c flLcC c v'C < < c?x occ «* Za% «C ^- CCS; ^ < (< c^: «X(^c ^ il, Marjolin, Andral, J. Cloquet, and M. Sanson. OBSERVATION II.1 Tumour slowly developed in the larynx—Hoarseness for six years— Aphonia—Death by suffocation. The twenty-second of December, 1826, I was called on by the authorities to make the examination of the body of Mr. Clavel, who had died suddenly in a baker's shop; I learned that the patient had long since lost his voice; that he had been treated for laryngeal phthisis; could not swallow liquids; was unable to take violent exercise, and that for two days he had complained of his throat. The body feeing well developed did not announce phthisis. All the viscera were successively examined ; there was venous in- jection, and the fluidity of blood consequent upon asphyxia, and they were all in a normal condition, with the exception of the larynx, which offered the following peculiarities : the epiglottis was healthy ; there was slight oedema of the sides of the glottis and of the epiglottic ligaments; the mucous membrane was bloated; the larynx, opened from behind, exhibited a tumour the size of a filbert, whitish, hard, fibrous, chapped, and pedunculated, growing from the right ventricle which it filled, and occupying almost the whole of the upper part of the larynx, so that when this organ was closed it was exceedingly difficult to introduce a very small crow quill. This tumour, which appeared syphilitic, was the true cause of death ; the slight swelling of the mucous membrane would have been sufficient, in this state of the larynx, to obstruct the passage of air. An inspection of the specimen would scarcely convince one of the existence of such an obstacle ; but its progress must have been exceedingly slow, for the voice had been altered five or six years, and thus the system had become reconciled to the obstruction. OBSERVATION III.2 M. Stassin, chief of the hussars of the chamber of deputies, a^ed sixty-three years, suddenly lost his voice, two years ago, without 1 This case was published by M. Senn, of Geneva, in the Journal des Progres des Sc. Med. 1829, t. v. p. 230. 2 Read before the Academy, Sept. 27, 1836, by M. R. Gerardin. ORGANIC ALTERATIONS. 29 appreciable cause. Leeches were applied to the upper part of the sternum, a blister to the chest, afterwards tartar emetic plasters, simple fumigations, and finally alum gargles were used.—All these attempts were fruitless. He took cold at the beginning of last winter, and during the whole season had cough, with thick sputa. For some months he has had oppression and hissing on inspiration. The patient could not ascend the stairs to his chamber without great pain in respiration, and was even obliged to suspend con- versation for want of breath. Thinking that the air of Normandy would prove advantageous to him, M. Stassin anxiously waited the close of the session, that he might return to Bayeux. On the thirteenth of July, 1836, on the eve of his departure, I was hastily called to see him—it was my first visit; he was sitting up in bed, panting, with hissing respiration; voice extinguished; cough hoarse ; face red; eyes an imated and prominent; in a word, there were all the symptoms of strangulation, with some indications of suffocative asthma. The skin was burning, pulse full and strong, the artery giving one hundred and thirty pulsations per minute. Some sputa in a vessel were thick and streaked with blood. I im- mediately practised venesection in the arm to the extent of fifteen ounces, which the patient bore wonderfully; some hours after- wards he was covered with perspiration, his aspect was more calm, and the pulse was diminished in force and frequency. 14th and 15th July, he continued better, notwithstanding some returns of the difficulty of breathing (etouffement.) Diet, pediluvium with mustard, enemata, emollient drinks, and a plaster (vigo cum mercurio) were prescribed. 16th. The night was not so good; the patient anticipated a re- newal of the first symptoms, and demanded another blood-letting, which was practised, and followed, as before, by great perspiration and marked amelioration. 17th. New difficulty of breathing, very decided hissing; anxiety. I made anther examination of the thorax; percussion was sonorous in its whole extent. The heart beat regularly and forcibly; no abnormal sound was detected. There was no inspiratory sound, though a slight bronchial rhoncus was heard with the cough. No redness nor pain in the bottom of the pharynx. The gullet might be pressed without producing any pain, which surprised the patient; fifteen leeches were applied at the summit of the sternum; slight melioration ; no fever, pulse soft, the same drinks. 18th, 19th, and 20th. At the request of the patient we applied twenty more leeches, and a blister to the chest. The plaster of vigo was renewed; the sputa became more abundant and thick, and they were occasionally streaked with blood. The patient did not complain; his strength remained, and a light narcotic procured for him a few hours' sleep. A week passed without any improvement, during which time the patient took three potions, in each of which was a dram of the white oxide of antimony. 30 TROUSSEAU AND BELLOC ON LARYNGEAL PHTHIS Our hopes were dissipated, the prognosis was bad, and on the 28th a third bleeding became necessary. This blood, like the pre- ceding, presented a thick clot, with little serum. On the surface 01 the coagulum were seen, for the first time, patches of the burly coai. The patient was not relieved by it; the malaise and obstiuctea respiration continued; the strength sensibly failed; the sputa are more abundant and puriform ;.the moral energy of the patient con- tinues the same; he has no apprehensions respecting the issue ot nis Auo-ust 1st. The night has been worse, threatened suffocation induced me to bleed again; the coagulum was covered with a thick white crust. There was no improvement; the patient gradu- ally lost his sensibility, and died on the 2d of August, at eleven o'clock A. M. In'the evening, I asked to examine the body, but was refused, though permitted to make an incision into the neck, when I re- moved the larynx and part of the trachea. The larynx was examined at my house : on raising the epiglottis, the glottis was found obstructed by a tumour; looking through the larynx, as through a spy-glass, it was observed that the passage for air was reduced to a sinuous passage, no larger than a chicken quill. Cutting into the posterior part of the larynx and trachea, and spreading the sides of the incision, there was found a tumour as large as a filbert, of a white colour, covered with asperities, from one to two lines long. This vegetation had a short peduncle occupying the right sinus. It seemed to be compressed by bringing together the sides of the incision, and to expand when they were extended.1 This tumour was of the same colour as the lining membrane of the larynx and trachea, in which was neither redness nor ulceration. The tumour cut readily under the scalpel, without producing any noise. M. Stassin had served under the republic in a regiment of hus- sars. He assured me that he had never contracted the venereal disease ; and since his return to civic life, his conduct had been too well known to suspect the truth of his assertion. Vegetations.—Syphilitic vegetations may invade the superior part of the air tubes: M. Rayer has preserved the most remarkable instance we have met with.2 Cancerous tumours are oftener found in this situation than syphilitic growths. Morgagni has an ex- ample, (epist. 28, art. 9 and 10.) We have also met with a case, (obs. 18th.) Tuberculous tumours and productions.—It is difficult to say whether the various alterations which we find in the larynx simul- 1 I should explain the marked improvement which followed the venesec- tion to the momentary collapse (jletrissure) of the tumour, which per- mitted a fresh entrance to the air; as well as to the relief given to the en- gorgement of the pulmonic circulation.—Author's note. 2 Traite des Maladies de la Peau. Atlas, pi. xv. fig. 21, 2de edition. ORGANIC ALTERATIONS. 31 taneously with tubercles in the lungs, should be ranked among tuberculous productions. Most authors do not recognise the characters of tubercles in the granulations so frequently found in the larynx of phthisical pa- tients, but consider them inflamed or engorged mucous follicles. Louis says, tuberculous granulations are never found in the larynx, epiglottis, or trachea—whence he concludes, that we should regard inflammation as the most frequent cause of these ulcerations. Andral (Clinique Medicale, torn. ii. p. 195) has often observed them, and thinks they are generally tuberculous. We will not hazard an opinion upon so delicate a question, as our researches have not been sufficiently extended. Analogous alterations in persons who have no tubercles in the lungs, will therefore be still more difficult to classify. It seems more easy to assign the pathological place that should be occupied by tumours in the neighbourhood of the larynx or trachea, which sometimes simulate laryngeal phthisis, and which may even, in some cases, produce it, as would appear from Mor- gagni. epist. 15, art. 15, quoted by us in observation No. IV. It fs evident, that such tumours often present every symptom of tubercle. . Observation VII., extracted from Irish Transactions, 1820, and No. V., communicated by M. Vernois, show in what respect these tumours may simulate laryngeal phthisis. In the last case, we see M. Andral deceives himself, inasmuch as there was no autopsy to show that the lungs were not tuberculous. The numerous cases which we have reported will obviate the necessity of entering at length upon a consideration of the other alterations of the larynx, that precede, accompany, or follow pul- monary phthisis. We will merely refer to the relations M. Louis has observed to exist between the various alterations of the larynx, the trachea, and the epiglottis. This short statistical table, although generally known, may not be considered misplaced in a work espe- cially devoted to the study of affections of these organs. Of one hundred and two subjects examined by M. Louis, eighteen had ulceration of the epiglottis, twenty-three ulceration of the larynx, and thirty-one had lesions of the trachea. We see here, that the frequency of ulceration is in the ratio of our descent from the external opening of the passage. We have already given what we conceive to be an explanation of this fact. Ulceration of the epiglottis.—In eighteen cases reported by Louis, twelve were in men, six in women. Five times they occurred alone, and without complication with those of the larynx or trachea. They were generally superficial, twice only reposing on the fibro-cartilage, and, one instance only excepted, they were on the laryngeal face of the organ. Lesions of the larynx were seen twenty-three times in one hun- dred and two patients ; sixteen in men, seven in women. In only 32 TROUSSEAU AND BELLOC ON LARYNGEAL PHTHISIS. two cases were they unconnected with similar affections of the epiglottis or trachea. The order of frequency, as to the points of attack, was as follows: the union of vocal cords, the posterior-part of the cords, the base of the arytenoids—the superior part of the larynx, and last, the inte- rior of the ventricles, which which were once found ulcerated. Ulcerations of the trachea.—Of the thirty-one cases, riine were females, and twenty-two men. They occurred most frequently at the inferior part of the trachea, near the bifurcation, and when large they occupied the membranous portion ; sometimes they were situate on the submucous tissue, at other times on the mucous tissue, which was sometimes thickened. Frequently, the cartila- ginous rings were eroded; once only they offered a solution of continuity; and in five cases of the thirty-one, the mucous mem- brane was destroyed throughout the whole extent of the membra- nous portion of the trachea. We shall, at present, refrain from any inductions, but merely record the facts as observed. Hydatids.—M. Pravas relates the following case :—A captain of galley slaves was brought to the hospital nearly suffocated ; respi- ration hissing, inspiration most difficult. All the means employed to assuage the patient's suffering proved unavailing, and after two and a half months he died. The autopsic examination showed two connected, semitrans- parent oval hydatids, as large as a nut, lodged under the epiglottis; the right one occupied the corresponding ventricle of the larynx. There were two soft bodies in the upper part of the glottis, pro- ducing all the symptoms of the "cedematous laryngeal angina" of Bayle. This is an important case, because it is one that might have been relieved by pressure. The plan of exercising compression, recommended by Thullier,1 should not, however, be indiscriminately employed, because of the frequent inflammatory character of this disease. False membranes.—Home, cited by Franck and Lieutaud, re- ports a case of false membrane cast off by a child, who had long suffered dyspnoea and altered voice : analogous false membranes were found in its trachea after death. J. Franck has noticed a still more curious example :2 " Yir conspicuus T, triginta annos natus, Grodni inhabitans, anno 1810, auxilium meum contra raucedinem, cum laryngis dolore, tussi clangosd, svffocationis periculum minitante, sputis puriformibus, made, febriculd et deglutitione Icesa (sinefaucium visibili affectione) quasiverat. Morbum a refrigerio corporis in itinere contracto originem caipisse putabat: neque minus fassus est, juvenem se syphilide quidem infectum, sed bene curatum fuisse. Cur a nihilominus a mercurio inchoata est, morbus autem in dies gravior exstitit. Atque sic quatuor hebdomadibus elapsis 1 Inaugural Thesis on cedematous laryngeal An°ina. 2 Praxeeos Medicse, torn. vi. p. 210. ORGANIC ALTERATIONS. 33 ceger Vilnam reliquit, aliorum medicorum euro, sese traditnrus. Ab his multa et varia remedia diufrustra adhibita sunt. Tan- dem trium mensium spatio interjecto, a morbi autem initio metise nono, vehemcntissim,e tussiens, pseudo-membranam trium polh- cum longitudinis, uniusque latitudinis, expuit. A quo tempons momento, non solum ab omnibus suis malis liber atus, sed etiam obesusf actus est." Andral says that pseudo-membranous productions of chronic character are less rare than is generally supposed -,1 we have never seen them. „,, Calculi have been found in the ventricles of the larynx. J ne thesis of M. Pravaz, contains the following case : A young lady for six years, at the close of each summer, had experienced anorexia, general indisposition, and difficulty of respira- tion; she had first a dry cough, then heat in the throat, and soon, an acute pain in the larynx; deglutition became more and more difficult, the voice was completely lost, and the dyspnoea was extreme. When the finger was applied to the superior part of the larynx, there was found a small fixed tumour, circumscribed and painful. The mouth and pharynx were scarcely injected. Finally, the tumour increased, deglutition was impracticable, and the expecto- ration was purulent; the face was pallid, the lips livid, the voice extinct, and suffocation imminent. This condition remained three days, when the patient spit up, without effort, two stones the size of peas; they were of a yellowish white colour, very hard, and of a rough irregular form. From ™e moment of their expulsion all the symptoms diminished, and the patient was completely restored. Lieutaud (lib. 4, obs. 77) quotes the following account from Kerk- ringius: AT " Quidam immani spirandi difficultate premebatur. l\on tamen tussiebat nee excreabat, nullaque erant asthmatis nee orthopneece symptomata ; cum superveniente febre vehementiori, illitc mittitur unde negant redire quemquam. " In propatulum veniebant varii lapides et diversa Jigurce, asperai arterice immediate* incumbentes, aded ut hominem pra- focaverint" , , Organic alterations of various forms and character may occur in the larynx and trachea, as in other mucous membranes; an enu- meration of them would transcend our limits, therefore we shall not continue the subject. Nor should we have reported the preceding cases, but that they were considered types with which comparisons might be drawn with nearly all the accidental lesions of these important organs. . We have but a few remarks to offer respecting foreign bodies that may be introduced from without, and which often cause immediate 1 Clinique Medicale, torn. ii. p. 195. iq__k trous o 34 TROUSSEAU AND BELLOC ON LARYNGEAL PHTHISIS. suffocation, or give rise to laryngeal phthisis, if not immediately ejected. Every one is familiar with the history of Provencal quoted by Desault.1 A cherry stone had fallen into the man's larynx ; all the symp- toms of laryngeal phthisis were manifested; Desault being^ con- sulted, proposed tracheotomy, which was refused; after suftering two years the patient died, and the nut was found in his larynx. The same author2 reports the case of a man, upon whomFerrand had performed tracheotomy, with the view of extracting a stone that had got into his larynx; the operation failed, and the patient died—the'stone had become lodged in the ventricles. In all analogous cases, at least when the body does not act che- mically upon the parts, suffocation is the most pressing danger, varying according to the size and asperities of the substance; but the indication is always to extract immediately, even when the symptoms abate. Temporising in this case may cause the death of the patient. OUGHT LARYNGEAL TO EE SEPARATED FROM TRACHEAL PHTHISIS? It will be seen that we have not acknowledged any distinction in the preceding pages, between the ulcerations of the two parts; there- fore it may be best to give some explanation at this place. Since the commencement of this century, and since M. Cayol's monograph upon the subject, most writers have recognised them as separate and distinct affections. We will now present our reasons for rejecting this arrangement. It is admitted that the simple forms of both arise from the same circumstances, and under the influence of the same predisposing or exciting causes. When they are symptomatic, the same diseases occasion both; thus, pulmonary tubercles cause more ulcerations of the larynx than syphilis : and ulcerations of the trachea are also more common with the former than with the latter disease. They are frequently co-existent in the same patient, whether idiopathic or consecutive, and often occur simultaneously in both organs. We are surprised that Cayol should have advanced a contrary opinion. In Louis' account of twenty-three patients with laryngeal ulcerations, there were but two whose tracheae were not similarly affected. The same thing has been observed by Lieutaud.3 " In cadavere cujusdam juvenis lue venerea laborantis occurrunt 1 (Euvres Chirurgicales, torn. ii. page 258. 2 (Euvres Chirurgicales, torn. ii. p. 274. 3 Historia Mat. Medic, lib. iv. obs. 81. ORGANIC ALTERATIONS. 35 varus exostoses in facie interna cranii. Interiora tracheae ET LARYNGIS LATERA PASSIM CARIE L^ESA CONSPICIEBANTUR. Pulmones deprehendebaniur tuberculosi, cum thymo putrido. Varice insuper conspiciebantur in abdomine viscerum laisiones, tt'C." The same author, loc. cit. lib. 2, No. 767, reports the following: " Secto cadavere enjusdam juvenis phthisici, propter vulgatissi- mam pulmonum stragem, larynx et trachea ulcus sordi- DUM INTUS SITUM EXH1BEBANT. ThymUS, SfC. Morgagni, (letter 15, artic. 13) says: Eo loco, tunica laryngem convestiens erat ex ulcer at a quemadmodum et qua proximos annulos aliquot tracheal arterial operiebat; quanquam hie le- We are surprised that Cayol, who quotes this last passage, did not observe that the lesions of both organs were simultaneous; and that he should have denied the existence of the fact so positively. We have thus combated the opinions of Cayol, because his name is considered authority on this subject. We could also array the opposing testimony of M. Double, of Borsieri, and of J. Franck. MM Louis and Andral have not clearly expressed their views on this point; but we may be allowed to infer from their writings, that they attach no great importance to the part of the air passages which may be affected with these alterations. Cayol insists upon a difference of symptoms in the two forms. We confess ourselves unable to distinguish them from each other. It will be seen in our chapter on Symptoms, that patients with the larynx affected have pointed to the trachea and upper part ot the sternum as the seat of pain. The sensations of the patient are not generally important in making the anatomical diagnosis ; and as to the orthopnoea which Cayol attributes exclusively to the ulceration of the trachea, our observations on tracheotomy, show the estimate we should have ot his opinion. Upon Cayol's hypothesis, how should we explain the considerable amendment which generally follows the opening of the trachea? If the obstacle existed below the artificial opening, respiration would be no easier after the operation. We do not consider it useless to distinguish the seat or place oi the lesion, but it is not of sufficient importance to make two distinct affections, where the cause is similar, the anatomical lesion the same, and the treatment differs so little. 