40. 8 p.m., temperature, ioo|°; 
pulse, 122; respirations, 46. Jaundice still con- 
tinues ; the patient complains of pain in the left 
hypogastric region. Percussion shows no increase 
in the area of hepatic dulness, and there is no sensi- 
tiveness on pressure. 
Bth, 8 a.m. Temperature, ioo|°; pulse, 120; 
respirations, 50. Noon, temperature, 102^; pulse, 
120; respirations, 50. 8 p.m., temperature, ioo-|0; 
pulse, 124; respirations, 50. The patient is very 
restless and weak ; jaundice is not so marked ; there 
is incessant cough, but no expectoration. Exami- 
nation of the larynx shows no subsidence of the 
congestion, and there is little or no secretion in the 
larynx and trachea. About 9 o’clock on thia even- 
ing, the patient complained of intense pain in the 
left hypogastric region, and suddenly cried out 
that “something had given way internally.” I 
saw him at about 9.30, and found the abdomen 
somewhat distended and painful; the skin bathed 
in cold perspiration ; the pulse feeble and scarcely 6 
BRYAN, 
to be counted. He did not rally from this condi- 
tion, and died at 1.30 A. M., death resulting proba- 
bly from the rupture of an abscess of the liver. 
It was unfortunate that a post-mortem exami- 
nation could not be obtained, so that the diagnosis 
could be verified. 
It is possible that the disease commenced as a 
primary erysipelas of the larynx, to which the 
pyemia was secondary. I think, however, that the 
history of the case points more forcibly to the 
urethra being the source of the infection that 
caused the blood-poisoning, with a secondary phleg- 
monous laryngitis. 
The history of acute edema of the larynx dates 
from 1765, when Morgagni1 found, upon post- 
mortem examination, a serous infiltration of the 
mucous membrane of the soft palate, fauces, and 
larynx. It was not, however, until 1808, when 
Bayle2 read his remarkable essay before the School 
of Medicine of Paris, that this disease received a 
place in pathology. He unfortunately gave it the 
name of edema of the glottis, which term we fre- 
quently find applied to cases of edema of the larynx 
even at this late period. After Bayle came Tuilier,3 
who in his thesis describes the symptoms of edema- 
tous laryngitis, and states that the fluid is either 
serous or sero-purulent. He was the first to estab- 
lish by means of a digital examination the existence 
of cushions or pads caused by the swelling of the 
ary-epiglottic folds. 
1 De Sedibus et Causis Morborum. 
2 “ Mem sur I’CEd&me de la Glotte,” Journ. de Med. de Paris, 
1819. 
3 Essai sur I’Angine Laryngee CEdemateuse. Paris, 1815. ACUTE EDEMA OF THE LARYNX. 
7 
Finaz de Seisel,1 was the first to suggest the passage 
of an elastic catheter into the larynx for the preven- 
tion of suffocation from edema of the larynx. It 
does not appear, however, that he ever performed 
this operation himself, but he had often seen it prac- 
tised by Desault. Numerous memoirs appeared after 
those of Bayle and Tuilier, but it was Bouillard2 that 
recognized the inflammatory nrture of the disease. 
He reported three cases, in each of which the edema 
was of the secondary variety. Cruveilhier* also 
recognized the inflammatory nature of the affection, 
and gave it the name of submucous laryngitis. He 
divided the disease into supra-glottic and infra- 
glottic edema. In 1852, Sestier4 wrote his elaborate 
treatise on edema of the larynx, and collected the 
surprising number of 245 cases. From these he 
compiled his statistical results, which have been 
made use of in every important communication on 
the subject since that time. In 1862, Mandl5 
studied chronic edema of the larynx with the aid 
of the laryngoscope, and recognized the ary-epi- 
glottic folds transformed into glistening cushions. 
This was the first communication on the subject 
after the introduction of the laryngoscope. 
Acute edema of the larynx may arise quite inde- 
pendently of any inflammation; in such case it is 
1 Quelques Observations Chirurgicals recueilles k I’Hotel- 
Dieu de Lyon. Paris, 1813. 
