%,^,~.u (y.6, j CHRONIC IRRITATIVE HYPEREMIA OF THE LARYNX. WM. C. JARVIS, M.D., NEW YORK. [Reprinted from the Archives OF Laryngology, Vol. iii, No. 2, April, 1882] CHRONIC IRRITATIVE HYPEREMIA OF THE LARYNX* / By WM. C. JARVIS, M.D., NEW YORK. I WISH to call your attention to an affection of the larynx which, though it may fail to excite much in* terest when taken in a pathological or physiological point of view, from its containing few of the complicated causes and effects that sometimes induce the physician to attach so much importance to diseases of infrequent occurrence, nevertheless demands earnest consideration by reason of its frequency, persistence, and the distress it occasions. Hyperaemia of the larynx, as is well known, occurs in connection with a number of laryngeal diseases, and is often due to an atonic condition of the mucous membrane, brought about by certain laryngeal paralyses and other affections in this part of the respiratory tract. The form of hyperaemia I have reference to, is that which accompanies almost every case of chronic nasal catarrh, and is caused by the action of irritating secretions. I will therefore speak of it as an irri- tative hyperaemia, since the expression will serve to sepa- rate the affection from the other forms of laryngeal hyper- aemia. I have observed a tendency on the part of some practitioners to include hyperaemia of the larynx under the head of chronic and subacute laryngitis. Chronic irritative hyperaemia of the larynx differs in several respects from these affections. The distinction between chronic hyperaemia of the larynx and subacute and chronic laryngitis is, I think, a well- * Read before the American Laryngological Association, Session 1881. Reprinted from the Archives of Laryngology, Vol. iii, No. 2, April, 1882;. 2 Chronic Irritative Hypercemia of the Larynx. marked one, and of much importance as bearing upon the treatment of the former affection. In the so-called subacute and chronic laryngitis the laryngeal and perilaryngeal mucous membrane is deeply congested and of an angry red color; there is often much cough, which is sometimes deep and painful. The attack generally comes on suddenly, and may disappear in a few days. Sometimes it is ushered in by an acute nasopharyn- geal catarrh; at other times a preceding catarrhal inflam- mation of the kind may not be discoverable. Localized thickenings of the laryngeal folds, ventricular bands and true cords are of common occurrence in chronic laryngitis. A raucous voice, is, as a rule, associated with these affec- tions. On the other hand, in chronic irritative hyperaemia of the larynx, the laryngeal mucous membrane is, in the majority of cases, not markedly congested, the discoloration in many instances being so slight as to be only distinguished by its contrast against the whiteness of the true vocal cords. Cough is not always associated with this complaint. A sharp sound made in clearing the larynx of mucus is, in most instances, the only annoyance of the kind complained of. The hyperaemia may be sometimes so intense as to take on a subacute inflammatory condition. Chronic irritative hyperaemia of the larynx, as the term implies, is always a secondary affection, and invariably fol- lows in the train of troubles brought about by the existence of chronic postnasal catarrh. The existence of a postnasal catarrh, does not, however, always imply a state of laryngeal hyperaemia. The occurrence and extent of the hyperaemia seem to be dependent upon the amount of the secretions poured into the pharynx. A slight excess over the normal amount may find an exit through the oesophagus. It is when the accumulated mucus becomes so large in amount, or the secretions so thick, they cannot be received through this natural channel, that an overflow takes place upon the delicate structures of the larynx. Once in contact with these parts, the glutinous mucus acts as a foreign body, and by its constant presence provokes a hyperaemia. Wm. C. Jarvis. 3 Sometimes the mucus becomes inspissated or even solid, in which case it not only acts more powerfully as an irri- tant, but also interferes with phonotion. I have in mind a case of the kind, in which the movement of one cord was so much interfered with as to give rise to a diagnosis of recurrent laryngeal paralysis. I was unable in this instance to dislodge the obstruction with the spray, but accomplished the result by means of a probe. This tendency of the mucus to dessicate is especially noticeable in laryngitis sicca. Diagnosis.—The diagnosis of hyperaemia of the larynx is based upon discoloration of the true cords. Sometimes care- ful inspection will only show fine markings of congested capillaries, running along the free edges or outer margins of the cords. In other cases the congestion of the cords will be found to be so great as to take on a purplish hue. Even in these cases one may fail to discover any marked change in the appearance of the mucous membrane in the vicinity of the cords. It is this intense form of hyperaemia that sometimes gives rise to a most distressing choking sen- sation. The feeling, as if of impending suffocation, is most apt to come on in the night, awaking those afflicted, and sometimes occasioning much loss of sleep. An early recognition of this affection is especially im- portant in the case of vocalists, who are subject to attacks of naso-pharyngeal catarrh. By promptly attending to the nasal trouble, one may remove the cause, and thus ward off a hyperaemia of the true cords, which is almost certain to follow the catarrh if it is neglected. A very