36 TROUSSEAU AND BELLOC ON LARYNGEAL PHTHISIS. CHAPTER III. CAUSES. Laryngeal phthisis is not a disease sui generis, as it nearly always presents itself with similar anatomical forms. It may exist alone, and without our perceiving any thing in the economy to explain its development, but it is generally a consequence of some organic lesions which, once established, become a true cause of laryngeal phthisis. These lesions are of an extremely varied nature, and if we embrace them all under the common denomination of laryngeal phthisis, it is because they generally provoke nearly similar func- tional disorders, depending rather upon the special destination of the organ, than upon their intimate nature. To study the causes of these diverse lesions, it would be neces- sary to review the whole nosological table. The object may be best attained by simply reading our cases, which will be better than any theoretical discussions into which we might enter. We have seen chronic laryngitis with or without ulceration, produced by an acute laryngeal angina, (obs. lix.,) by tracheotomy practised in croup, (obs. xv.,) by a sharp cry, (xlvi.,) by habitual exercise of the voice, (xx. and xxxiii.,) by immoderate venery, (xii.,) by masturbation, (xiii.,) by periodical exanthemata, (xxxiv.,) by cancer, (xviii.,) by tumours in the larynx, (i. and seq.,) by syphilis, (xvi. and xvii.,) principally by phthisis pulmonalis, (xix. et alii.) In fine, those constitutions which are most inclined to develope chronic ulcerative diseases, and particularly the scrofulous and tuberculous constitutions, singularly predispose to this disease. All habits of life which favour the development of these constitu- tions may be considered as predisposing causes. Internal or external tumours that compress these organs, may give rise to this disease, as appears in the following cases : OBSERVATION IV.1 Extreme dyspnoea—Dysphagia—Death—A suppurating tuberculous tumour opening into the trachea and compressing the air tubes and pharynx. Mulier octogenariS major, despirandi, deglutiendique difficultate, cum faucium ardore conjuncta, multos jam dies querebatur cum' in nosocomium Patavinum excepta est. Jbi tam gravi paroxysmo difficilis respirationis corripitur, ut eo propemodum exanimetur. Servatur tamen, consequente sputo graveolentis puris, cui sanguis admistus erat. Ciim mulier laryngem tanquam morbi sedem non modo indicaret, sed digitis prehendendo antrorsum traheret et sic 1 Morgagni, De sed. et causis morb. Ep. 15, art. 15. CAUSES. 37 paulo facilius spiritum duceret; introspectae sunt fauces, et uvula quidem, atque ascendentes ad ipsam musculosi arcus apparuerunt retrorsum arcti; ut id pharyngis orificium, quod ad os est. dilatatum videretur, eaque loca paulo magis ruberent quarn soleant; sed nihil prseterea conspicere licuit; sic dies quindecim, aut eo amphus, cum iis sputis et difficultate respirandi mulier perstitit, donee magis hfcc urgente, irritis omnibus auxiliis, conficeretur circiter kalendas Septembris anni 1725. Collum, in quo.evidens erat morbi causam latere, dissectum est; eaque ad hunc modum inventa : In asperse arteriae lergo, intervallo transversi pollicis infra cartilaginem cricoideam, tumor excreverat ad magnitudinem dimidiatae nucis juglandis, gulam quidem retro- positam premens, sed arteriam illam multo magis; ut hums viam ibi angustissimam redderet, in qua per oblongam patebat scissuram. Hac dilatatS, tumoris cavuminspectum est putridarefertum materia, pariete autem comprehensum interius duro, extenus vero ex qui- busdam quasi milii granulis facto subflavi coloris. Ex quibus dua? quoque constabant glandulae, tumori extrinsecus proximae. singula? modicum pisum sequantes; ut ex una, harum simili, sed magis adauctaeffectum esse tumorem appareret. Ex gula sectione per- ducta ad pharyngem, haec intus maxime rugosa comperta est, sic tamen, ut digitas rugas dissolvere liceret, pharyngemque ad ampli- tudinem justam reducere. OBSERVATION V.1 Suppurative tumour between the oesophagus and the cricoid cartilage- Dvsphagia, aphonia, symptoms of pulmonary phthisis in he last stage- Death—Necrosis of the cricoid cartilage—(Edema of the glottis. Mrs Manque, of Paris, aged 64, a wine merchant, entered the hospital on the 4th of July, 1834. She has a delicate constitution; the pilous system is moderately developed ; the muscles presented the appearance of the first stage of marasmus. Few details of the previous history could be obtained, as the patient articulated with great difficulty. ,, , , She had not been rheumatic, not subject to take cold had never spit blood, nor been asthmatic. Ten years ago she had a pleurisy, with pain in the left side which lasted twenty days; since Then she has had neither cough nor dyspnoea. One month ago she had a violent fever, with delirium, which her physician told her was characteristic of pleurisy (fluxion de poitnne.) Of this she recollects no symptoms, but was bled thrice in two days, and had blisters applied over the left posterior side of her thorax. Menstruation commenced at 16 and continued regular until 47, when it ceased ; she has had three children. She was taken about three weeks ago, soon after leaving Hotel » Communicated by M. Vernois, Interne of the hospitals. 38 TROUSSEAU AND BELLOC ON LARYNGEAL PHTHISIS. Dieu, where she had her last illness. This affection commenced with a dull pain in the posterior region of the gullet, so that diffi- culty of swallowing was one of the first symptoms. Difficulty of respiration appeared soon after, and continued to increase, causing a very fatiguing cough, with viscid liquid expec- toration. She retained her appetite, but was obliged to adopt a restricted diet because of the pain in the larynx and oesophagus; she began to have regurgitations. Her debility, on leaving 1'Hotel Dieu, was increased by these causes as well as by a copious serous diarrhoea. The voice was perceptibly altered; she had employed no treatment for the affec- tion, and at last, urged by the serious nature of the symptoms, she came to La Pitie. On the visit of the 4th she was as follows :—Hair thin, fair and gray; skin dry; extreme debility, supination, but on an elevated plane. Confusion, (etourdissemens,) vertigo, and constant tinnitus aurium; no pain in the limbs; intellect clear; at intervals consi- derable faintness; nothing remarkable about the eyes; the pupils perhaps a little contracted; nostrils dry; lips violet, tongue par- taking somewhat of this colour ; thirst so great that she can scarcely satisfy it; anorexia; very difficult deglutition ; frequent regurgita- tion of food ; sense of weight and constriction in the pharynx ; no pain in the epigastrium; abdomen sunken, neither tympanitic nor painful. Many stools of diarrhoea; urine scanty; no perspi- ration. Frequent cough, with very frothy muco-purulent expectoration. Voice very hoarse; considerable dyspnoea; respiration hurried, (thirty-six in a minute;) slight pain in the larynx when pressed; loud tracheal rattle. Auscultation was not carefully attended to, but the respiratory murmur was soft and clear; diagnosis, phthisis in the last stage. Prescription : a cup of the white decoction of Sydenham, and a draught with one ounce of the syrup of poppies. 6th. The same general condition ; at times the dyspnoea becomes much more violent; no sleep.—Continue the same treatment. 7th, 8th, and 9th. During these days the dyspnoea made great progress; the patient could scarcely swallow a few mouthfuls of tisan, and vomited three fourths of it, which was attributed to the ulceration of the epiglottis and the pain caused by the contact of liquid with these parts. The volume and form of the neck in the region of the larynx were not observed. The voice was lost and the patient was in imminent danger of asphyxia. On the 9th at the morning visit, the pulse was sometimes hard, and again imperceptible. The cough and expectoration disappeared, and the symptoms increasing in intensity. She died on the 10th, at one in the morning. I opened the body on the 12th, at eight in the morning. Effusion of yellow limpid serum in the pleuritic cavities, (about a pound ) CAUSES. 39 very strong old adhesions near the base of the left lung, none on the right. The lungs were of a bluish colour, they floated on water, and were engorged with black blood. No tubercles. When about to detach the larynx, I felt a tumour at its posterior part which strongly compressed the oesophagus; I dissected out the parts with care—the oesophagus was somewhat contracted opposite the tumour, but not perceptibly dilated above. There was no com- munication between the tumour and the trachea or oesophagus. There was fluctuation, and when opened there was nearly half an ounce of concrete, thick, yellow, greenish pus, which had detached all the submucous cellular tissue from the upper part of the larynx. and thrust back forcibly the mucous membrane of the oesophagus. The cavity would have held a large nut; its walls were fringed with false membranes, composed of many yellowish, purulent layers. The surrounding cellular tissue was friable, but without purulent fistulas. The cricoid cartilage was entirely denuded, its edges were carious, resembling the pumice stone, and above they were hard, and appeared ossified. The glottis was quite de- formed ; its lips, or borders and the two cords that bound the inferior part of the ventricles, were swollen, and completely obliterated the opening into the trachea. Holding it up like a spy-glass, scarcely a ray of light could be seen. The rest of the mucous membrane was red and injected, but presented no ulceration, except the epi- glottis, which was somewhat oedematous. The other parts of the larynx and bronchia were not altered ; the trachea contained frothy mucus. Heart.—The whole tissue engorged with black blood ; the right cavities filled with bluish coagula; valves healthy. Stomach.—Of a grayish colour, very much shrivelled, and with corrugations on its inner face. Intestines without remarkable alteration. The colour, alone, presented a few scattered patches of red. The uterus was small, and contained many little peduncu- lated hydatids, which se med to grow from the mucous membrane itself. Kidneys and bladder healthy. The brain was not examined. We here see that a tumour between the oesophagus and cricoid cartilage occasioned not only all the symptoms of laryngeal phthisis, but those also of phthisis pulmonalis, so much so that M. Andral, from a superficial examination, it is true, made a diagnosis of phthisis pulmonalis in the last stage. It is true that the abscess prevented deglutition as well as respira- tion, so that the patient must have died from hunger as well as asphyxia; thus we see the lungs were engorged with black blood, and the stomach was shrunken. We value this observation because it presents two causes of death, and confirms what we have said respecting the manner in which death may occur in this disease. 40 TROUSSEAU AND BELLOC ON LARYNGEAL PHTHISIS. OBSERVATION VI.1 Violent effort to avoid falling—Pain at the upper part of the sternum- Tumour in front of the trachea—Death—Tumour on the right of the trachea—Destruction of three of its rings by the abscess communicating with the trachea—No tubercles in the lungs. A woman of 40, who had always enjoyed excellent health, while sitting in a chair one day, made a violent effort to avoid a thre-it- ened fall, and at the same instant experienced an acute pain at the upper part of the sternum which continued for some days; after a remission of two weeks it returned, and with it a tumour was de- veloped in front of the trachea, which was dissipated, and the pain relieved by a plaster. Eight months later there was cephalalgia, with difficulty of re- spiration, which increased for two months and compelled the patient to enter the Hopital de l'Unite, when she had the following symp- toms:—slight alteration of features; respiration laboured, sometimes threatening suffocation ; a slight, rather painful swelling above the sternum and in front of the trachea; cough frequent; sputa and mucus abundant; deglutition difficult and painful at the moment when the portion of food passed that part of the oesophagus which corresponded to the disease; pulse small, corded (serre,) frequent. M. Corvisart suspected a tumour in the walls of the trachea, and made an unfavourable prognosis. Treatment palliative. After two weeks, as all the symptoms decreased, we entertained some hope that the tumour might be discussed. A few days later, the first pus was observed in the sputa, which continued to increase in quantity, 16th. Blisters to the arm. 19th. Exasperation of the symptoms; respiration very difficult; upright posture absolutely necessary; sinking. 20th. Cadaverous expression ; functions disturbed. 21st. Death. Autopsy.—Lungs sound throughout; a small tumour was ob- served near the bifurcation of the trachea extending two inches along its right side. The interior of this tumour was brown ; three of the subjacent rings and the corresponding mucous membrane were half destroyed, and a communication was thus established with the trachea. The rest of the mucous membrane was engorged, and covered with brownish mucus, mixed with a white substance like that observed in the sputa. OBSERVATION VII.2 Pain in the throat—Dysphagia—Dyspnoea—Threatened suffocation__Tra- cheotomy—Complete dysphagia—Death—A considerable abscess com- pressing the trachea and oesophagus and communicating with the upper part of the larynx by erosion. A woman had been suffering for a month with pain in the throat and difficulty of swallowing, which continued to increase 1 Extracted from the Thesis of M. A. Sauvee. 1 Irish Transactions of 1820. CAUSES. 41 notwithstanding general and local venesections had been prac- tised. Dr. Carmichael found the patient in such a state that he thought immediate tracheotomy necessary. There was some hemorrhage, which was soon arrested; respira- tion was performed by the artificial opening, which relieved the patient, but deglutition continued almost impracticable. A. gum elastic tube could not be introduced into the oesophagus, and the patient could not be fed; three days after the operation she threw up a quantity of pus, and expired. Autopsy.—An abscess, extending from the second or third ver- tebra to the sixth or seventh, compressed the oesophagus and upper part of the trachea. It communicated with the larynx by a very small erosion; in other respects the whole respiratory apparatus was in a good state. Independently of these causes relative to the constitution, there are still two whose consideration is difficult—age and sex. ^o-e.—Laryngeal phthisis is rarely developed before the age of puberty and is uncommon in advanced life. Of all the cases we have seen or quoted, there were few patients less than twenty or more than fifty years old; they were generally between their thirtieth and fiftieth years; the observations XI. and LIX. though relating to infants, were decided cases of laryngeal phthisis, and under No. XV. are related two instances of its following trache- otomy. The same remark has been made by all authors who have written upon this subject. , J. Franck' expresses himself as follows :—" Si infantes phthisi laryn^ea? venerea? affectos excipiam, fateri debeo, omnes segraetos pubertatis epocham superasse; plurimi inter 30 et 40 aetatis annum versabantur." 101». Sex —According to a series of observations made from lblo to 1821 by M. Serres, at La Pitie, and those by M. Louis in his beau- tiful work on consumption, it has been established that, among the tuberculous at least, these alterations are more frequent among men than women. We refer the reader for a more detailed account to our chapter on organic alterations. Franck,, whose authority we are glad to cite, because his remarks show that this singular influence of sex is not observed in France alone, thus ex- presses himself, torn. vi. p. 206:— . "Solum novem feminas inter aegros meos invenio et inter istas quinque morbum ex syphilide acquisivere. Quae observatio, si cum ilia in capite prajcedente allata comparatur, patet laryngem marium revera longe magis quam ilium feminarum morbis ob- noxium esse. Interea et observationem contranam experientia mea suppeditat; die enim 17 mensis Octobr. 1816 pro viro phthisi laryngea laborante in consilium vocatus sum, qui se jam tres sorores eodem morbo amisisse retulit." 1 Praxeos Medicse, torn. vi. p. 206. 13-c trous 4 42 TROUSSEAU AND BELLOC ON LARYNGEAL PHT These remarks relative to age and sex agree remarkably ; indeed we find women less liable to alterations of the larynx than men , and children, whose constitutions are so analogous to those 01 tne more delicate sex, partake of the same immunities. As exciting causes of laryngitis, we find acute affections 01 ine larynx, forced exercise of the voice, frequently renewed colds, re- pression of dartrous affections, blows, falls, wounds, chills, loreign bodies, &c—These causes will be the more apt to produce laryn- gitis according as the patient may have the taint of either ot tne constitutions which predispose to it, and according to the time he may have been exposed to the influences above mentioned. CHAPTER IV. SPECIES. 1st. It is difficult to classify diseases so as to satisfy both the imagination and truth. If we look at the results of the efforts to establish a good nosological classification made by so many eminent men since the time of Sauvages, we shall almost conclude that it is superhuman to effect one. It is because diseases are complex, depending upon the causes that produced them and the constitution in which they occur, and liable to be modified by many circumstances. They are functions, not entities, and these abnormal functions, like normal ones, may vary in every individual, and in every condition of life where they occur. Whether, then, we class diseases according to symptoms or ana- tomical lesions, which are both cause and effect, we shall omit one of the elements of the problem, and have a defective classification. We have entered into these details in order to meet the objections that may be urged against our arrangement, and to show the value we attach to it. We shall divide laryngeal phthisis into four principal species :— 1st. Simple laryngeal phthisis—Under which head we shall embrace that produced by causes common to other phlegmasia?. Some eminent physicians of the present day refuse to admit the existence of laryngitis, independent of consumption ; before the discovery of auscultation, and in the infancy of pathological anatomy, we may conceive that diseases of the larynx, complicated with softening of tubercles, may have been frequently considered simple laryngitis. Thus, the partisans of the opinion against which we are contending, are always complaining of the inaccuracy of the earlier observations, arguing from the inadequate means of thoracic exploration, that obtained before the time of Laennec. SPECIES. 43 It was important to collect the testimony of physicians who, having before proclaimed the isolated existence of laryngeal phthisis, could since, by the aid of this valuable diagnostic means, verify their prior views. M. Double, who was one of the first in France (Stances de la Societe de Medecine, an. XIV.) to point out the existence of laryn- gitis, independently of pulmonary tuberculisation, has since been able to collect new facts, which, by the aid of autopsy or aus- cultation, have confirmed his earlier convictions. His opinion, which he has communicated to us at consultations and scientific meetings, may be expressed in these terms:— "Laryngeal phthisis is undoubtedly often united with pulmonary phthisis ; but it is frequently unaccompanied by any lesion of the lungs. Many facts, proved by symptomatology, auscultation, and autopsy, establish this proposition." Cayol, who some years later held the same views, continued to support them; and we have heard the renowned Laennec himself, show by relating numerous facts observed in his practice, the inde- pendent existence of laryngitis. (See the observations V11I, IX, X, XI, XII, XIII, XIV, and XV. 2d. Syphilitic:—that which is produced by venereal ulcers, pri- mitive or consecutive, whether they attacked the larynx, in the first place, or were propagated from the pharynx. (Observations Nos. XVI, XVII, XLIX, (1, 2, 3,) L, and LI.) 3d. Cancerous:—that which arises from a cancerous tumour in the larynx. (Observation No. XVIII.) 4th. Tubercular laryngeal phthisis .