2 “ Recherches et Memoires pour servir al’Histoire de I’Angine 
Laryngee GEdemateuse,” Archiv Gen. de Med., 1825. 
3 Traite de Anatomic Pathologique. Paris, 1852. 
5 “De la Laryngite GEdemateuse Chronique,” Gaz. des Hop., 
No. 69, 1862. 
4 Traite de I’Angine Laryngee GEdemateuse. Paris, 1852. 8 
BRYAN, 
characterized by an infiltration of a serous fluid in 
the submucous connective tissue of the larynx. It 
may occur in the course of hepatic obstruction, in 
acute and chronic nephritis, from malarial cachexia, 
from blood-stasis in the course of chronic disease of 
the heart and lungs, and, according to Von Ziems- 
sen,1 as a result of circumscribed obstruction in the 
laryngeal veins as a result of compression of the 
superior and inferior thyroid veins. That form due 
to inflammation is characterized by an infiltration of 
a serous, sero-purulent, purulent, and sometimes by a 
sero-sanguineous fluid in the submucous connective 
tissue. According to the statistics of Sestier, the 
disease seldom occurs before the age of fifteen 
years, and generally attacks persons between eigh- 
teen and fifty years of age, the majority of his cases 
being between eighteen and thirty-five years. Of 
187 adults, 131 were men and 56 were women. Be- 
fore thirty years of age the disease was generally a 
complication or sequel of some acute disease, while 
after that period it occurred in the course of chronic 
affections of the larynx. 
In 1873, George von Hoffmann2 found among 
6062 post-mortem examinations made at the Berlin 
Charite, from 1869 to 1871, 33 cases of edema of the 
larynx, 10 of which were primary and 23 second- 
ary. In 1879, Felix Peltesohn3 found, in 3387 
post-mortem examinations made at the same insti- 
1 Cyclopedia of the Practice of Medicine, vol. vii; N. Y., 
1878. 
2 Edema Glottidis, Berlin, 31. Marz, 1873. 
3 Berl. klin. Wochenschr., October 28, 1889. 9 
tution (from 1873 to 1878) 210 cases of acute edema 
of the larynx. Of these 149 were in men, 40 in 
women, and 21 in children. He found that the 
disease affected men generally between eighteen 
and sixty years, while the women were generally 
between eighteen and thirty-four years. Forty- 
four of his cases were due to local affections, and 
164 were in consequence of general diseases. 
In studying the etiology and prognosis of edema 
of the larynx, the statistics of Sestier cannot be 
taken as a guide, for it must be remembered that 
they were compiled before the days of the laryngo- 
scope, when it was impossible to make a positive 
diagnosis. Furthermore, he did not separate the 
acute from the chronic form of the disease, and he 
included cases in which a dense deposit was present. 
The statistics of Hoffmann and Peltesohn, having 
been taken from the post-mortem room, represent 
only the fatal side of the question; and, as the 
latter author states, if the records of a large clinic 
were available, other figures than he gives would be 
obtained. It would also be interesting to know 
what influence the modern treatment of this affec- 
tion has had on the rate of its mortality. For this 
purpose I have collected the cases on record in the 
library of the Surgeon-General’s Office of the 
United States Army, and have found reports of 96 
cases. Of this number 86 were in adults—73 in 
men and 13 in women, 2 being in negroes—and 10 
in children. The majority of the cases were be- 
tween twenty and fifty years of age. In the cases 
of children, 7 were under six years, the youngest 
ACUTE EDEMA OF THE LARYNX. 10 
BRYAN, 
being only five months. In 4 cases the edema was 
the cause of sudden death. 
Edema of the larynx is said to be primary or 
secondary, but on this point authorities are not in 
accord. Gottstein1 doubts whether it ever occurs 
as a primary affection, and believes that in the 
majority of cases it is partly or entirely due to local 
disturbances. Mackenzie2 believes that in the cases 
of edema following simple inflammation, the disease 
is due to blood-poisoning. He states that in every 
case that has come under his observation ample 
opportunity of acquiring septicemia has been pres- 
ent. Virchow3 is of the opinion that in all cases of 
acute edema without a clear etiology, the affection 
is really one of primary erysipelas of the larynx. 