slight conges- tion, by blunting the sharpness of the true cords' edges, may lower the vocal register to an extent seemingly out of pro- portion with the amount of existing hyperaemia. In con- firmation of this fact I have observed elevation and strength of voice return, proportionate to the gradual disappearance of the hyperaemia and clearing up of the edges of the true cords. The treatment of this affection, I think, should principally be directed to its cause. The indirect cause, in this instance, being a naso-pharyngeal catarrh, and the direct one an irritating secretion, immediate relief from the latter, and subsequent removal from the former agent are Chronic Irritative Hypercemia of the Larynx. called for. If it were possible by means of sprays to keep the upper surface of the larynx free from the foreign secre- tion, the hyperaemia might be kept in abeyance until the cause is removed. The rapid and incessant accumulation of mucus makes this impossible. Turning attention to the nasal catarrh, more or less tur- binated hypertrophy will be discoverable, with its attendant irritating secretions. The first indication is, naturally, to re- move every vestige of hypertrophy that may, in accordance with sound judgment, be productive of this secretion. I invariably make use of the wire-snare nasal ecraseur in- vented by me for this purpose, with which you are ac- quainted. It seems to me more stress should be laid upon the removal of small hypertrophies which, on account of their non-interference with nasal respiration, are permitted to remain undisturbed. I have known discharges, kept up by hypertrophied superior turbinated tissue, in no way in- terfering with breathing, to cease soon after removal of the growth. By means of the Ecraseur, and transfixion needles devised by me to go with it, I have never found any diffi- culty in removing nasal hypertrophies, no matter what may be their size or variety. My efforts in this direction have been followed by most satisfactory results, but I will refrain from giving a history of the cases, as it would lead me too far from my subject. . Next in order comes thorough and frequent cleansing of the nasal cavities, followed by the application of astringent solutions. In my hands insufflation of powders has been followed by so much irritation, as to discourage me in their general use. Iodoform, provided its odor be properly dis- guised, seems to possess few of the objections that contra- indicate the use of the other powders. In connection with the nasal therapeutics, it is often advisable to spray the larynx with mild astringent solutions, their application to be preceded by the use of a cleansing fluid. Coarse and powerful cleansing sprays for the nose, and fine cleansing and medicated sprays for the larynx, have given me the best results. A fair trial of fine and low pressure cleansing sprays for the nose has induced me to abandon them as Wm. C. Jar vis. 5 being of little use. The brush and sponge brought in con- tact with the delicate vocal structures are, in my experience, even when lightly applied, too irritating. I, however, use the brush to apply nitrate of silver to the larynx, but satu- rate it well with fluid, and gently press out the solution against the edge of the epiglottis. The medicated solution will trickle into the larynx and give the desired effect. K ARCHIVES OF LARYNCOLOCY EDITED BY LOUIS ELSBERG, M.D., NEW YORK, J. SOLIS COHEN, M.D., FREDERICK J. KNIGHT, M.D., PHILADELPHIA, BOSTON, GEORGE >M. LEFFERTS, M.D., NEW YORK, IN CONJUNCTION WITH Dr. J. BOECKEL, Strasburg; Prof. Burow, KOnigsberg ; Prof. Gerhardt, Wurzburg; Dr. Heinze, Leipzig; Dr. Koch, Luxembourg; Prof. Krishabkr, Paris ; Prof. Labus, Milan ; Dr. Massei, Naples ; Dr. Morell Mackenzie, London ; Prof. Oertel. Munich ; £r. Felix Semon, London ; Dr. Smyly, Dublin; Prof. Voltolini, Breslau ; and Prof. Zawerthal, Rome. It is believed that the time has come for the publication of a journal devoted to the specialty of Laryngology. So much has been achieved in this department of medicine during the last twenty years, that in the regard of both the profes- sion and the lay public it has acquired recognition and a certain amount of inde-" pendence. In the further advance in every right direction the Archives is in- tended to give important aid. None of the existing medical journals can occupy its place ; it competes with none, and supplements all. It is to be a bond of union between the specialists themselves, and also between them and the general profession. 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Society Transactions, /. e., reports of the proceedings of Laryngological Societies, or of matters relating to Laryngology occurring in.other societies and not previously published. II. Report of Contemporary Literature, viz., a. Reviews and Notices of Books and Pamphlets. b. Digest of the Literature of every part of the world. III. Miscellany, viz., News Items, Editorial Announcements, and Answers to Correspondents,—the latter being planned particularly for communication between specialists and gen- eral practitioners. The Archives of Laryngology is handsomely printed in large octavo form, each number containing 96 pages, and the articles are fully illustrated whenever their subjects render this desirable. It is issued quarterly at the price per number of $1.00, and the subscription per year of........ G. P. PUTNAM'S SONS, 27 & 29 W. 23d St., New York, London : N'. TRUEBNER & CO., 59 Ludgate Hill. Paris : 1. B. B AILL1ERE, 19 Hautefeuille. 7. 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