-—that which commences after the manifestation of pulmonary tubercles. (Observations Nos. XIX, XX, XXI, XXII, (1st and 2d.)) Perhaps we should admit the existence of another, which we would call dartreuse; but we have not yet a sufficient number of facts to establish this as a species. We shall, nevertheless, present the following case: Miss_________•, aged twenty-one, was taken with an eczema of the scalp, which soon left that position, and spread to the face, then to the alae nasi, and to the interior of the nasal fossa?, when the face was cured. The nasal fossae soon recovered, but a severe sore throat was the consequence; as that got well, an obstinate cough, with almost complete extinction of the voice, supervened. Topical treatment was applied to the larynx; the symptoms disappeared, but the eczema returned to the fossae and aloe nasi, whence it was dispelled by the treatment, and in a fortnight the larynx was again seized. It was agreed to adopt general treatment by sul- phur baths, mercurials, and bitter tisans; the symptoms soon dis- appeared, but the patient is still liable to become hoarse from the slightest cause. 44 TROUSSEAU AND BELLOC ON LARYNGEAL PHTHISI EXAMPLES OF SIMPLE LARYNGEAL PHTHISIS. OBSERVATION VIII.1 Repeated colds.—Increasing dyspnosa.—Hemoptysis.—Voice shrill, then hoarse.—Death in the sixteenth month.—Glandular granulations in the larynx and trachea.—No tubercles in the lungs. I knew a female, of about thirty, who had been very subject to catarrhal attacks, which terminated in spitting of blood, and great difficulty of breathing. She would never consent to being bled; the menstrual discharge was suppressed, and a pain appeared in the larynx. The voice was first shrill, afterwards hoarse. She could not be relieved by any change of position : her breathing was equally painful, whether she reclined or sat up, though the respira- tion was rather less painful when the head was inclined towards the thorax; her pulse was corded and frequent. She died about the sixth month of the attack, without having suffered remarkable sweats, or colliquative diarrhoea. An inspection showed that the seat of the disease was in the larynx and trachea: the lining membrane was red, and covered with glandular granulations that partially occluded the air passage: the two largest were in the larynx. The lungs were healthy; only the vessels seemed rather fuller than usual, and the right auricle and ventricle contained a good deal of blood. According to Portal, pulmonary phthisis often follows laryngeal and tracheal; because, says he, the lungs are the last to be affected. In this case, although deficient in detail, we see that the patient died from slow asphyxia. There was no marasmus; respiration was always laboured ; the patient was obliged to incline the head forward to get breath; and, finally, the lungs, their vessels, and those of the systemic circulation, were in that state of engorgement which commonly follows death by asphyxia. OBSERVATION IX.2 Repeated colds.—Haemoptysis.—Aphonia.—Tumefaction of the larynx — Emollient treatment.-Death.-Ulceration of one of the arytenoids, and of one of the aryteno-epiglottic ligaments.—No pulmonary tubercles. A nailer, aged thirty, large and of strong constitution, entered the Hospital. He has been sick for a long time, and has been fre- quently attacked with colds. « Extracted from Portal's work on the Nature and Treatment of Phthisis. i ans, lolly, p. 189. 1 From the Thesis of M. Sauvee. SPECIES. 45 The disease commenced with a considerable haemoptysis, which recurred, after a few days, in a milder form. Face lean, features altered, tongue natural; no pain in the throat, loss of voice; larynx increased in size. The thorax was sonorous ^Thfwnx^otgh not painful, seemed to be the only affected point. Professor Corvisart suspected ulceration of its membrane, and gave an unfavourable prognosis. Diluent drinks, and fumigations with tepid water, were pre- 5C23d 'The same state; some pain within the larynx. A blister was applied over the painful spot; the same regimen 24th. Remarkable improvement, cough rare, painful, mucous SP26th. Return of the pain in the throat, difficult deglutition, entire extinction of the voice, insomnolence. ... • „ nc tup All the symptoms were exasperated in the beginning of the month, and an obstinate diarrhoea weakened the patient. 12th Expectoration, for the first time, of muco-purulent matter; T5thVTK^^ I-ve been passed in extreme "S^ much less than that observed in prions who die of pulmonary phthisis. The upper part of the Dhar^nxdeemed to be partially closed. One of the arytenoid car- ulagT was ulcerated. The left superior ligament of the glottis was destroyed by the same ulceration. Nothing remarkable was observed on opening the thorax. OBSERVATION IX. (2d.1) r< l omnkvcPma of the lungs.-Organic affection of the heart.-Death (^^ijZ^S^V^^^ aDd ulC6ratiVe ^ng,US'"" observed during life. fiodard Louis, a*ed sixty years, a carman from the department nf Afcne wa brought to the Pitie on the 7th of December. Though b ef eS 'with an extremely robust constitution, he was attacked with a general pulmonary emphysema. He also had a disease of ^Phearf which had been pronounced hypertrophy of the left ven- ule an/shght obstruction of the aorta. Being threatened with asphvxta when he came, he was relieved by general bloodletting fnPd bhsterl Still, he occasionally relapsed into the same condition, whe^attempting to sit up a little. At last, one of these attacks was ! ra?w considerably reduced, and, among other pheno- ™™ the voice was observed to be nearly lost; but there was no &ySp^m that attmcted attention to the larynx: the patient i Recorded by M. Fournet, Interne of the hospitals. 46 TROUSSEAU AND BELLOC ON LARYNGEAL PHTHISIS. experienced no pain there, and the circumstance was attributed to his extreme debility. The last day of his existence, the aphonia became complete; respiration was very high, difficult, laboured, braying, hoarse, and having a dull sound in both inspiration and expiration. Death occurred on the 30th of December, 1836. The autopsic examination was made the next day, twenty hours after death. There was considerable pulmonary emphysema; serous effusion into the pleuritic cavities; considerable hypertrophy of the left ventricle, with insufficiency of the left auriculo-ventri- cular valve, and plates of ossification on the internal face of the aorta. We were astonished to find the larynx and trachea affected as follows:— Their lining membrane was of a very lively red, with little whitish spots, each of which was a superficial ulcer, embracing almost the whole thickness of the mucous membrane. The ulcer- ations were most numerous towards the superior opening of the larynx. Two of the largest were situated upon the upper liga- ments of the glottis, and extended to the epiglottis and to the aryteno-epiglottic ligaments. A considerable swelling, rather oede- matous than phlegmonous, occupied the whole cavity of the larynx, and nearly obliterated the lateral ventricles. The aryteno-epiglottic ligaments were affected with considerable cedematous swelling throughout. All these alterations were greater at the upper part of the larynx, decreased rapidly towards the trachea, and dis- appeared about its middle. OBSERVATION X.1 Aeute catarrh, with pain in the throat, and increased hoarseness.—Emol- lient treatment.—Improvement.—Relapse.—Sharp pain in the larynx — Severe cough, purulent sputa.—Voice dull and cavernous.—Death on the forty-third day.—Ulceration of the laryngeal mucous membrane.—Caries ot the arytenoids.—Trachea untouched, lungs sound. A female, of thirty, was taken with cold and fever, sore throat, and mucous expectoration. The larynx soon became painful and there was some hoarseness. Gentle remedies and laxatives afforded relief; but on the thirty-third day, the patient was imprudent in her regimen, and the disease became more violent. There was no pain in the thorax, but it was very severe in the larynx. The fever became high, and the cough extremely fa- tiguing; the sputa soon presented a purulent aspect. The cough which was deep and dull, might be compared to the bellowing of an ox; and the patient expired on the forty-third day. Autopsy.-There was ulceration of the mucous membrane of the 1 Journ. de Med. de Corvisart, Leroux, et Boyer vol. i SPECIES. 47 larynx; the arytenoid cartilages were carious, and covered with purulent sanies that exhaled a very fetid odour. The trachea was not affected; the oesophagus preserved its integrity, and the lungs were very healthy, as were all the thoracic viscera. The examination of the abdomen presented nothing worthy of note." OBSERVATION XI.1 N----, set. twelve, of a sanguine temperament, was taken with an acute fever and delirium. The fourth day, there was pain in the throat; voice hoarse and sibilant: (emollient fumigations, and a blister to the larynx.) The eighth day, the disease seemed to incline towards a favour- able termination. On the seventeenth, the pain in the larynx was more marked; deglutition of fluids was difficult, cough frequent, pulse small, ac- celerated. Expectoration abundant; the features altered ; finally, after sweats and colliquative diarrhoea, the patient died about the end of a month. Autopsy.—The larynx contained a grayish liquid; the epiglottis was thinned; the cricoid cartilage was thickened in some places, and ulcerated at others. Unfortunately, M. Laignelet does not inform us of the lungs, though it is presumable that he would not have failed to mention any important alterations that might have presented themselves. OBSERVATION XII.3 N----, set. eighteen, a barber, of lymphatic temperament, after excessive venery, experienced pain in the larynx ; the voice changed, the respiration gradually became difficult; he occasion- ally threw off mouthfuls of frothy, red blood, and in the evening he had irregular general chills. After suffering five months, he entered Hotel-Dieu; when he had general emaciation, pale skin, sunken eyes, sharp features, a bright blush on the cheeks, intense pain in the throat, voice more altered, sputa purulent and lumpy, night sweats, and small, fre- quent pulse. He died after staying four months in the hospital. Autopsy.—The whole laryngeal mucous membrane was ulcer- ated, as were many points of the arytenoid cartilages. The lungs offered no alteration. 1 Extracted from the Thesis of M. Laignelet. * Ibid. 48 TROUSSEAU AND BELLOC ON LARYNGEAL PHTHISIS. OBSERVATION XIII.1 N____, set. twenty, of feeble constitution, addicted to masturba- tion since he was fifteen, about a year ago experienced pains; in tne larynx, afterwards alteration of the voice; at first it was shrill, ana then entirely lost. Towards the last, deglutition of liquids became impracticable; the expectoration purulent and abundant; tne pulse corded and frequent; and he finally died, after about a year s On opening the body, the lungs were found healthy, the aryte- noid glands ulcerated, and most of the glandular crypts of the laryngeal mucous membrane were either tubercular or ulcerated. OBSERVATION XIV.8 Colds, with loss of voice.—Slow progress of the affection at first, and after- wards increased frequency of the paroxysms of asthma.—Death—Consi- derable induration of the soft part of the larynx.—No tubercles. Cugney, set. forty-nine, was an errand-man, native of Paris, ro- bust constitution, and had served nine years as a soldier. His only previous indisposition had been two severe colds. In 1834, he was violently kicked by a horse, and though knocked down, he suffered no other inconvenience than oppression of breath- ing and loss of voice, which passed off in eight days. Six months afterwards, in the midst of his laborious exercises, which com- pelled him to speak constantly, he was taken insensibly with loss of voice, which gradually increased, and was accompanied with cough and considerable oppression. These symptoms generally occurred at night. He employed no treatment. Since his entrance into l'Hotel-Dieu, (February 6th, 1835,) to the 4th of March, he had three attacks of asthma, which were so intense as to threaten asphyxia: two of these paroxysms occurred in the evening, the other at night. They all yielded rapidly under the influence of blisters and hot sinapisms3 to the front part of the neck. Leeches were also applied to the same region ; but all these means were but temporary, their good effects lasting only a few days; after which he relapsed into the same state. On the 2d of March he was in the following condition :—Con- siderable emaciation; respiration difficult, continued, and sonorous; hissing and hoarse inspiration; expiration, on the contrary, easy, and without any sound. On auscultation, the vesicular murmur was only heard at very limited points; but, in its place, there was 1 From M. Laignelet's Thesis. 8 Communicated by M. Fournet. 3 We supposed that hot sinapisms were no longer employed, since the discovery that the globules of mustardjwere coagulated by heat, and ren- dered almost inert.— Translator. SPECIES. 49 a braying, sonorous, sibilant tracheal respiration ; percussion gave a dull sound at every part of the chest; the voice was hoarse, slender, difficult, and laboured ; the cough was harsh, braying, and dry; the expectoration was sometimes white, thick, not homoge- neous ; sometimes formed of little brownish masses, thick, mixed with blood, rather frothy, and with little whitish muco-purulent masses scattered through it. The beats of the heart were regular, without abnormal sound, but strong and lasting, especially the first. The larynx was very moveable; not painful, easily grasped, and preserved its natural form. On the 2d of March, I first tried catheterism of the air-passages; but the gum-elastic sound, used without the stilet, was stopped at the glottis, beyond which it could not pass. The 3d of March, the attempts at catheterism were renewed with a tube bent at an obtuse angle, and by carrying the beak of the sound as nearly as possible on the median line, I could easily make it pass between the superior vocal cords ; then withdrawing the style, while the index finger, in the pharynx, held the sound, so as to avoid injuring the parts of the larynx against which it rested, it was easily pushed into the bronchia; and by withdrawing and advancing it alternately, I could assure myself that there was no tumour in the trachea. Immediately after another attempt in the evening, the patient forcibly ejected a compact dense sputum, which was composed of brown, yellow, and whitish purulent matter, streaked with blood. After the catheterism of the 3d of March, he again threw up a similar mass, but smaller, more yellowish, and before the operation he had raised a large yellow mass, mixed with white pieces. This kind of expectoration occurred at other periods ; sometimes he coughed convulsively for some instants, and was suddenly relieved by ejecting one of these muco-purulent masses; sometimes they were forcibly ejected by a simple effort of expectoration, without cough. He always felt relieved, as though these masses had been foreign bodies introduced into the larynx from without. It is important to observe, that in each of the catheterisms that were practised, the epiglottis was standing vertically, so that the instrument penetrated the glottis without the necessity of raising the organ with my finger. The patient was generally free from fever. If, at the moment of one of the inspirations, the trachea was grasped by the thumb and finger, it was felt to dilate sensibly; it is true, this sensation was increased by the previous collapsed state of the trachea at the moment of inspiration ; but, taking this into the account, the dilata- tion was still quite manifest. On the morning of the 5th of March the patient died in one of the intervals of calm, or of partial relief that separated the paroxysms. Autopsy twenty-eight hours after death. Larynx and trachea.—There was no malformation on the exte- rior of the larynx, except that instead of the crico-thyroid fossa, 50 TROUSSEAU AND BELLOC ON LARYNGEAL PHTHISIS. there was a decided prominence owing to the induration and swel- ling of the soft parts, and indeed this was verified upon dissection, for the crico-thyroid membrane, the cellular tissue, and the submu- cous follicles appeared almost cartilaginous, and were three lines thick. Before dissecting off the indurated parts, it was impossible to move the thyroid on the cricoid cartilage at their juncture; the membranes that unite the thyroid to the hyoid bone retained their natural laxity and pliancy; and their movements were free. The epiglottis was placed vertically, and so maintained by the retraction, swelling, and induration of the middle glossoepiglottic ligament, and the neighbouring soft parts. If it was depressed upon the opening of the glottis, it instantly resumed its vertical position when the pressure was removed; the summit, in consequence of unequal contraction on one side, seemed to have deserted the median line to incline towards the side where it was drawn by the greater thickening and induration of its ligaments. The latter glosso-epiglottic ligaments were tense and voluminous, and formed resisting borders to the glottis, which circumscribed and diminished its diameters. On a careful examination of the degree of contraction of the space between the right and left vocal cord, I observed, 1st, that it was most remarkable opposite the inferior cords; that the thickening of these ligaments was such that they were in contact for the lower three fourths of their extent, and even compressed each other; and that, opposite the arytenoid cartilages, there was a lozenge-shaped opening two lines long, by one or more broad; 2dly, on the con- trary, through the whole extent of the superior cords, there was but a slight diminution of the space that naturally exists between them. Immediately below the contraction there was a dense, thickened, viscid sputum, precisely similar to the masses above described. The swelling and induration of the interior of the larynx had caused the complete occlusion of the lateral ventricles; though it was rather a closure of their orifice than of their cavity. When in juxtaposition, the vocal cords of each side presented a plain surface, behind which was the ventricle, so that, at first sight, it conveyed the impression that the vocal cords and the cavities between them had been entirely destroyed by ulcerative action. After observing these different transformations of structure, I carefully examined the other alterations of the larynx. First. The mucous membrane of the epiglottis, indeed of all the neighbouring parts without the larynx, was reddened, and this colour increased in proportion as we approached the interior of the organ. On the inferior face of the epiglottis the redness was more marked, and there was a thickening and softening which increased towards the inferior part of the larynx. In the whole of this extent the surface was sprinkled with whitish granulations, which were easily removed by the forceps, and which were merely engorged and softened mucous follicles. At the lower part of the larynx the mucous membrane insensibly lost its thickening and redness • at the SPECIES. 51 top of the trachea there was a large red ecchymosed patch; through the rest of this organ there was occasional redness, which gradually became paler, and almost entirely disappeared in the bronchia. Throughout the whole extent of the membrane that we examined, there was no trace of ulceration. Secondly. When the mucous tissue was raised, a great many of softened granules were observed, similar to those mentioned in a preceding paragraph. Thirdly. The cellular tissue surrounding the thyro-arytenoid and lateral crico-arytenoid muscles had acquired a thickness of four lines, and a schirrous hardness; it grated under the scalpel like true lardaceous tissue. Fourthly. The thyro-arytenoid and lateral crico-arytenoid muscles alone were altered, scattered, and almost lost in the schirrous cellular tissue, but were still readily identified by the direction of their fibres and by their pale colour. Fifthly. The parcel of granules that compose the gland of the epiglottis was much swollen, and their tissue softened. Sixthly. With the exception of some points on the thyroid, and the complete ossification of the posterior part of the cricoid cartilage, the skeleton was not at all changed; the first three rings of the trachea were united into one, though two irregular lines marked the places of their primitive separation. Lungs—both were adherent throughout by strong and abundant cellular tissue. There were two kinds of alterations at different points. First. The most common was a reddish brown tissue, easily torn, containing a great many very large air bubbles that started out upon compressing the cut surfaces. This tissue was engorged with blood, intimately combined with it, and not merely effused ; so that it was almost impossible to express it, or wash it off. The colour, and want of resistance, made it resemble red hepatisation ; but, on the other hand, it possessed characters that constituted it very distinct from the alteration of the first stage of pneumonia. Secondly. In some limited points the pulmonary tissue was of a grayish, brownish red, and of a consistence that reminded one of the alteration known as carnification of the lungs. This portion was destitute of air bubbles; a little engorgement was found in circumscribed parts of the lateral anterior regions, but there was a great deal of emphysema. It is doubtful whether either of the lun^s contained one or two cubic inches fit for respiration. 