Cases do occur, however, that are apparently pri- 
mary, and in nearly all of them there is a history 
of exposure to cold, while the body is in a low 
state of health or after great bodily fatigue. By 
reference to the tabulated list of diseases causing 
edema of the larynx, it will be observed that bodily 
fatigue and exposure to cold constituted the cause 
in thirteen cases. Marboux* reports an interesting 
case, apparently of primary edema of the larynx, 
in a man, who prior to the attack was in perfect 
health. While bathing with some companions, his 
1 Die Krankheiten des Kehlkopfes, p. 100. 
2 Diseases of the Pharynx, Larynx, and Trachea, p. 201. 
3 Verhandlungen der medicinischen Gesellschaft, Berlin, 11. 
Mai, 1887. 
* “ Reflexion sur I’etiologie et la symptomatologie de I’OSdema 
de la Glotte,” Rec. du Mem. de Med., Paris, 1875, 3 sen, xxxi, 
382. ACUTE EDEMA OF THE LARYNX. 
head was forcibly submerged under the water, and 
in less than twenty-four hours he had a severe attack 
of edema of the larynx. 
The disease occasionally occurs in the course of 
an acute laryngitis; but it is more frequently due 
to the extension of an inflammation of the adjacent 
parts. I find that it was the result of an acute phar- 
yngitis in three cases, of tonsillitis in six cases, in 
three of which the inflammation had progressed to 
suppuration, and in one case it was due to an ab- 
scess in the tonsillar region. 
Edema of the larynx is sometimes developed in 
the course of syphilitic and tuberculous inflamma- 
tions of the larynx, although Gougenheim1 thinks 
that true edema occurs very rarely in tuberculosis 
of the larynx, and, when it does occur, it is gener- 
ally the result of caries of the cartilages. On the 
other hand, pseudo-edema is of much more frequent 
occurrence in the course of tuberculosis. This con- 
dition is not characterized by a collection of fluid 
in the cellular tissues, but by an infiltration of 
tuberculous material. 
Diseases of the kidneys have long been recog- 
nized as constituting a cause of acute edema of the 
larynx, but an infrequent one. Fauvel,2 in 1863, 
was the first to call attention to acute edema of the 
larynx as the primary symptom of disease of the 
kidneys. He reported three cases in which the 
edema was the first and only symptom of renal 
disease. Since that time Waldenburg3 and De 
1 “ De I'CEdema Laryngien dans la Tuberculeuse du Larynx," 
Ann. des Maladies de I’Oreille et du Larynx, 1884, x, 226. 
2 Aphonie Albuminurique, Rouen, 1863. 
3 Allg. med. Centralzeitung, 1865, 10. 12 
BRYAN, 
Bary1 have made similar observations, the latter 
author reporting a case of acute edema of the 
larynx in a child as the first symptom of acute 
nephritis following scarlet fever. Among the gen- 
eral diseases that seem to give rise to edema of the 
larynx may be mentioned typhoid and typhus fevers, 
debility following chronic malarial poisoning, rheu- 
matism, septicemia, and pyemia. 
The following is a tabulated list of the cases that 
I have collected, showing the diseases that preceded 
acute edema of the larynx: 
LOCAL DISEASES OF THE 
THROAT AND LARYNX. 
Acute laryngitis. . .9 
Subacute laryngitis . . 1 
Pharyngitis . . .4 
Erysipelas . . . .3 
Tonsillitis . . . .6 
Abscess in tonsillar region . 1 
Tuberculosis of the larynx 3 
Diphtheria , 1 
Syphilis of the larynx . 2 
Extension of an inflamma- 
tion of the cellular tissues 
of the neck . . .1 
Straining of the vocal cords 2 
Scald throat . . .3 
Consecutive to chronic 
bronchitis . . .1 
Ecthyma of the face extend- 
ing into the larynx . . 1 
38 
GENERAL DISEASES. 