52 TROUSSEAU AND BELLOC ON LARYNGEAL PHTHISIS. OBSERVATION XV. Chronic laryngitis succeeding croup. Mitler, aged five years, was tracheotomised in the last stage of croup. The symptoms disappeared, and on the fifteenth day we removed the canula. Six weeks afterwards, the voice, which had never been quite restored, began to fail; the little patient experienced some dyspnoea after violent exercise, going up stairs, running, or even walking fast. The inspiration was sibilant, especially when he spoke much, or recited his lesson. These symptoms continued for three weeks, at which time we were consulted. A powder of one dram of alum to one ounce of sugar was blown into his larynx four times a day, and in a few days he was cured. A similar fact.—The same thing occurred with young Branville, aged seven years, who had also been operated on in the same way in a severe attack of croup. In his case, insufflations were not necessary; revulsives and pediluvia, gradually diminished the oppression, and the mucous membrane of the larynx completely relieved itself. EXAMPLES OF SYPHILITIC LARYNGEAL PHTHISIS. OBSERVATION XVI. M. P., aged thirty-six, living in Auxerre, called upon us on the third of January, 1834, for an aphonia that had commenced three years ago, and which had been complete for six months. He gave the history of the disease as follows : Ten or twelve years ago he contracted a blennorrhagia, and eighteen months afterwards he had chancres on the corona glandis. He was very mildly treated; the blenorrhagia yielded in two or three months to emollients followed by balsam copaiba, and the chancres were treated by mercurials; they soon yielded, and the patient, then a young man, tired of pursuing a treatment which appeared futile, threw aside the medicines as soon as the ulcers were healed. He continued to enjoy good health until 1830, at which time he frequently had a sore throat, with hoarseness, and some difficulty in swallowing. Emollients and leeches generally dissipated these symptoms, the gravity of which was not suspected by the patient. In the course of 1832 the voice was perceptibly altered, and the sore throat was almost unremitting, though M. P. did not become alarmed, because he attributed these derangements of his health to the fatigue to which he was exposed, and to the continual efforts of the voice which he was obliged to make in his occupation Towards the middle of 1833 the pain in the throat became per SPECIES. 53 manent, the difficulty of deglutition increased, and the voice daily lost its natural sonorous tones. At the same time his appetite diminished, and his ordinary freshness of colour was replaced by a yellowish tint and precocious wrinkles. Notwithstanding all these symptoms, wishing to relieve his father from care, he continued his rude profession, following the prescrip- tion of M. Paradis, which was no doubt very judicious, but being without avail, he came to place himself under our charge. Present state.—The patient seemed to be a man of strong consti- tution; his temperament sanguineous, eyes bright, movements quick, appearance intelligent. He complained of a pain in the throat, which for three months had almost prevented him from swallowing liquid or solid food; during the same period he had suffered with a wry-neck, that had kept his head turned towards the right shoulder. The patient could scarcely obtain a few minutes' rest, tormented as he was by the pain that the slightest involuntary motion caused him while asleep. The antero-superior border of the left trapezius muscle, and its insertion on the same side were painful under pressure. The voice was nearly extinct, and the patient obliged to speak low. When he raised his voice, the first syllables only were heard. No decided inflammation was found in the mouth ; the tonsils, the pharynx, and the veil of the palate were perhaps a little red, an indication of chronic inflammation or congestion. There was no uvula, nor any cicatrix in its place, and his parents declared that he had always had a nasal voice. Externally, the laryngeal region was decidedly swelled; pressure on the thyroid cartilage gave some pain. There was no fever; the appetite, although diminished, was so good that the patient blamed his sore throat, because it prevented his gratifying it. The digestive functions were unimpaired; the respiratory murmur pure throughout the thorax. There was an occasional slight, dry cough, caused by a sort of titillation in the throat; no spitting of blood: he expectorated some small rounded, viscid,'transparent, and occasionally yellowish sputa. There was considerable dyspnoea (essoufiement) when the pa- tient walked fast, or went up stairs. Our first visit was in the evening. We sent the patient to bed, and applied an ammoniacal blister to the affected part of the trape- zius, which was spread with a grain of the sulphate of morphia, and prescribed' frictions morning and night, with the following :— *. Ung. hydrarg. fort. 3j. . _ _ Hydriod. potass, grs. xxxvj. M. The next morning, he was delighted to have slept the whole night • his wry neck had disappeared, and he was charmed with turning his head in every direction. We touched the gullet and larynx with a solution of equal parts of water and nitrate of silver. The frictions to be continued. 54 TROUSSEAU AND BELLOC ON LARYNGEAL PHTHISIS. Four days later, the pain in the throat had nearly disappeared; the patient swallowed food and drinks with pleasure; the voice was perhaps rather less cracked. We laid aside the topical application of morphia to the blister; the wry neck did not return. We directed the patient to touch his throat with a solution of nitrate of silver, which he could easily do with a little instrument that we gave him. The frictions were continued. After twenty days of this treatment, during which M. P. took four baths, and used full but mild diet, the voice recovered its na- tural volume, or nearly so, for his friends had forgotten the original sound, which they had not heard for so long a time. There was no pain in the throat, notwithstanding the frequent exposure to cold and moisture on the banks of the river. The dyspnoea (essouflement) had disappeared. Suspecting that syphilis had something to do with the disease from which M. P. had been so happily relieved, we proposed a mercurial treatment. He took a bath of the sublimate ; but busi- ness called him to Paris, whither he went, and laid aside all treat- ment. Twelve days had scarcely elapsed, when the pain in the throat returned. The patient wrote for the formula of the solution of nitrate of silver: it was sent, and all the symptoms disappeared under its use. Returning to Auxerre, he took cold in the carriage; and when he arrived he had pain in the throat, and the wry neck had re- appeared: two days of the same treatment sufficed to overcome these symptoms, and the patient, thinking himself cured, neglected the general means above mentioned, and married about August or September. During this period we had removed to Paris. On the 18th of November we received a letter from M. P. announcing his arrival, and begging our attendance. On the 19th, we found him suffering a good deal with his throat, and with a considerable extinction of the voice. At the base of the left tonsil, at its junction with the tongue, there was a circum- scribed but deep ulcer, surrounded by a very dark circle of inflam- matory redness. The whole aspect of this ulceration had some- thing suspicious about it, though not precisely like a true venereal chancre. We urged perfect rest, directed him carefully to avoid cold and moisture, and touched the ulcer with a solution of eight grains of the sublimate and two grains of opium to an ounce of water and at the same time ordered pills of the proto-iodide of mercury. The patient could not swallow the pills, which were rejected bv the nose, and on account of his business could not remain in doors. In spite of the cold, wet weather, he daily left his room at six o'clock, and went about town to sell his goods, exposing himself to all changes of temperature. Besides, he was obliged to speak SPECIES. 55 constantly to his workmen, which he admitted was very fatiguing to his throat. We substituted the liquor of Van Swieten for the pills of proto- iodide of mercury, but as his stomach would not bear it, we were forced to lay it aside. He objected to the mercurial baths, which rendered him very sensitive to cold. We dared not use mercurial frictions to one exposed the whole day to cold and moisture, and were limited to local applications, hoping that our patient would take rest, and undergo a methodical treatment, as soon as he had finished his business. On the 22d of December, the ulceration was completely cured, and the pain almost gone, but the voice was still cracked, (vioUe;) the patient went to Auxerre, where he promised us he would adopt suitable treatment. He did nothing. On the 23d of February, 1835, we saw him again in Paris. The pain in the throat had returned; the whole pharynx was red, and the.tonsils were much tumefied, but no ulceration was observed. There was intense headach ; the face was red, the eyes injected; the pulse, natural in frequency, was full and hard. We prescribed confinement to his room, an emollient gargle, sinapised pediluvia night and morning, and twelve leeches to the anus. The patient, still engaged with his business, instead of keeping his chamber, remained in the open air, exposed to the wind and rain, from morning till night. The pediluvium and gargle having diminished the pain in the throat, he negtected the leeches, because he was unwilling to lose the time. We saw him on the 2d of March: he said that he had suffered greatly with his throat for three days. We examined him, and were alarmed to observe that the left tonsil was half destroyed by a very deep chancre, as large as a five-sous piece; its prominent and ragged edges, and its grayish base, but too plainly disclosed its venereal character. The patient was afflicted, and promised to do every thing we might ask. We again recommended rest, which he much needed. We ap- plied the twelve leeches to the anus, and touched the ulcer according to the method of M. Malapert, with a solution of sublimate eight grains, opium two grains, and water one ounce. 5 We again tried the liquor of Van Swieten, with which we asso- ciated a solution of the extract of opium, to be added at the moment it was used: we gave a tisan of sarsaparilla. Four days of this treatment stopped the progress of the ulcer; its edges sank, it assumed a better appearance, and was less painful. From this time the patient resumed his labours, despite all our re- peated advice, counting, he said, upon our prescriptions. The ulcer was completely healed at the end of eighteen days, notwith- standing the exposure to cold and damp, and although M. P. had merely touched it with the mercurial solution for a fortnight. 56 TROUSSEAU AND BELLOC ON LARYNGEAL PHT He had to return to Auxerre; and on the 24th of March, the day of his departure, he attracted our attention to the swelling ot his feet that had just appeared. This symptom, added to consl(?er' able emaciation, loss of appetite, and general debility, seemed a bad omen. , , He had scarcely reached home when the oedema increased; and as diarrhoea supervened, the antivenereal treatment was necessarily suspended. j , Although every thing was done, for two months, to combat the serous infiltration, it would not yield, but reached the peritoneum, and the patient finally died about the first of June. During the latter stage of the disease, he did not suffer any pain in the throat. He had taken internally five grains of the sublimate during the whole course of his disorder, and three baths with three drams to each. There was no autopsy. M. Paradis wrote, that with a most careful examination of the chest during life, he had been unable to discover any sign of pul- monary disease. We had made the same remark. OBSERVATION XVII. Syphilitic laryngeal phthisis.—Mercurial treatment.—Cure. Rousset, a cook, aged thirty-one years, large and of good consti- tution, a blonde, with a lymphatico-sanguine temperament. She was married and had two children, one of whom died at birth, the other at the age of forty days. She has never been sick; her mother died in childbed, and her father, at fifty-two, enjoys good health, except an asthma, which is very troublesome. Almost every day he has a fit of coughing, which expels a good deal of mucus, and then ceases for the rest of the day. This he attributes to the dust he inhales at his occupation of baking. The patient has never had cold until last February, when she was taken with a severe catarrh that required several bloodlettings, and lasted three months. While suffering under this cold, she was suddenly taken with hoarseness when sitting on a stone bench. This continued, despite the removal of the catarrh, and went on increasing until the voice became completely extinct. Present state, (September 18th, 1835.) Complete aphonia, slight cough, little pain in the throat. The patient, who has always been short breathed, says the dyspnoea has increased since the ap- pearance of the aphonia. The least exertion causes quick and laboured respiration, though the sound is free and pure throughout the chest. There is no pain in the larynx, even under considerable pressure. The pharynx is not red; the tonsils are the seat of a circumscribed SPECIES. 57 redness, without decided tumefaction. The right one presents a solution of continuity, which resembles an old cicatrisation. The skin is florid and soft; her embonpoint, although diminished by indisposition, is still considerable. There is no other inconve- nience than the aphonia. Appetite good, digestion easy, menstru- ation regular, no fever. Prescription.—Rest. 28th September. Same state. Prescription.—Make ten inspirations a-day with a portion of powder composed of one eighth acetate of lead and seven eighths of powdered sugar-candy. 25th. The patient finds her voice somewhat restored: we can hear her more easily. Same prescription. 1st of October. The voice is decidedly stronger and clearer, the general health is good; the patient, who never has any pain in the throat, complains that for three months she has felt an acute pain in the right ear when she swallowed. The throat beino- carefully examined, it was perceived that the right tonsil is the seat of two or three small ulcerations; superficial, but of a suspicious aspect. The left tonsil has a slight erosion of its mucous membrane. The bones of the nose have been a little swollen for a fortnight; the skin over the tumour is red, tense, and painful on pressure. She says that sometimes during the past year, she has passed purulent matter by the nose. She denies havino- ever had any thing that would lead her to sus- pect a venereal disease. Her husband has had it for fifteen months, but has abstained from connection during his indisposi- tion 1 Same prescription. 3d of October. The voice is still stronger and clearer. 1 he general health continues good. The physician who takes charge of the ward laid aside the saturnine inspirations. 8th of October. The voice is little changed. She expresses her- self better than yesterday, because she had obtained some of the powder of the acetate of lead, which she had used, contrary to the prescription of the physician. The patient, having left the hospital, came to consult us. I he voice is the same; the tumour on the left side of the bones of the nose is less red, but painful to the touch : looking at the handker- chief we saw that the mucus was mixed with yellow, greenish purulent matter, streaked with blood and without odour. The re- spiration was easy by each nostril, the throat was not painful to the touch or on swallowing; the slight ulcerations of the tonsils were flattened, but not entirely dissipated. We touched the larynx with the nitrate of silver, although she had her menstrual discharge. 13th. The voice is still about the same, perhaps a little stronger. We touched again with the nitrate of silver. 13__^ trouso 58 TROUSSEAU AND BELLOC ON LARYNGEAL PHTHISIS. 15th. Same state; touched again with the caustic. The nose is as before. 20th. The patient is chilly; the voice is again completely lost; the nose still suppurates freely; the external swelling continues, and is perhaps increased. Suspecting a venereal affection, we prescribed the pills of Dupuytren, (three per diem,) and the tisan of guaiacum and sarsaparilla. Topical applications were laid aside. 23d. The same state continues; perhaps the voice is rather clearer. We prescribed, besides the pills and tisan, six inspira- tions a day, of 9>. Hydr. chlor. mit. gss. Hydrar. perox. grs. xii. Pulv. sacch. purific. ^ss. M. 27th. The voice is better; the nose in the same state. 30th. The melioration, though slight, continues appreciable. Same prescription. 8th November. All treatment has been laid aside since the 2d, because she had no money to purchase medicines;—the voice is sensibly improved; the nose is less swollen and red; suppuration continues. We persuaded her to resume the treatment, and we substituted the tisan of bitter-sweet for the sarsaparilla. 14th. The improvement goes on increasing; the voice is almost natural; the nose runs as before, but is less red and less tumefied. Same prescription. The patient being destitute of means, and unable to pursue the treatment, we persuaded her to enter the Hotel-Dieu ; she was admitted into the ward of M. Recamier; we called to see her at the end of a week, and found she had left the day before. 5th of February, 1836. We met the patient, who was coming, she said, to give us an account of herself. She had been twenty-four days at the hospital St. Louis, where she had been subjected to an anti-syphilitic treatment of sarsapa- rilla tisan, sudorific syrup, and pills of proto-chloride of mercury. Her voice is natural; the nose had ulcerated externally while she was in the hospital, but the cicatrix is now firm. The nasal mucus is still purulent and sometimes bloody. The tonsils have deep ulcers. The general health is good. She has been urged to claim our advice by the physicians of St. Louis, who regretted her leaving them. We prescribed the pills of Dupuytren. We again saw her after she had followed our treatment for some time, and was per- fectly cured. SPECIES. 59 EXAMPLE OF CANCEROUS LARYNGEAL PHTHISIS. OBSERVATION XV1II. Hoarseness — Oppression — Orthopnoea—Threatened suffocation—Trache- otomy—Improvement—Introduction of a permanent sound—Death eleven months and a half after the operation—Tubercles in the lungs, some of which were softened—Carcinomatous tumour in the larynx—Destruction of the cartilages. Mrs. P., aged thirty-two years, wife of a wine-merchant, has always enjoyed good health; none of her kindred have suffered with phthisis. There is nothing to induce a suspicion of syphilis. In August she went to Versailles ; exposed herself in the park, and returned with a hoarseness that nothing could control. Her general health continues good; she has never had haemop- tysis, oppression, nor cough. In September, 1834, more than two years after this occurrence, there was complete extinction of voice. In the beginning of December there was some oppression and shortness of breath when the patient walked fast. 15th December. The oppression, which had hitherto been slight, now became constant during the night, and there are occa- sional fits of suffocation. 1st of January. The paroxysms become more intense and fre- quent; sometimes they seem to threaten asphyxia. The family, justly alarmed, called us in consultation with MM. Gendron, Hymely, and Guillon. It was decided that tracheotomy was the only resource, but that it should be postponed as long as possible. 6th of January. Asphyxia was so imminent that we were called in the night to perform the operation ; which terminated happily, except a Venous hemorrhage, which was checked by compression. From the instant the air had free access to the lungs by the artificial opening, she experienced a great improvement. 10th January. She sat up, and on the 1st of February went to her neighbour, Dr. Evrat, who was affected with a similar disease, to persuade him to undergo the same operation. For five months the improvement continued. She constantly wore a canula in the trachea, and when she wished to speak she closed the aperture with her finger. Towards the third month she could in this way articulate some words at the top of her voice. , In September, 1835, eight months after the operation, the tumour, which had remained stationary at the left side of the larynx, began to increase rapidly, and soon appeared between the upper border of the wound and the canula. Ulceration was soon set up, and frequent hemorrhages resulted. On the 15th of November, she was suddenly attacked with lever, with a stitch in the side, and with a very fatiguing cough. On 60 TROUSSEAU AND BELLOC ON LARYNGEAL PHTHISIS. the left side of the thorax all the signs of pleuritic effusion were observed. Hectic fever ensued, and the patient died about the 10th of December, 1835. Autopsy.—The lungs offered many tubercles, some of which were softened. A considerable purulent effusion occupied the left pleuritic sac. The thyroid gland was decidedly hypertrophied, though its tissue was sound. The larynx was the seat of extremely serious lesions. A great many tumours of variable size, isolated or grouped, occupied all the interior of the larynx, the epiglottis, and a part of the trachea; externally, they projected considerably above the canula,Jand before the larynx, making a tumour as. large as a middle-sized apple. They were here uneven and irregular, and the skin over them was livid, thin, and ulcerated. On each side, principally on the left, and before the thyroid body, there were a great many similar little tumours in the cellular tissue. Within the larynx, at the points unoccupied by the tumours, the mucous membrane was ulcerated and fungous. The aryteno- epiglottic ligament of the right side was healthy, except a slight swelling of the mucous membrane; the left ligament was con- verted into an irregular mass, of the same nature as the tumours. The cartilages of the larynx were broken, and the fragments were found in the tumours. The tonsils were healthy, except a slight tumefaction. The oesophagus, was so contracted at its commencement, that it was not more than two lines in diameter. Cutting into the tumours we have attempted to describe, a few of them were consistent, and creaked under the scalpel, having the colour of the inside of a horse-chestnut, and resembling, in consist- ence, encephaloid, rather than tubercular tumours,—while the smoothness and colour of the cut made them analogous to tuber- cular ganglions. The others were softened and converted into yellowish matter. M. Cruveilhier, to whom we showed the specimen, pronounced the affection to have been of a cancerous character. EXAMPLES OF TUBERCULAR LARYNGEAL PHTHISIS. OBSERVATION XIX.1 Tubercular laryngeal phthisis—Suppurated pulmonary tubercles__Deep ulcerations of the larynx—Destruction of the epiglottis. A gardener, aged thirty-three years, tall, of a lymphatic and san- guine temperament, of a strong constitution and good figure came 1 Louis, Recherches sur la Phthisie, p. 254. SPECIES. 61 to the hospital of La Charite, on the 6th of September, 1824. Five years before, he had peripneumonia, after which respiration re- mained perfectly clear, and from an earlier period he had been subject to a hoarseness which recurred every winter. He attri- buted his indisposition to a sickly season, and had discontinued his labours for six weeks. At first there was cough, with irregular chills, and clear and rare sputa, like broken saliva. The cough continued; the sputa have been rather less clear and more abundant for four months. He has always been very sensitive to cold; the least depression of the temperature gave him a chill. He has had almost constant copious night-sweats, and the fever has increased for the last six months. For the last three, the voice has been somewhat changed; the upper part of the larynx has become the seat of acute pain, and for six weeks drinks have been occasionally rejected by the nose. The appetite had been diminished from the first; for some time digestion has been bad, and there has been occasional vomiting during the cough. No pain in the epigas- trium; no pleuritic affection; no haemoptysis; emaciation has been advancing for three months. Seventh September, face rather pale, debility, insomnolencefrom the cough ; hoarseness, voice broken, extremely cracked. Constant sharp p°ain between the thyroid cartilage and hyoid bone, with dryness and heat, increased by the cough, by speaking, by bending the neck, and by deglutition, which is often difficult, and provokes the rejection by the nose of part of the drinks. The cough is frequent; oppression during the night; a few opaque, yellowish or 0-reenish sputa floated or were at the bottom of an abundant trans- parent fluid. The chest gives a clear sound on both sides anteriorly. Pressure is painful under the left clavicle, the expiration tracheal; under the rio-ht the respiration seemed rather stronger than natural; between the^shoulders it was bronchial, and the voice very ringing —pulse moderately accelerated, heat natural, tongue and pharynx in a healthy state, epigastrium not painful. The patient had a good stool during the night, and only complained of the pain in the throat. Prescr.—Looch, potion gommSe, deux cremes de nz. (A linctus, gum water, and two portions of rice.) The pain continues. There was for some days only a slight heat in the larynx. Constant aphonia, sputa, greenish and thick. Diarrhoea supervened, with loss of appetite, and continued, without interruption, from the 15th to the 31st, when he died. In the mean time, the epigastrium was sensitive to pressure, and the patient imagined he perceived pulsation with the pain. The tongue con- tinued natural. Autopsy.—Neck.—There were numerous little ulcers scattered over the base of the tongue and the inferior parts of the pharynx. The epiglottis, the lateral ligaments, and the superior vocal cords were entirely, and the inferior cords were partially destroyed. Almost all the surface corresponding to this destruction had an uneven aspect, a reddened colour, and some hardness. The aryte- 62 TROUSSEAU AND BELLOC ON LARYNGEAL PHTHISIS. noid cartilages were healthy, and their articular surface naked. The mucous membrane of the trachea was of a delicate rose colour, of a natural thickness and consistence, Thorax.—The lungs were voluminous, and the pulmonary vesicles were generally dilated. The right lung adhered through- out, the left was perfectly free, and had at the summit a sort of depression which corresponded to a small hard mass of gray semi- transparent matter, placed half an inch from the surface, whence a number of rays of the same character were sent off. Near it was a cavity of medium size, furnished with a false membrane, and some portions of hepatised lung. In other parts there were many gray semi-transparent granulations, which decreased from the summit to the base of the organ. In the upper lobe of the right lung there was a considerable excavation, communicating with another in the lower lobe. They contained a red, thick opake fluid, and were tapestried with a gray, firm, semi-transparent false membrane. The rest of the superior lobe contained many softened tubercles and gray granulations, which were numerous in the lower lobe. Heart and aorta in a natural condition. OBSERVATION XX. Pulmonary phthisis, ten months afterwards symptoms of laryngeal phthisis. —Death after three years.—Larynx ulcerated.—Lungs tuberculous. N----, crier, aged forty years, very robust, and of a sanguine temperament, had, during his infancy, two attacks of quinsy at the age of puberty, nasal hemorrhage, and at thirty-four, haemoptysis. From that time he occasionally felt pain in the chest; the cough, at first dry, was afterwards accompanied with purulent sputa, and with chills in the evening, and night sweats, chiefly on the thorax. A year and a half after the establishment of the pulmonary phthisis, symptoms of laryngeal phthisis were developed ; the voice was gradually lost; the larynx became more voluminous and painful to the touch; liquids were swallowed with pain ; marasmus finally ensued, and the patient died after three years of suffering. Autopsy.—The lungs were tuberculous at some points, in others, ulcerated, and containing foyers of pus. The laryngeal mucous membrane was very much ulcerated. OBSERVATION XXI. Laryngeal, after pulmonary phthisis.—Aphonia for eighteen months —Prior history unknown.—Death.—Remarkable alteration of the larynx—A tubercular excavation healed. y A mason, aged forty-four years, entered the wards of the Clinioue of the Medical Faculty of Paris. ^ 'Extracted from the Thesis of M. Laignelet. SPECIES. 63 He was thin,fretful, and appeared hypochondriac ; intellect dull; when questioned he answered in monosyllables, and seemed a very idiot. No fever. He has had aphonia for eighteen months, no other symptom that he complained of, and it was evident that he had been brought to the hospital by his parents, in order to rid themselves of the trouble of keeping him. We learned that he had been idiotic twice, and that he had recently fallen into his present state of prostration after an attack of fever. . . He remained bed-ridden for three weeks, without wishing to rise, without speaking a word, without eating, and finally died of starvation. At the autopsy the brain offered no alteration ; the intestines were shrunk and rather inflamed. The respiratory apparatus chiefly attracted our attention ; at the summit of the left lung there was an enormous tubercular excava- tion which could have contained the fist—its walls were chiefly furnished with a soft membrane, analogous to the mucous tissue; at points a semi-cartilaginous consistence prevailed ; the surround- ing pulmonary tissue was of a blackish gray, and presented some tubercles that were not softened. At the summit of the other lung there were also a few crude tubercles. The larynx, detached with care, offered the following alterations : The vessels at the base of the tongue were much injected, and even dilated, so that all this region presented a diffused rose colour, beneath which were large red, vascular arborisations. The same kind of injection was observed in the mucous membrane of the top and sides of the epiglottis, as well as in the excavations between the external face of the aryteno-epiglottic ligaments, and the inner face of the thyroid cartilage, but it became paler as it approached the under side of the epiglottis, and the inner surface of the larynx. The colour was blood red, and so uniform that it hid the subjacent arborisations. Within the larynx, the pale injections were more marked, and more arborescent about the ventricles and vocal cords than at any other part of the cavity. The mucous membrane was covered with a pale rose coloured mucus ; this mem- brane was decidedly thickened, particularly in the larynx, and the alteration was more marked on the vocal cords and ventricles than in their neighbourhood. Nothing unnatural was observed in the upper opening ot tne larynx nor in the epiglottis. . The superior vocal cords were much swollen, especially the iett, the swelling reached to the base of the epiglottis, nor was it mere enlargement5; there were mamillary protuberances, and distinct, but smalfulcerations, as large as a pin's head; and at the back of the superior vocal cords they were interrupted by a deep ulceration as large as a cherry-stone. On the right side the ulceration had a true cicatrix, which was irregular, whitish, hard, and mammelhform. On the left side the ulcer was deeper and circumscribed by a blacK- 64 TROUSSEAU AND BELLOC ON LARYNGEAL PHTHISIS. ish tissue, and communicated with a sort of excavation, the black bottom of which was formed by the posterior face of the ossified thyroid cartilage which had begun to be necrosed. The inferior ligaments of the glottis were less ulcerated than the superior; still the left one seemed divided for the most of its length by a longitudinal and superficial ulceration, the bottom of which was cicatrised. The ventricles of the larynx were tumefied, their capacity was slightly diminished by the swelling of the ligaments above and below. A blackish tint was observed on each side of the inner face of the larynx, below the vocal cords, and opposite the cricoid cartilage, it appeared to belong to the deep seated parts, and to be seen through the transparent mucous membrane. The exterior of the larynx offered no alteration whatever. In this case we see an aphonia that lasted eight months, and a serious, alteration of all the tissues of the larynx. These dis- turbances evidently followed the softening of the pulmonary tubercles, which could be seen in the large cavern at the summit of the left lung. The sort of mucous membrane that lined this cavity, showed that the softening had long been effected. The brain presented nothing remarkable, and we are forced to conclude that death was chiefly induced by the organic lesion of the larynx, at first produced by the matter of the softened pulmo- nary tubercles, and afterwards continuing, although the cavities seemed disposed to heal. Possibly the lesion of the larynx in its turn contributed to pro- duce the crude tubercles that were observed in the lungs at the moment of death. May not the laryngeal phthisis have been successively effect and cause 1 OBSERVATION XXII.1 Feeble constitution, with congenital predisposition to phthisis.—Frequent recurrence of catarrhs, generally neglected.—Hoarseness; increasing difficulty of respiration, threatening asphyxia.—Progress slow at first, afterwards rapid.—Effects of medical agents at first doubtful, after- wards imperceptible.—Tracheotomy.—Complete recovery from the ope- ration.—Threatened tubercle of the lung.—Left the hospital.—Death from acute phthisis three months after the operation.—Pathological anatomy of the larynx and trachea. Joseph Morin entered the hospital on the 24th of June, 1835; he was thirty-years old,—a turner,—born at St. Senas,—generally resided at Ivry. In consequence of his delicate health, and feeble, lymphatic constitution, he could not give us a distinct account of the commencement of his disease, although he related what had happened for the last eighteen months. During this period he had been subject to frequent colds, with pains in the throat, and hoarse- 1 Communicated by M. Fournet. SPECIES. 65 ness. Three months before he entered the Hotel-Dieu, having one of his attacks, he had applied leeches to his throat. It also appeared that his mother and one of his brothers or sisters had died of phthisis ; he had seemed better than usual, and was taking iodine by the advice of a country physician. On the 24th of June, the day of entrance, he was feeble, rather pale, somewhat emaciated ; voice hoarse and broken, with a sense of pain or rather obstruction in the throat, and in the region of the larynx, to which he often put his hands ; expectoration rather scarce, viscous, and thick, after fits of coughing and stifling, which were at first rare and slight, but finally acquired increased fre- quency and intensity:—while they lasted, the respiration was hur- ried, orthopnaeal, sonorous, sometimes rather hissing, the face was anxious, and the features contracted; at other times the patient was calm and the respiration only a little sonorous and accelerated. The exploration of the chest gave little result; the sound was good, both right and left, and an obscure respiration, neither ex- panded nor vesicular, was perceived at the summits of the lungs, especially of the left, and no abnormal sound was observed, except a slight indistinct crepitus, which towards July became more dis- tinct and persistent. There was an occasional, irregular, febrile condition, with some dryness of the skin. For the first fortnight, gargles, emollient cataplasms to the neck, the frequent application of a few leeches to the lateral regions of the larynx, pediluvia, and a mild diet, were the only means resorted to. At first they were uncertain, and finally lost all influence upon the disease, which became worse and worse. On the 8th of July the voice was lower, hoarser, and more ob- structed, and the respiration more difficult, laryngeal and hissing. These symptoms increased with astonishing rapidity. The patient suffered continual orthopnoea, and occasional fits threatening suf- focation : which were only relieved by the expulsion of a portion of dense viscous mucus. Since the beginning of July, the larynx had been rubbed with the unguent of Autenrieth,—a good many pustules appeared, which provoked a sharp smarting, but produced no melioration of the dyspnoea. Leeches were applied to the sides of the larynx on the 10th and 11th, but without any benefit. On the evening of the 11th, wishing to postpone tracheotomy by relieving the threatened asphyxia, I applied a blister to the front part of the neck. It operated finely, though the patient scarcely felt the pain; but on the next day he had more orthopnoea, and in the evening his face was pale, ashen, and of a violet tint about the mucous orifices ; the tongue was pale violet. The coldness of the extremities, the clammy sweat on the whole body, which commu- nicated the sensation of cadaveric coldness to the face and chest, all announced a speedy dissolution. With a faint and broken cry he demanded the operation. I practised it immediately. It afforded relief; and after the usual accidents, respiration was 66 TROUSSEAU AND BELLOC ON LARYNGEAL PHTHISIS. accomplished through the canula, and convalescence was rapidly established. From the 3d to the 9th of August, the patient continued in a comfortable condition, occasionally interrupted by fever, malaise, and debility; about the end of this time, he fell into a state of ennui and nostalgia, which caused a constant desire to return home. On the 19th of August, yielding to his demands, we let him go ; as he could now wait upon himself and attend to the canula. When he parted from us his words were rather higher, and better pro- nounced than they had been. By auscultation, we perceived at the anterior summit of the left lung, a slight crepitant rhoncus, but only on strong inspirations ; the resonance of this side of the chest was perfectly good; the obscurity, and incomplete pulmonary expansion, hitherto observed, still continued. Morin went to live at Ivry, where he seemed to improve rapidly at first; but in spite of his care, the good regimen to which he submitted, and the great healthfulness of the place, the same gene- ral fever and restlessness, observed at l'Hotel-Dieu, returned, and soon assumed the hectic character. Emaciation, progressive de- bility, and an abundant colliquative diarrhoea, followed ; and after escaping the dangers of a serious operation, this unfortunate man died towards the end of September with the rapid progress of an acute phthisis. To the last he breathed through the canula with- out experiencing any difficulty. The physician who attended him at Ivry, when he opened the body, found great tuberculisation of the summits of the lungs, especially the left. He had the goodness to bring us the larynx and trachea, which I showed to M. Trousseau; and after examin- ing it, we had it drawn by M. Chazal. The os hyoides and the thyro-hyoid membrane were not altered. The tissues that covered the anterior part of the thyroid cartilage, preserved their colour and natural elasticity. But the cellular tis- sue on the lateral parts of this cartilage was rather dense ; and the muscular fibres of this region, both the thyro-hyoids and the infe- rior constrictors of the pharynx, were brown or blackish, and slightly softened. The space comprised between the inferior bor- der of the cricoid cartilage, and the first ring of the trachea, was occupied by a prominent, irregular tumour, formed of the scirrhous induration of the soft parts of this region. The cellular tissue was whitish, and of a semi-lardaceous consistence, while the brown muscular substance was confounded with it. This induration and swelling extended through all the upper part of the trachea, especially around the wound of this oro-an- but it decreased as it left the larynx, so that the cellulo-fibrous tissue that surrounds the trachea was healthy in its two lower thirds The opening made by the operation remained gaping • its bor- ders projected forward, and were plaited or crimped by the projec- tion of the cartilaginous rings that had been divided, and which SPECIES. 