Chronic disease of the 
kidneys ... .3 
Typhoid fever ... 3 
Typhus fever ... 6 
Debility following mala- 
rial fever ... 5 
Rheumatism . . 1 
Frost-bite and resulting 
gangrene . . . 1 
Gastric fever . . . 1 
Septicemia . . .’ 1 
Pyemia . . . . 1 
Part of a general edema 
for which no cause 
could be assigned . 1 
Alcoholism ... 2 
Variola . , . , x 
Consequent on great bod- 
ily fatigue and exposure 
to cold. . . -13 
39 
1 Archiv fur Kinderheilkunde, 1886, viii, 96. ACUTE EDEMA OF THE LARYNX. 
13 
Traumatism . . .5 
Following the administra- 
tion of large doses of 
iodide of potassium . 1 
On forcible submersion of 
the head under water . 1 
7 
Leaving the etiology in 12 cases unaccounted for. 
In general, the edematous infiltration is developed 
in those parts of the larynx in which the submucous 
cellular tissue is in greatest abundance. These 
parts are the anterior surface of the epiglottis, the 
ary-epiglottic folds, and the ventricular bands. 
Hajek1 has recently made some interesting experi- 
ments on animals to discover the parts most prone to 
edematous infiltration. He finds that there is a layer 
of loose cellular tissue on the anterior surface of the 
epiglottis that passes up to within half a centimeter 
of its border and there ceases. From this point the 
membrane is firmly adherent to the cartilage. This 
cellular tissue on the anterior surface of the epiglottis 
is continuous with that lining the lateral walls of the 
pharynx in front of the pharyngo-epiglottic liga- 
ment. The ary-epiglottic folds are made up of two 
layers of cellular tissue, the internal being continu- 
ous with that found at the apex of the epiglottis on its 
aryngeal surface, while the external is continuous 
with that lining the pyriform sinus and the lateral 
wall of the pharynx behind the pharyngo-epiglottic 
ligament. This arrangement of the submucous 
cellular tissue and the position of the pharyngo- 
1 "Anatomische Untersuchungen fiber das Larynx-oedem,” 
Archiv fiir klinische Chirurgie, xlii. 146. 14 
BRYAN, 
epiglottic ligament, which divides this part of the 
larynx into anterior and posterior portions, have a 
very important influence on the course of an edema. 
It is frequently observed that in edema of the ary- 
epiglottic folds due to local causes, such as ulcers, 
traumatism, perichondritis of the arytenoids, the 
infiltration is limited by the pharyngo-epiglottic 
ligament; and it is only when the edema is of great 
intensity and the collateral inflammation is decided 
in degree that this ligament is broken through. 
As the submucous cellular tissue of the anterior sur- 
face of the epiglottis and that of the ary-epiglottic 
folds are separated by the pharyngo-epiglottic liga- 
ment and pass up into the lateral wall of the 
pharynx on either side of it, it is clear that inflam- 
mations of the pharynx may occasionally extend to 
the anterior surface of the epiglottis, and occasion- 
ally to the ary-epiglottic folds, accordingly as the 
inflammation is on a piane anterior or posterior to 
the pharyngo-epiglottic ligament. Edema of the 
anterior surface of the epiglottis never passes over 
the border of this cartilage to, enter the laryngeal 
cavity, and it only passes over into the ary-epiglottic 
folds when the infiltration is so extensive as to break 
through the ligament. 
The edema is generally confined to that part of 
the larynx above the vocal cords. It, however, 
occasionally extends below the cords affecting the 
trachea and bronchi. In rare cases, it is limited to 
that part of the larynx below the vocal cords, in 
which case it is known as the sub glottic variety. 
This form of the disease was recognized by Sestier, 
Cruveilhier, and Gibb, and of the 96 cases I find ACUTE EDEMA OF THE LARYNX. 
that 2 are of the sub-glottic variety: in one, re- 
ported by Gibb,1 in a man thirty years of age, who 
had an inflammation of the cricoid cartilage due to 
traumatism, a resulting abscess caused edema of the 
sub-glottic space; in the other, reported by Lefferts,2 
in a boy five years of age, the disease followed 
exposure to cold. Both patients recovered. 