67 were not covered by any membrane of cicatrisation—the interven- ing tissue was somewhat thickened. The trachea was dilated in its antero-posterior diameter at the wound by the separation of the rings, and at the same point it was narrowed in its lateral diameter; but, below this, it was much flat- tened from front to rear, and the transverse diameter was much increased. Blackish, indurated bronchial ganglia, surrounded the extremity of the trachea at its bifurcation. The epiglottis was permanently erect, and curved like a spout. The swelling of the aryteno-epiglottic ligaments was such that the superior opening of the larynx was reduced to the following dimensions,—transversely, four and a half lines; from front to rear, four lines. The two enormous tumours that resulted from this swelling, completely filled the spaces between the postero-lateral portions of the thyroid cartilage and the posterior opening of the larynx; embracing the arytenoid cartilages and adjacent Pa.rts>— they extended to the borders of the epiglottis, and even diminished, by their bulk, the antero-posterior diameter of the oesophagus. There was less swelling on the left than on the right side ; its cha- racter was cedematous; but the deeper and more central parts were somewhat indurated. . The postero-inferior (little) horns of the thyroid cartilage were naked, and projecting in the midst of the ulcerated, grayish, indu- rated, and divided soft parts that surrounded them. This part ot the cartilage, for the extent of seven lines, was hard, ossified, and blackish; in a word, necrosed. From this point to the top of the trachea, there was a large rounded excavation, nine lines in diameter, the borders formed ot degenerated tissues, of a grayish black; at the bottom we saw the whole of the posterior part of the cricoid cartilage, naked, ossified, and converted into a blackish rough necrosis, one part of which was already isolated by the effort at elimination ; it was contained in a kind of excavation, with solid, but not bony walls, and was a true sequestrum. . n , The posterior membrane of the trachea, as well as the cellulo- fibrous external tissue, was much indurated, and three lines thick ; the muscular coat constituted the greatest part of the thickening, and presented bundles of fibres, separated by whitish bands, that were lost in the submucous cellular tissue, or in the fibrous sub- stance externally—they were composed of indurated intermuscular cellular tissue. . , The tracheal glands were increased in size and indurated , at the upper part of the organ, where the alteration was greatest, they were even confounded with the induration of the tissues. All the inner part of the larynx, above the vocal cords, was swelled, and occupied by extensive but superficial ulcerations, divine- the part a reticulated aspect. They only occupied the thick- less Sf the mucous membrane. Anteriorly, the vocal cords were 68 TROUSSEAU AND BELLOC ON LARYNGEAL PHTHISIS. swollen so as to reduce the ventricles to two little dimples, but the posterior half of the cords and ventricles was obliterated by a arge ulceration, occupying all the lower third of the aryteno-epiglottic ligaments, and extending to the inferior border of the cricoid carti- lage, being sixteen lines in its vertical and thirteen in its transverse diameters. The bottom of this deep, irregular, ulcerated surface, presented at its upper part some shreds of blackish and hardened tissue; below, there was a large excavation, in which were seen ne- crosed fragments of the cricoid cartilage. To the right, it was not so deep, and seemed only formed by the decomposition of the soft parts around the ossified and necrosed cartilage. The sequestrum was found to the left of this excavation, where the walls were shining, resistant, and cartilaginous in their characters. Below the anterior part of the superior vocal cords, the mucous membrane was covered with patches of little superficial ulcera- tions. Similar alterations were also observed at the upper part of the trachea, around the wound of the operation. OBSERVATION XXII. bis. Frequent catarrhs.—Aphonia.—Inspiration of alum.—Sulphuretted draughts. —Melioration.—Return of the symptoms.—Touching the throat with nitrate of silver, no beneficial results.—Rational signs of pulmonary phthisis. Madame M---- was twenty-nine years old. Her mother had been a victim to the cholera, and her father died, at forty, with ca- tarrh. She has not nursed any of her six children, two of whom died young; one of the others, five years of age, is scrofulous; and two little girls, one three years and the other eleven months old, are rachitic. The patient has always been subject to colds in the winter. In the month of July, 1835, she took a more violent and more obsti- nate cold than she had before experienced, and spat blood four or five times, which had not before happened. On the 26th of August, she was in the following state:—The menstrual discharge had been suspended for three months; fatiguing cough, especially at night; almost deprived of sleep; viscid, opaque sputa, adhering to the vessel; dulness under both clavicles, espe- cially the right. Respiration not mixed with rhoncus, but the expiratory murmur much stronger than the inspiratory. Considerable dyspnoea; extreme debility ; general pallor. At the same time that the cough began there was hoarseness which, within a fortnight, has amounted to complete aphonia- still there is no pain in the larynx, nor difficulty of deglutition. Nothing observed on examining the throat. l Pulse eighty-five. Scarcely any appetite, but digestion good. SPECIES. 69 Prescription.—Infusion of pectoral flowers; night and morning a pill of a grain of powder of digitalis, to be progressively in- creased to twelve grains a day. . 10th of September. The cough is diminished; the digitalis caused some nausea, and dazzling of the eyes; the urine is more abundant; the general health and aphonia remain the same. The dose of digitalis was diminished two grains per day. 19th. Some melioration, no nausea, urine abundant ; pulse seventy; aphonia continues complete. .. Prescription. Inspirations three times a day of the following powder:— &. Acet. plumb, crystal, p. i. Pulv. sacch. cryst. p. vii. M. Stop the digitalis, which is too depressing. . . 21st. She complains that the powder caused long and fatiguing fits of coughing. We observed that she had used it too freely, and diminished the quantity one-third, after which there were only a few efforts at coughing which soon ceased; the pulse is sixty; sne feels pretty well, though weak ; she has always perspired freely; her voice has returned a little; she makes herself heard, and emits the sound with some force. Draught with half a grain of opium: to drink through the day four coffeecupfuls of the following solution :— *. Potass, sulphat. gr. xij. Aqua destillat. i$. iv. M. Each dose to be mixed with half a glass of milk and water. 23d September. Marked melioration; the voice has more reso- nance, expectoration easy, not much cough, appetite improved. She grows stronger. Same treatment. f .. 26th. The patient is gaining strength; she sits up part ot he day; she sleeps well; the appetite improves; the expectoration preserves its characters; the night sweats continue; the voice is more sonorous and stronger than at our last visit. 29th. She says she feels stronger; her voice is still a f'ttle pack- ed, but nearly/natural; she has continued the saturnine inspira- tions without interruption. Same prescription. . . . 3d of October. The improvement continues; she sustains her strength; the appetite improves; the cough is less violent and less fatiguing, but she had a considerable haemoptysis this morning. The night sweats have not ceased. The same prescription. _ 8th Another haemoptysis, but milder; the same state of progres- sive melioration; auscultation gives the pure respiratory murmur but expiration is louder than inspiration; the voice remains as before' 14-a *rous 6 70 TROUSSEAU AND BELLOC ON LARYNGEAL PHTHISIS. The same prescription, except the inspirations. 11th, 14th, and 17th. Same state, strength increasing, night sweats diminishing, the sputa are less abundant, and more mucous. Same prescription. 20th. The patient went out yesterday; she feels better; the voice is more harsh. 23d. Some streaks of blood in the sputa; the voice is still harsher; all the functions are well performed; the cough grows less frequent and less fatiguing. Same prescription. 27th. The aphonia is almost as great as at our first visit. Same prescription. 30th. Same state; same prescription. 5th of November. More night sweats; expectoration easy; the sputa are more mucous, and less abundant; some fits of coughing which are rather fatiguing; slight fever. She has been out for some days. Considerable oppression, but she can go up stairs; digestion easy; appetite as good as in health; almost complete aphonia. We touched the larynx with a solution of one ounce of alum to a pound of water. The patient said she had been advised to use for several days inhalations of an infusion of elder, which seemed rather to increase than diminish the aphonia. 8th. The same hoarseness and fatiguing cough; night sweats have returned for two days; she complains of their insipid and nauseous odour. The throat was touched with a solution of alum. Same prescription; draught with half a grain of extract of opium. 12th. Complete aphonia ; same general state. The throat was touched with a solution of one part of nitrate of silver and four parts of water. 15th. There was an abundant haemoptysis yesterday; less night sweats. The nitrate of silver has effected nothing; it is to. be renewed. 20th. No change since the 15th. The touching with the solu- tion to be discontinued. 23d. Same state. We applied a cautery to the left arm; con- tinue the solution of the sulphate of potash, and the draught with half a grain of opium. 15th of January, 1836. We had ceased visiting the patient for two months, during which time she had been frequently better and worse. During the last month, the night sweats have recurred with renewed intensity. The oppression is considerable; the cough fatiguing • expectora- tion easy, streaked with blood; the pulse small, feeble, frequent, with decided exacerbations in the evening. We thought we heard gurgling in the summit of the right lung; still, she is full of hope, and has sufficient strength to attend to her daily occupation. The appetite, although diminished, is still pretty SYMPTOMS. 71 good; the food is well digested, and her voice is somewhat im- proved. Prescription. Draught of sulphuret of potassa four grains, water three ounces. In the evening, a julep, with half a grain of opium. February 1st. Nearly the same state, but the patient has had, during the past week, a dysentery, with violent colic. Hectic fever cannot be mistaken. The appetite diminishes from day to day, the strength fails, and it is easy to prognosticate the termination of this terrible assemblage of symptoms. It is difficult to assign a place to the laryngeal phthisis, in the order of development. The alteration of the lungs was observed at the same time with that of the larynx, and the patient said the hoarseness and catarrh came simultaneously. At any rate, we have seen that the voice was nearly restored, while the pulmonary dis- ease continued. It seemed checked in its progress, the appetite and strength returned, the night sweats diminished, and the pulse re- gained its natural standard. Suddenly the hoarseness returned; it could not be modified by the means employed, and the pulmonary affection assumed renewed activity. . It is easy to see the influence exerted by the affection ot tne larynx on that of the lungs; which proves, at least, that if the tubercular diathesis had produced primarily a disease of the larynx, it could, in turn, impress pulmonary tubercles with new activity; and, moreover, that we should not neglect treatment of the larynx, even when we attribute the disease to the lungs. CHAPTER V. SYMPTOMS. After describing, in a general manner, the symptoms of laryn- geal phthisis, we shall specify the forms and peculiarities of each species- and then endeavour to point out the relations that exist between especial lesions of the larynx and particular series of symptoms. And, in review, we shall mention the diseases that might be confounded with laryngeal phthisis, and show how they differ from it. m . General symptoms of laryngeal phthisis.—During the first period of the disease, local symptoms alone claim the physician s attention The general symptoms are rarely developed, except when acute diseases of the larynx give rise to laryngeal phthisis, or when that assumes a threatening aspect. It is, therefore, the local symptoms that should first attract our whole attention. 72 TROUSSEAU AND BELLOC ON LARYNGEAL PHTH A. Alteration in the quality (timbre) of the voice.—This is one of the first symptoms that attract attention. At first, it is oiten a simple want of power; oftener a decided hoarseness. Sometimes continual, at others, recurring only when the larynx has been fatigued, or when the patients have been exposed to a change of temperature. It is an important fact, that the transition to a colder atmosphere is less prejudicial than the change from cold to warm. This sin- gular result has been repeatedly observed in our patients, and we confess we have been much surprised at it. The voice, also, be- comes hoarser, in proportion to the time the patient has been up, so that, on the morning visit, when the patient has just awoke, we have observed the voice much clearer than in the evening. This is probably owing to the larynx having gained some repose during sleep, and becoming fatigued during the day. Another observation, which seems to have escaped writers, is, that if there be a good appetite for food, the hoarseness is generally very decided, and that it disappears, more or less completely after the meal, but soon returns to the same point as before. It is not a useless exercise to examine into these minor details, because we may be often deceived in our diagnosis of the state of the larynx, if we are ignorant of these singular changes, and of the causes which produce them. The menstrual period, also, affects the hoarseness, which is generally greatest at the approach, or passing off of this discharge. Venereal indulgence, also, increases it considerably. The hoarseness is intermittent in the first stage, but soon becomes continual, and may remain so until the close of the disease, though extinction of the voice often supervenes in the second stage. It is difficult to describe the approach and symptoms of the hoarseness ; though a practised ear recognises some sounds which correspond to peculiar forms of alterations in the larynx. Thus, there are some kinds which convey to the ear a mucous and broken sound, but which show that the column of air has not a free pas- sage ; this is what we have called the mucous hoarseness: it is heard in simple catarrhs, and when constant, commonly only indi- cates catarrhal inflammation. In other cases, the voice is hoarse, uneven, and rough; this we call stridulous: it is a bad symptom, as it almost always corre- sponds to an ulceration, or to vegetations in the larynx. The aphonia, by which we mean the complete loss of the faculty of speech, comes on in the second stage of the disease, and is a serious symptom, but subordinate to many conditions which mo- dify it. The aphonia, which comes on suddenly, with an acute disease of the larynx, and continues when the disease has passed into the chronic form, is not nearly so alarming as that which advances progressively. That which succeeds the mucous hoarseness is not so bad as that which follows the stridulous, for obvious reasons. SYMPTOMS. 73 In some patients, the aphonia presents curious varieties. The voice may be completely extinguished in the evening, and merely hoarse in the morning, at the moment when the patient gets up, and immediately after eating. This form may indicate a superficial organic lesion, or simply a catarrhal affection. The inequality of the voice is a more common phenomenon in laryngeal phthisis than has been commonly supposed, or than the patients themselves believe. When the larynx is diseased, the volume of sound is instinctively diminished, and the emission of air is generally proportioned to the intensity of phonation. But, patients who, in spite of the alteration, wish to give the original force to their voice, find that the want of calibre and strength ot the vocal instrument gives rise to unexpected and discordant sounds. We have often noticed this in singers and advocates. Colonel B., who enjoyed a high reputation in the army, furnishes a remarkable instance. .. He had a chronic affection of the larynx of two years standing. In ordinary conversation, his voice offered the stridulous hoarse- ness in a slight degree, but it was perfectly even, and, except its force, it was easily modified for animated discourse. But, when he commanded his regiment, there were such uneven and singular bursts, that nothing short of the greatest respect prevented the offi- cers and soldiers from laughing. The finals, for which the vocal tube had to be largely opened, could not be pronounced without change ; thus, the word lance was never uttered without the sound beiug converted into a broken cry. This has some similarity to what is often observed in youth at the age of puberty; differing in this, that the latter are not hoarse, but have two different timbres, and a discordance of the voice. B Cough —Does not differ from that observed in most diseases of the thofax: it is generally frequent, and by spells. The sound always corresponds to that of the voice. When there is aphonia, or the stridulous hoarseness, it has a peculiar sound, which it is important to have well described. We have called it eructant, because, when the patient coughs, he seems to make a suppressed eructation. This character is always diagnostic of a serious alteration of the larynx. In a common cough, we may observe that the air is expelled by the action of the diaphragm and expiratory muscles, while it is re- tained, on the contrary, by the contraction of the glottis; the ex- nulsory effort finally overcomes the resistance and drives the air Through the larynx with a sound which we call "cough. Now when the sound, instead of being clear and short, is pro- longed and gulping, it is because the glottis is unable to move freely or because deep ulcerations prevent it from closing; which explains why the eructant cough is so bad a symptom. The difference in frequency is altogether inexplicable. Some are tormented by an incessant cough, so obstinate that they cannot 74 TROUSSEAU AND BELLOC ON LARYNGEAL PHTHISIS. enjoy a moment's rest, and their food is rejected by the contrac- tion of the expiratory muscles; others, whose autopsy presents the same lesions, have scarcely coughed, and succumbed only under the increasing swelling of the mucous membrane of the larynx, and the consequent asphyxia. The cough is generally calmed by food and drinks during the first stage ; but, in the second, aliments pass partially into the larynx, and cause convulsive fits of cough, which nothing will relieve. The frequency of the cough is not nearly so unfavourable a symptom as its hoarseness, and the change in the volume of the voice. Some persons have an obsti- nate cough for years, while their lungs remain free, and there is no alteration in the larynx: one of our patients, Baron Tre- mont, is in this situation. He coughs in the most fatiguing manner; the most energetic medicines afford him no relief; but his voice remains clear, and nothing indicates tubercles of the lungs, or ulceration of the larynx. C. Signs furnished by the expectoration.—The expectoration in simple laryngeal phthisis furnishes negative rather than positive signs. It is commonly purely mucous, transparent, and not very tenacious; sometimes very abundant, and a simple mucous secre- tion (phlegmorrhagie;) sometimes less copious, when the matter is more thickened. When there is an ulceration, the expectoration, without losing the characters already described, offers some peculiarities. Little puriform masses, often mixed with streaks of blood, and even quite bloody, are expectorated, without effort, rather by an attempt to clear the throat than by a cough. We shall hereafter see the diag- nostic value of the abundance of puriform expectoration. D. Pain.—In more than half the cases of laryngeal phthisis there is no pain from the beginning to the end of the attack. It is even remarkable, that they who complained a little at the com- mencement of the disease, when the phlegmasia was acute, did not suffer at all when the mucous membrane and the cartilages of the larynx were nearly destroyed by ulceration or necrosis. In a few, there is some pain in the larynx, especially at the origin of the trachea; it is rather a sensation of smarting, which we have never found very distressing to the patients. On the con- trary, almost all suffer acutely when they swallow, and patients tell us they feel no pain in speaking or breathing, but when they swal- low, and therefore their disease must be in the pharynx only. An examination of the pharynx shows nothing which could explain the symptoms ; and if we have an opportunity of making autopsic examinations of the organs of voice, we find considerable organic alterations. How, then, shall we explain this want of correspond- ence between the anatomical lesions and the symptoms? We think it may be easily done. What parts of the larynx are ordinarily most affected ? By turning to the chapter on pathological anatomy, it will be seen that, in ulceration, caries, or necrosis, the mucous SYMPTOMS. 75 membrane, which covers the epiglottis, the aryteno-epiglottidean ligaments, and the arytenoid cartilages, is almost always the seat of inflammatory engorgement. Now, this forms the anterior part of the pharynx, and no effort of deglutition can be made without the mass of food being pressed against these inflamed and often ulcer- ated tissues. When, on the contrary, the front part of the larynx is touched through the skin, the inflamed mucous membrane is protected by the hyoid bone and thyroid cartilage, and, consequently, does not receive impressions of pain, unless we indent the cartilages, or move them considerably: add to this the fact, that the membrane at the upper opening of the larynx is endued with extreme sensibility, while that lining the organ has very little:—we have satisfied our- selves of this by experiments made when we have been obliged to perform tracheotomy. E. Signs obtained by inspection.—By opening the patient's mouth widely, and depressing the tongue with the handle of a crooked spoon, so as to bring the base of the organ well forward, the veil of the palate, the uvula, the tonsils, and the bottom of the pharynx are brought into view. It is important to ascertain the condition of these parts, especially when we have syphilitic laryn- geal phthisis. The state of the uvula, also, deserves especial atten- tion, because the procidence of this organ may sometimes cause serious inflammatory symptoms in the larynx. But the exploration of the epiglottis is of extreme importance, as we have before remarked : although this organ belongs to the tongue, its pathological relations require it to be considered as an appendix to the larynx. Pathological anatomy shows us, indeed, that the larynx is rarely much diseased, without the epiglottis par- taking in the affection. But there are few patients in whom we can see the epiglottis: we have met but two, in whom the throat and the tongue were so formed that we could see the whole of its upper surface. By making the patient utter a cry during the examination, the epiglottis may be seen starting forward at every expiration. In these two patients, whose disease was not far advanced, the mucous membrane was of a cherry red, and decidedly thickened. It may be inferred that the aryteno-epiglottic ligaments and the lining of the larynx were in the same condition. It would, doubtless, be very important to be enabled to examine the larynx by means analogous to those furnished by the speculum. Some years ago we endeavoured to construct a speculum laryngis. M. Selligue, a very ingenious mechanic, himself a sufferer from laryngeal phthisis, of which he has been completely cured, con- structed for his attending physician, a speculum formed of two tubes, one of which conveyed light to the part, while the other re- turned the image of the glottis, reflected in a mirror at the guttural extremity of the instrument. M. Sanson, cutler, made us a spe- culum on the principle of that just described. This instrument is 76 TROUSSEAU AND BELLOC ON LARYNGEAL PHTHISIS. of difficult application, and there is not one patient in ten who can bear its introduction. Indeed, its volume fills the space comprised between the free border of the veil of the palate and the upper surface of the tongue. When placed in the mouth, it provokes such uncontrollable starts, (haut le corps,) that it is necessary to remove it immediately : if it touch the bottom of the gullet, which is almost sure to happen, the pharynx contracts convulsively, and with such energy as to force the instrument into the mouth. In the most favourable case, when the instrument can be retained in the isthmus of the gullet, the inevitable constriction of the pha- rynx still prevents our seeing the deeply-seated parts. There is another difficulty, which is enough in itself, to prevent our using this instrument. The epiglottis covers the upper part of the larynx so completely as to prevent the possibility of obtaining a reflection of the parts in a mirror; and further, the light intro- duced by the instrument must fall upon the upper or lingual face of the epiglottis, and, consequently, casts its shadow precisely on the larynx, and thus hides it from our view. Bennati was, there- fore, mistaken, when he pretended to have seen the glottis with the speculum of Selligue; he generally saw only the lingual surface of the epiglottis, and very rarely the superior opening of the larynx, and that only when the accidental elevation of the epiglottis permitted. The glottis is so deeply and peculiarly situated that it is impos- sible to explore it with the speculum even in the dead subject, much less upon the living, especially when we consider the con- vulsive effort that attends its introduction, even in those who have been most habituated to it. We have never observed swelling of the anterior region of the neck in simple laryngeal phthisis; this is owing to the mucous membrane being separated from the subcutaneous cellular tissue by the whole thickness of the cartilages. It is remarkable that even when there is considerable necrosis or caries of the cartilages, there is seldom any external tumefaction which would lead us to suspect such serious disorders. We have only once seen a tumour point between the cricoid and thyroid cartilages ; this was almost insensible at first, but coincided with decided laryngeal phthisis. It was necessary to perform tracheotomy to prevent asphyxia, and we afterwards saw the tumour developed as an enormous cancer. Obs. XVIII. F. Signs obtained by touch.—In pressing the larynx a crepita- tion may sometimes be perceived, which has been mentioned by some authors, especially by M. Laignelet, as a sign of laryngeal phthisis. This sign at first deceived us, thinking it was produced by the rubbing of the necrosed portions against one another. But experi- ence has taught us that it is most frequently found when the larynx is perfectly healthy; hence it loses its value as a diagnostic. Still it should not be neglected, but we must pay great attention to dis- SYMPTOMS. 77 tinguish whether the crepitation be produced by the friction of the cartilages against the vertebral column, or whether it result from the grating of portions of cartilage that have been separated from each other by caries or necrosis. In the latter case the noise would probably be drier, and might be produced by squeezing the larynx; while in the former, it is never hard, except when the whole organ is moved. We confess we have never distinctly heard the crepitation resulting from the pathological state of the larynx. As for touching by the mouth, which is advised in almost all works on cedematous laryngeal angina, we may observe, that the exploration of the glottis is physically impossible, as the finger cannot be introduced into the larynx. The examination must be confined to the epiglottis and upper part of the larynx. But this exploration is attended with more difficulty than is sup- posed by those who theoretically recommend it without having practised it on many subjects. It is far from being so simple as touching the neck of the uterus; as soon as the finger has reached the base of the tongue and has merely touched the epiglottis, there is so energetic and general a spasm induced, that the finger can re- main in contact but a second or two, so that we cannot thus obtain much information, and can only detect great alterations, such as vegetations or tumours. We cannot by this means ascertain the existence of ulceration in the aryteno-epiglottic ligaments;—at least, we have never been able to do it, although accustomed to this mode of examination. We read with astonishment what some authors tell us in their writings upon cedematous laryngeal angina ; when they say it is very easy to recognise this serious disease by the touch. We es- teem it a very difficult, if not impossible diagnostic means, for the reasons already stated. Touch is, therefore, rarely applicable in our diagnosis of diseases of the larynx. G. Signs furnished by respiration.—These are among the most important next to the signs furnished by the voice. In the first period of laryngeal phthisis, the respiration is not generally dis- turbed, except under peculiar circumstances, and when the patient takes violent exercise, in which case the inspiratory sound is a little braying; nothing of the kind is observed in expiration. If by chance in the course or at the commencement of the first period there should suddenly occur an increase of laryngeal inflammation, then symptoms of acute croup will be manifested ; but this is an exceptional case, and in proportion to the progress of the disease wrll be the increase of oppression, which may be owing to two causes. If the disease of the larynx have induced consumption by the means we shall explain, or if there exist simultaneously pulmonary tubercles,—a powerful cause of laryngeal phthisis, the patient will have shortness of breath and panting on the least exercise, and sometimes even when in a state of repose. In this case 78 TROUSSEAU AND BELLOC ON LARYNGEAL PHTH the oppression does not differ from that observed in cases of debility and other forms of phthisis. But there is another important torm of dyspnoea,—that which accompanies narrowing of the larvnx- This has peculiar characters, and we shall endeavour to describe its form and course. When the disease has been of long standing, and the obstruction begins to attain considerable age, the patients who had suffered mere panting (anhtlation) accompanying their debility, begin to experience what they call fits of asthma ; at first, these occur in the latter part of the night, sometimes they are awakened four or five nights successively by paroxysms which increase in force. During the day they are better, but have an unusual difficulty of respira- tion, especially when they take violent exercise, or ascend a stair. After a while they cannot lie in bed, but remain seated and propped up with pillows. They have similar attacks during the day, and from this time the inspiration is hissing and respiration is prolonged and braying. In a few days, such violent paroxysms come on, that the sense of impending suffocation causes the patient the deepest anxiety ; the fits pass off, leaving continued orthopnoea. More violent and more frequent paroxysms follow, until the patient finally perishes from suffocation. These fits are truly frightful; with livid face, open mouth, ex- panded nostrils, suffused and projecting eyes, and streaming with perspiration, the patient rapidly paces his chamber, and occasionally lays hold of objects that he may breathe more easily; sometimes the head is inclined upon the breast, but more frequently reversed; when, at last, overcome with fatigue, he sits down for an instant, soon to get up again. He tears all covering from his head, neck, and chest, and exposes himself eagerly to the cold air at the window, which he throws up with a sort of transport. Inspiration is hissing, short, and executed by the whole of the inspiratory muscles; but expiration, although less braying, is long, and as laborious as inspiration. Expiration is generally passive, but in these cases it is quite as active as inspiration. At last the patient falls into profound depression ; respiration is more frequent, shorter, and apparently easier; the breath is not warm; the whole body grows cold; the face changes from livid to pale, and is glossy; the eyes grow dim, and death occurs in a sort of calm. The time from the first fit of orthopnoea until death is generally fifteen to twenty days; the fits begin to recur more than once a day about five days before death. To this, however, there are numerous exceptions. Sometimes a paroxysm occurs in the course of the dis- ease, which proves almost immediately fatal. We will state two cases of this character; the first was noted by M. Marjolin and ourselves; the second by Morgagni. SYMPTOMS. 79 OBSERVATION XXIII. Forty-two years of age—Previous good health—First symptoms in the larynx—Sudden attack of suffocative angina—Voice hoarse, almost ex- tinguished—Progressive swelling of the lips of the glottis—Threatened asphyxia—Crude pulmonary tubercles. Dr. C. of Calais, came to Paris, in the month of October, 1835, to consult M. Marjolin, who asked us to see the case with him. The patient was 42 years old, and had led a very busy and laborious life; he had always enjoyed good health. In March, 1835, he began to have some dry cough, which became more fre- quent, but was still unaccompanied with expectoration. There was soon some difficulty of respiration, which did not prevent him from making thirty or forty professional visits every day. Last August, he was taken in the street, one morning, with a fit of suffocation, which increased so rapidly that he was unable to proceed. When bled, he breathed more easily, and was taken home, where he was bled again, and leeches were applied, followed by revulsives. After fifteen days he was somewhat relieved, and returned to his business. He still had fits of dry, rough, hoarse cough, and short- ness of breath. He was soon unable to go up stairs without suffer- ing great inconvenience. When we saw him there was considerable alteration of the features; he says he has been greatly emaciated since he was taken. Expiration was easy; inspiration laborious and hissing; the cough had precisely the sound of a hoarse eructation (rot enroue.) We made him read; the timbre of his voice was hoarse and rough ; when he took breath, after reading a passage, the inspira- tory sound seemed distant, and accompanied with a decided hissing. We carefully examined the lungs, and found manifest dulness at the summit of the left. Bellows' sound on expiration ; no pulmo- nary expansion at this point; some moist ronchus. There could be no doubt as to the diagnosis; pulmonary tuber- cles were evidently present, but scarcely any had been softened, as he had no expectoration ; and still the larynx was so much diseased that he had been threatened with asphyxia, and the oppression con- tinued to make constant progress. We merely advised him to use simple means, and in two days he set out for Calais. A fortnight had barely elapsed, when we heard that he had another attack of suffocation, which resisted the most energetic measures. We must mention another case (No. 49.) that of M. P. who had been for several months in a state of constant orthopnoea, from which he recovered: though for a long time we thought tracheotomy would be our only resource. The cases of Madame **** (Obs. 49 bis.) and 80 TROUSSEAU AND BELLOC ON LARYNGEAL PHTHISIS. of Miss Basinet (No. 49 ter.) were of a similar character, and all were attacked with laryngeal angina, presumed to be syphilitic. The progress and order of these symptoms are the more import- ant, as by them alone the physician can judge of the propriety of an operation. . Indeed he must know what is the usual term of the period of dyspnoea, and he should know exactly what are the signs of ap- proaching dissolution, that he may hold himself in readiness to per- form tracheotomy, and not practise it sooner or later than neces- sary. When on the subject of treatment, we shall specify when and how it should be performed. Let us now recur to the respiration, and the forms it presents in the last period of the malady. Bayle and M. Thuillier have particularly insisted, that when the aryteno-epiglottic ligaments were cedematous, inspiration was more difficult than expiration ; and they have made this an essen- tial character. We must say, that although aware of the value they attached to this symptom, and seeking it with much care and attention, we have never been able to meet with it. It is true that there is a decided hissing during the inspiration, and that this is not observed in the expiration; but the same sound may be observed in all cases where the larynx is narrowed, at any part or in any way; because, in the inspiratory effort, the air traverses the larynx with double velocity, as may be readily ascertained by counting the precise period of the two movements, by the second hand of a watch; it follows, that the increased velocity must produce a much louder noise than the gentle and slow expiratory movement. The difficulty is not dependent upon the free border of the cedematous ligaments falling into the larynx during inspiration, and thus diminishing the capacity of the glottis. This ingulfing of the superior border of the larynx is not so easy as has been supposed. Indeed, in inflammatory oedema—and we have shown that this disease is nearly always inflammatory—the consistence of the mucous membrane, and especially of the sub- mucous cellular tissue, is not that of flaccidity, but generally of extreme tension. In the dead subject, it is true that these OBdematous parts are sometimes so flaccid that they quiver, and might be made to obey the pressure of the inspired air; but this is a very rare circum- stance, and we have yet to learn that it is any thing more than an effect of decomposition, or that it does not result from the blood of the engorged parts leaving them, and in that way producing the flaccid condition, which did not exist during life. The same phe- nomenon may be observed in other tissues, which were tumefied and resisting previous to death, but sunken and flaccid afterwards. We must now turn to the great question of intermissions in the fits, and in the spasms of the bronchia. Autopsy shows us a fact, which will not explain the symptoms, to wit, incomplete obliteration of the larynx. Careful observers SYMPTOMS. 81 find that the glottis is never entirely closed, and that there is always a passage for the air. Hence the conclusion has been drawn that there had been a spasm of the bronchia, complicated with the dis- ease of the larynx, which was the final cause of death. This idea appeared the more plausible, because intermissions had been ob- served in the paroxysms. In regard to the anatomical fact, cited by the partisans of this idea, we should first say, that the swelling of the mucous mem- brane, though/considerable during life, diminishes after death ; and consequently the opening of the glottis at the autopsic examination may be larger than it had really been while the patient lived. But, admitting that the glottis had the same capacity during life, still death was caused by want of sufficient air—if not by asphyxia, in the rigorous sense of the term. It is absurd to suppose that the epiglottis could be completely closed during life, for the occlusion would not bring on death by slow asphyxia, such as we observe in croup and laryngeal phthisis, but it would cause immediate asphyxia in the space of one or two minutes. Hence the passage of air must have been free until a certain point. It is not the same with insufficient respiration. If the glottis have a capacity represented by two, instead of a capacity equal to four, and if, for the proper aeration of the blood, the air should bear a proportion to the natural dimensions of the glottis, is it not evident, that with this diminished capacity, the lungs will receive only half as much air as is necessary for sanguification ? On this hypothesis the venous blood will not be completely arte- rialised, and the patient will be in the same predicament as the animal upon which Bichat experimented, when the blood flowed from the carotids of a bright vermilion if the trachea was left open, brownish when half closed, and black when the air was excluded: thus, when from any cause the larynx is half closed, the blood assumes the character of that in the animal which did not breathe a sufficient quantity of air, and it must follow that if asphyxia ensue slowly, it is no less a real asphyxia. It is easy to make analogous experiments on ourselves. Thus, if you breathe through a tube equal in capacity to one of the nos- trils, respiration will be found to go on comfortably, and the func- tions will be well performed. But if you take a quill, respiration will soon become laborious, and at last true orthopnoea and a sense of suffocation will supervene. Considering the influence exerted by the blood on the nerves and nervous centr s, and their effects upon respiration, we may understand all the spasmodic phenomena, and all the nervous symptoms, and we shall comprehend the intermission, as being like that observed in most neuroses; so that we need not have re- course to spasms of the bronchia, which no one has ever seen. They who have attempted to explain asphyxia by spasm, have looked for some anatomical element in these tubes which could account for it. Muscles have been demonstrated, and we have the 82 TROUSSEAU AND BELLOC ON LARYNGEAL PHTHISIS. high authority of Reisseissen and Cruveilhier, that the bronchia are semi-cartilaginous and semi-muscular. We admit, that with the aid of the magnifying glass and the finest instruments fibres are found in the bronchia, which in their fascicular arrangements, bear a very close resemblance to mem- branous muscles, such as those of the intestines. But mere ana- tomical resemblance is not all that is wanting, especially as it is seated rather in the colour than the texture : it must be a func- tional resemblance, which our experiments have failed to demon- strate. If the bronchia were provided with muscles of organic life, they ought to be contractile; and this contractility should be mani- fested by motion, as it is in all muscles of the same class. The following experiment seems to show the non-existence of contractile fibres. We have had several horses killed by a sudden blow on the head, and immediately opened their abdomens; then by a large and rapid incision, we detached the diaphragm, and removed the trachea, the lungs, and the heart. With long buttoned scissors we cut the principal divisions of the bronchia, and stimulated them in every way, in order to excite muscular movements. But we have never seen the slightest contraction in any of our various experi- ments, whilst the heart, the muscles of the life of relation, the intestines, and the bladder, long continued to offer evident signs of this contractility. If it be objected that the bronchial muscular coat is endowed with less energy, and therefore soon loses its function, we answer that in the same animal the muscles which have most energy are the first to lose their contractility; thus, death begins in the muscles of the life of relation, then in the heart, and in the heart, first the left side, then the right ventricle, and last the right auricle. The digestive tube next parts with its vitality, and of this apparatus, the oesophagus before the intestines. If we study these phenomena in other classes of the vertebrata, we shall find that birds, which seem endowed with the most ener- getic external life, lose their muscular excitability very rapidly after death; then come the mammalia, which preserve it rather longer; next in order, reptiles, in which it remains a long time after apparent death ; and finally, fish,—the heart of an eel has been seen contracting twenty-four and even thirty-six hours after death. If from the vertebrata we descend to insects, we shall see that some of them preserve their muscularity for an extraordinary length of time; the head of a decapitated beetle may preserve its power of closing its horns forcibly for four, six, or even eight days. If, then, the muscular coat of the bronchia possessed any con- tractile property it would not be extinguished in two or three minutes. Perhaps it will be said we cannot justly estimate the influence of the nervous system, and that the cessation of the cerebrospinal influence may suffice to abolish contractility immediately. But this objection, which is absurd, may be solved by a direct and pal- SYMPTOMS. 