The vocal bands are very rarely affected, as they 
contain very little cellular tissue. However, I find 
2 cases recorded. In one reported by Natier,3 the 
infiltration was due to tuberculosis; in the other, 
reported by Semon/ the edema was due to excessive 
use of. the voice. 
The order of frequency of the parts affected in my 
list of cases was: the epiglottis alone in 7; epi- 
glottis and ary-epiglottic folds in 14; ary epiglottic 
folds alone in 5 ; soft palate and ary-epiglottic folds 
in 3 ; arytenoids and vocal bands in 1 fright aryt- 
enoid in 1 ; arytenoids and commissure in 4; vocal 
bands alone in 2 ; right arytenoid and correspond- 
ing ary-epiglottic fold in x ; epiglottis and aryten- 
oids in 1. 
The disease is generally bilateral, but occasionally 
it affects only one half of the larynx. Feiber5 de- 
scribes a case in which the-edema was contiguous to 
an acute pharyngitis, and in which the infiltration 
1 Lancet, London, Sept. 4, 1869. 
2 New York Med. Journ., Aug., 1877. 
3 Ann de la Policlinique de Bordeaux, 1889, i, 71. 
4 “ Isolated Edema of the Vocal Cords,’’ St. Thomas's Hos- 
pital Reports, vol. xiii. 
5 “ Zur Behandlung des circumscripten Kehlkop-foedems,’’ 
Wochenbl. d. k.-k. Gesellsch. d. Aerzte, Wien, 1870, 497. BRYAN, 
was limited to the corresponding half of the larynx. 
S. Solis-Cohen1 reports two cases, both of traumatic 
origin, and Lefferts2 one case that followed exposure 
to cold. 
Acute edema of the larynx occasionally sets in 
with such suddenness that no warning is given, and 
the patient dies before aid can be rendered. Gen- 
erally, however, the onset is more gradual, and the 
patient complains of a sensation as of a foreign body 
in the throat, the removal of which he attempts by 
swallowing and by the insertion of the finger in the 
throat; deglutition is painful and difficult, the voice 
is altered in timbre, dyspnea is always present, and 
the inspirations are frequently accompanied by a 
whistling, stridulous sound, especially when the 
ary-epiglottic folds are the seat of the infiltration. 
The patient is restless and has an anxious expression, 
and unless relief is obtained the face becomes 
cyanotic, and death results from asphyxia. 
The diagnosis of this affection is not difficult: the 
symptoms of stenosis, in connection with the dyspnea 
and the alteration of the voice, indicate the larynx 
as the part affected, and by means of the laryngeal 
mirror the nature of the affection is at once revealed. 
The tumefied parts are red, though sometimes trans- 
lucent and pale-yellow in appearance. In the ab- 
sence of the laryngoscope, exploration with the 
index-finger as recommended by Tuilier can be 
practised, when the swollen epiglottis or ary-epi- 
glottic folds can be felt. Great care must be exer- 
1 The Medical News, Phila., 1885, xlii, 677. 
2 New York Med. Journ., Aug., 1877. ACUTE EDEMA OF THE LARYNX. 
17 
cised in carrying out this procedure for fear of 
causing suffocation. 
Although acute edema of the larynx is a very 
serious affection, the prognosis is now not so un- 
favorable as it formerly was, owing to the practice 
of scarifying the swollen parts, and also to the 
early performance of tracheotomy when indicated. 
Sestier found that of 213 cases 158 proved fatal, 
in spite of tracheotomy having been performed in 
thirty. Bayle gives much more unfavorable figures, 
as 16 of his 17 cases proved fatal. Kilim (quoted 
by Kdnig1) collected 95 cases, 36 of which were fatal. 
Of the 96 cases that I have collected, the disease 
proved fatal in 34, giving a mortality of 35 per cent., 
which is a little less than that given by Kilim. The 
prognosis must be greatly influenced by the cause of 
the edema and by the intensity of the inflamma- 
tion, as well as by the age and sex of the patient. 
That form due to an extension of inflammation from 
the pharynx generally does well when taken in time, 
but when the inflammation is due to erysipelas, or 
to constitutional causes, such as typhoid fever, septi- 
cemia, and pyemia, the chances are extremely un- 
favorable. The disease is more serious in men than 
in women, while the greatest mortality is in cases 
between ten and forty years of age. 
Prompt local measures must be employed in order 
to relieve the obstruction to respiration. In no 
severe disease is there such speedy relief obtained 
by means of a simple operation as in acute edema 
of the larynx from scarification of the swollen parts. 
Sometimes the relief appears almost magical. Pro- 
1 Lehrbuch der Chirurgie, Bd. i, 615. BRYAN, 
posed and practised by Lisfranc in 1825, scarifica- 
tion did not receive the recognition of this eminent 
surgeon’s colleagues, probably, as suggested by Dr. 
Bartlett,1 on account of jealousy. We even find 
Cruveilhier,2 a number of years later, saying he 
“doubts whether this little operation of scarification 
has ever been performed.” It was not until 1847, 
when the late Dr. Gurdon Buck,3 unaware that scari- 
fication of the epiglottis had been previously per- 
formed by Lisfranc, practised it at the New York 
Hospital, and owing to his series of successes the 
operation became a popular one. It is best per- 
formed with the laryngeal lancet, with the aid of 
the laryngeal mirror, but in the absence of these it 
can be effected with the ordinary curved bistoury, 
covered, except for the last quarter-inch of its length, 
with adhesive plaster. After scarification, gargling 
with warm water will greatly facilitate the expulsion 
of fluid from the tissues. The cold coil or an ice- 
bag should be placed over the larynx, and the patient 
be directed to swallow cracked ice frequently. This, 
in conjunction with the hypodermatic injection of 
pilocarpine, as first proposed by Gottstein,4 will 
hasten the absorption of the fluid and often prevent 
a recurrence of the edema. The atmosphere of the 
room should be rendered moist by boiling water, 
containing the compound tincture of benzoin. In- 
halation of astringents will often assist in the absorp- 
1 “The History, Diagnosis, and Treatment of Edematous 
Laryngitis,” Western Journ. Med. and Surg., Louisville, 1850, 
vol. xxxiii, 209. 
2 Diet, de M6d. et de Chir. pratique, “ Laryngite,” xi, 41, 
3 Trans. Amer. Med. Assoc., Phila., 1848, i, 135. 
4 Die Krankheiten des Kehlkopfes, S. 104. ACUTE EDEMA OF THE LARYNX. 
19 
tion of the infiltrated fluid and the restoration of 
the inflamed membrane to health. 
If, in spite of the scarification, the edema con- 
tinues and the dyspnea increases, then tracheotomy 
should be performed without further waiting. The 
lives of many patients have been saved by the early 
performance of this operation; and remembering the 
liability of the edema to extend into the trachea, it 
is best to operate low down, making sure that the 
knife has entered the trachea, so that the tube will 
not pass between the swollen mucous membrane and 
the wall of the trachea—an accident that has hap- 
pened to good operators. 
Intubation has been successfully practised by 
Desault,1 Macewen,? Meier,3 Ingals,4 and Altamirano,b 
but it has not been performed often enough for any 
estimation of the value to be placed upon it as a sub- 
stitute for tracheotomy. Its efficiency, of course, 
depends upon the part of the larynx that is edema- 
tous. Ingals refers to one case in which the ob- 
struction to respiration could not be relieved by the 
laryngeal tube. It would seem, however, that cases 
of chronic edema and those acute cases in which 
the edema is moderate in degree and in which there 
is danger of paralysis or spasm of the posterior crico- 
arytenoid muscles, such as in the unfortunate case 
reported by J. Solis-Cohen,6 are best suited for intu- 
bation. 
1 Charazac: 6tude sur I’CEdeme du Larynx, Paris, 1885. 
* Brit. Med. Journ., Dec. 28, 1878. 
3 Med. Record, May, 1888. 
4 Sajous’s Annual, vol. iv, 1890. 
6 Diseases of the Throat and Nasal Passages, p. 443. 
5 Ibid. The Medical News. 
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