83 pable fact. The trachea of a horse may easily be'exposed for several inches; if it be then cut, lacerated> or stimulated in any way, it is impossible to perceive the least muscular contractility. In the numerous operations we have performed upon the trachea, we have never perceived any muscular contractions in its fibres; and when we have passed probangs into the bronchia we have never felt the whalebone clasped by the contraction of the bron- chia, even when the sponges were soaked with very irritating fluids. How can we admit the spasm of the bronchia in the face of all these facts ? Why should we bend all analogous laws of anatomy and pathology to "explain phenomena that are rendered perfectly clear by the partial occlusion of the larynx? Further, if this orthopnoea were caused by spasm of the bronchia, why does tracheotomy afford instant relief? An examination of the simplest physical laws will show more clearly the slender basis of this theory of spasm. In the orthopncea, when the inspiratory effort creates a tendency to vacuum in the thorax, the pressure of the external air is such that the lower part of the sternum is pressed in, and nearly touches the vertebral column. But, we ask, if the air entered the chest freely, what an immense energy there must be in the spasmodic contraction of the bronchia to resist the pressure of the atmosphere ? and this in a muscular tissue, in which contractility has never been demonstrated! This explanation has invaded almost every department of our science. A surgeon experiences a sudden difficulty when intro- ducing the tube of Anel's syringe, and explains it at once by the intervention of spasm, rather than by a simple sanguine congestion, caused by the irritation of the instrument. It might as well be said that the nasal fossae, those bony canals, endued with a delicate mucous membrane, were affected with spasm, when, without appre- ciable cause, and without the possibility of the secretion of mucus, and simply by a sudden swelling of the olfactory membrane, stop- page of the head, and impossibility of breathing through the nostrils, suddenly occur. Again : why should we refer to spasm, when it is so easy to ex- plain the symptoms by the swelling of the mucous membrane 1 But, it will be asked, why should these singular intermissions occur, if the disease be not nervous, but depend upon a fixed, immovable organic lesion 1 We answer, by referring to a law of our organism, a law de- rived from facts. A cancer is immovable, the pains are intermit- tent ; a calculus remains in the bladder, though the symptoms are not constant. Intestinal inflammation is ever present in dysentery; the colic occurs at long intervals. The product of conception re- mains in the uterus during parturition, but the pains are intermit- tent. The collection in a hernial sac constantly strangles the intestine, while the vomiting, the syncopes, and the colics are paroxysmal. There is undoubtedly something nervous in all this; 84 TROUSSEAU AND BELLOC ON LARYNGEAL PHTHISIS. but, while making this concession, we are far from admitting that it is wholly nervous. The reader will pardon our entering into so long a discussion. It was necessary to have our premises well established; and we hav>5 endeavoured to clear up a question that has been long and sharply debated, and which is not yet clearly settled in the minds of some eminent men. We have been un- willing, in this examination, to oppose assertion to assertion, but have endeavoured to confirm our views by experiments which seemed to us conclusive. Signs furnished by the mode of deglutition.—In some patients attacked with this disease, besides the pain in the act of deglutition, already noticed and explained, we find another serious symptom, to which our attention is naturally directed ; it is the impossibility of swallowing liquids or food that is minutely divided, and cannot be formed into an alimentary bolus. Most authors attribute this phenomenon to the destruction of the epiglottis, thinking that this organ did not exactly cover the entrance of the larynx, and that, at the moment the food passed the base of the tongue, it necessarily fell into the air passages. The facts which we have observed have taught us nothing respecting the mechanism of this functional difficulty. They have only proved that the destruction of the epiglottis did not prevent some patients swallowing perfectly; and that others, whose epiglottis was untouched, could not execute any movement of deglutition without letting the food enter the larynx. Examples will be found in the two following cases. OBSERVATION XXIV. Detmer, a currier, has been a vigorous man, of quick and pas- sionate character, of a bilious temperament, and was born of pa- rents who died young; his father was destroyed suddenly by a fit of mania, to which he was subject; his mother sank under typhoid fever. The patient, who is in his fortieth year, has been subject to re- turns of cold every winter for eight or ten years, sometimes accom- panied with pleuritic pain : he was treated for pleurisy three years. During his catarrhal affections, he has had five or six attacks of sore throat, which yielded readily to simple means. In December, 1834, he took his wonted cold, which, as usual, harassed him very much, though he never spat blood. This cold was accompanied, from the beginning, with sore throat and an ob- stinate hoarseness, which increased until June, when the tonsils were touched with burnt alum, and he took eight or ten grains of the extract of hemlock each day. These measures proving ineffica- cious after a week's trial, they were abandoned after eight days, and the l«ft tonsil was incised. The operation was unsuccessful. Insufflations were made with a powder of nitrate of silver. No benefit was derived from this medication. 22d September, 1835. Present slate : general emaciation, pallor SYMPTOMS. 85 of the face and skin. Complete aphonia for four months; acute pain in the throat when he swallows either solid or liquid food. The rio-ht tonsil is deeply ulcerated, as is the remnant of the lett. The bottom of the gullet is of a livid red. The larynx is not the seat of any pain, except when the finger is placed on the right superior border of the thyroid cartilage, where a little eminence is felt, as large as a pin head, which is sensitive under pressure. 1 he respiration is not hissing, and the air seems to enter the lungs with- out any hindrance. There is considerable dyspnoea whenever the patient takes a few steps; the cough is frequent and fatiguing, with considerable expectoration: some of the sputa are streaked with pus; others viscid, small, opaque, rounded, and swimming in a sort of mucilage. Thorax resonant throughout; gurgling under he clavicles; pervigilium caused by the cough; night sweats on the face and chest; pulse small, frequent, and weak ; appetite irregular digestive functions good ; neither diarrhoea nor constipation; urine na23d September. We recommended the patient to enter the Hotel Dieu, where he was admitted, and placed under thecue of M. Gueneau de Mussy, and he was ordered-Gargle of barley water one pound, honey of roses two ounces, and hydrochloric acid twentv drops; gum water, poppy tea, soups. 28th Same state, perhaps more debility. Same prescription. (The nails a^e not curved, or, at least, they have not the curvature peculiar to phthisical patients.) _ . 5th of October. Same state; same prescription. 9th The patient is growing weaker; his features are altered, the abdomenPrS tumefied and torpid; there has been constipation for eio-ht davs. Death occurred at seven in the evening. lltopsjThirty-nine hours after death.-The lungs are crowded wifh tubefcles in all their stages; there are several caverns at the SULar!/n^-Hypertrophy of the follicles at the base of the tongue; their mucous membrane is the seat of flat, irregular ulcerations esoeciX towards the base of the epiglottis, where it is eroded and SSv- the fiSborder of the epiglottis is partially destroyed, and Fr^larivstohed; its tissue is altered towards the upper part, so lu Fuu\J^\Zw cheesy fragments may be removed by a scalpel hand e Th^^ aryteno!epiglo?tic folds are tumefied, puffy and pre- sent he fritted aJpect of old ulcers. The arytenoid cartilages ap- sent tne ireueui p ft Qne mere u a lmle KpSSS fSl atpVct, from which ichorous pus may be PrAlUhe laryngeal mucous membrane presents a sombre yellow aspect and Zpuffiness analogous to that of the ^yteno-ep.glq*Uc hTments the ventricles of the larynx are almost faced by this ligaments, entering angle, formed by the tfpSof tt'thyrXa^tilage, there is arf uleeratK.wh.ch has 14—b 86 TROUSSEAU AND BELLOC ON LARYNGEAL PHTHISIS. destroyed the whole thickness of the mucous membrane and carti- lage, and its base, which is the external perichondrium, is much softened at this place. The mucous membrane, that covers the laryngeal face of the epiglottis, is almost entirely destroyed; the superior vocal cords are confounded with the investing mucous membrane, and partially transformed into a lardaceous tissue, which creaks under the knife; the arytenoid cartilages are de- stroyed in their two upper thirds. Before dissecting the larynx, we pressed the epiglottis down over the glottis, and found that it covered only about two-thirds of the aperture. This is an important observation ; for, on the very morning of his death, Delmer drank, without manifesting any pain in swallowing. This observation is very analogous to one noted by M. Louis, in whom the epiglottis was entirely destroyed; but, in his case, de- glutition was difficult, and the patient seldom swallowed drinks without rejecting part by the nose. We now present the history of a patient whose epiglottis was entire, but who rejected both food and drinks by the nose, and let them fall into his larynx. OBSERVATION XXV. General eczema, disappearing under proper treatment.—Pain in the larynx. —Hoarseness, dry cough, abundant expectoration, then dysphagia.— Spontaneous melioration.—Reappearance of the symptoms after a cold.— Emaciation.—Complete aphonia.—Repeated fits of dyspnoea.—Trache- otomy.—Death soon after the operation.—Lungs tuberculous.— Ulceration of the larynx and trachea.—Ossification of the cartilages. M. L., of Dunkirk, aged fifty years, came to Paris, in August, 1835, to consult M. Marjolin. He had lost his voice: a serious affection of the larynx was prognosticated. We were called in, and continued to treat the case conjointly; and, until his death, on the 9th of December, 1835, he submitted to the medications we had prescribed. M. L. had been captain in the marine, then in the merchant ser- vice; he rarely took cold; and neither he nor any of his family had ever experienced symptoms of thoracic disease. He has had three children, neither of whom have been scrofulous or tuber- culous. In the month of August, 1835, shortly after establishing himself at Dunkirk, M. L. had an eruption over his whole body, which, from his description, we suppose to have been eczematous. At first it was confined to the face, and was unsuccessfully treated during a year; finally, in 1826, it disappeared, but a pain in the throat immediately came on, with a sense of oppression, and for some time the patient had a fetid expectoration of bad character. Two blisters, applied to the arms, relieved all the symptoms. In SYMPTOMS. 87 1828, the disease of the skin yielded, and was only observed to return at distant intervals, and with very mild characters. In 1829 and 1830 he was bled; in 1831 one of the blisters was laid aside. Every thing went on well until July, 1833; this year he had not been bled. M. L., without any appreciable cause, now began to experience pain in the region of the larvnx, with a dry cough. Towards the end of the year, the voice became hoarse, and was accompanied with tenacious expectoration, which was only expelled by c0"sl- derable effort. From the month of December, 1833, until May, 1834, the patient was confined to his room, and the pain in the larynx was very acute, especially in efforts at deglutition. He could only swallow liquids, and that with great pain ; some drops always entered the larynx, and caused an extremely fatiguing cough. In the months of May and June, 1834, the cough and hoarseness increased, and finally there was complete aphonia. But in July, the symptoms were completely removed, the appetite re- turned, deglutition became easy, the cough ceased almost entirely, the strength returned, and the voice was restored, though hoarse and weak. This state continued until August 1835, when M. L. took a severe cold after exposure. Deglutition immediately be- came difficult, the cough obstinate and paroxysmal, the expectora- tion abundant. Three months later he decided to come to Paris, at which time we first saw him. . He is emaciated and pale, although his muscular system is still well developed. His strength has failed considerably within a few months. Cough frequent, and without noise, only producing a hollow and metallic sound; complete aphonia; deglutition of liquids impossible, except by very small quantities, and only when the head is thrown forward. In spite of these precautions, a few drops sometimes enter the larynx, which cause an obstinate and convulsive cough ; larynx painful upon pressure. A careful ex- amination of the mouth, that shows the tonsils are a little swollen, and that the mucous membrane of the back part of the pharynx, is covered with hypertrophied follicles. The most scrupulous examination of the chest, at different times gave no evidence of organic lesion of the lungs. There was constantly a greenish, homogeneous expectoration, which is partially diluted in water, and settles to the bottom of the vessel, bearing a strong resemblance to tuberculous matter Ihis f, excretion was more abundant than it should have been if it came * from the larynx alone. Moreover, the nails had the peculiar conformation so often asso- ciated with tubercle, (tabidis ungues adunci,) and this sign, con- ioined with others, now assumed some importance. Auscultation was deficient in one sign of immense value, the resonance of the voice. His aphonia prevented our observing its modifications ; and as there was much hissing in the larynx, we could not appreciate the various respiratory sounds. 88 TROUSSEAU AND BELLOC ON LARYNGEAL PHTHISIS. We put the patient on the use of asses' milk and artificial Bonnes waters; and of irritating, followed by narcotic frictions to the front of the larynx; we used insufflations of the subnitrate of bismuth, of alum, of sugar candy, calomel, and of acetate of lead; we touched the upper part of the larynx with a solution of nitrate of silver. All our endeavours were inefficacious; after remaining three months at Paris, M. L. departed for Dunkirk, where he used milk and Bonnes waters. It should be remembered that he had a cau- tery on one arm, a blister on the other, and a hemorrhoidal fistula, which suppurated considerably. So far he has had no fever; about the beginning of November, the pulse was accelerated; the heat of the skin became more de- cided, and at the same time his appetite diminished, emaciation increased, and there was occasional diarrhoea; in a word, all the symptoms of consumption were manifested. Still, about the 24th of November, he had a fit of slight dyspnoea about three o'clock in the morning. The attack lasted two hours, and he was not other- wise disturbed. He had a slight paroxysm the next day. 26th. He had two less violent attacks. 27th. A much worse fit occurred in the morning, after which the difficulty of respiration continued. The attacks became more protracted and violent from day to day. He could no longer ascend the stairs without feeling suffocated. At night he could only sleep in a sitting posture, and propped up with pillows. Although in our consultation we had foreseen this aggravation of the symptoms, and had presented the necessity of a surgical operation (tracheotomy,) the family remained free from alarm, and M. L. himself, who wrote to us on the 2d of December, spoke of a rather greater difficulty of respiration, which was only expe- rienced on going up stairs. But on the 5th of December, a fit of suffocation came on with so much violence, about four o'clock in the afternoon, that their family physician, Dr. Delherbe, was called for the first time. He found him in a state of impending asphyxia. Dr. Delherbe instantly perceived the necessity for tracheotomy, but being unwilling to assume the responsibility of the operation, he wrote, with M. L.'s consent, for us to come with all haste. We did not receive the letter until the 7th, at two o'clock p. m., started at seven, and were unable to reach Dunkirk until the 9th, at three in the morning, just two hours after M. L. had expired. M. Delherbe gave us the following details:—The night of the 5th and 6th he was very much disturbed. As it had been observed that the attacks were worse at the close of the day, large doses of sulphate of quinine had been administered. The 6th was passed pretty comfortably; the night of the 6th and 7th was worse than the preceding. On the 7th there were two attacks which were near destroying the patient. The morning of the 8th he was in a horrible situation ; from two until seven p. m., there was a little calm, after which suffocation recommenced with new intensity. At SYMPTOMS. 89 nine, M. L. received the letter we had written from Paris two hours before our departure, by which we announced our arrival at ten o'clock; this hope made the patient more comfortable. At eleven suffocation became so threatening that Dr. Delherbe held himself ready for the operation. At one o'clock on the morning of the 9th, while we were detained at the port of Bergues by the severity of the military regulations, the patient, about to breathe his last, finally authorised M. Delherbe to practise tracheotomy. This operation was neatly performed. A gum canula was in- troduced into the artificial opening, but was almost immediately obstructed, and death ensued a few moments after the operation. At nine o'clock, eight hours after death, we proceeded to make the autopsic examination, assisted by MM. Delherbe and Boudi- nier. The lungs contained a great many crude tubercular masses ; some were suppurated and excavated at the summit of the organ. There were no adhesions, nor traces of pleurisy nor pneumonia. We removed the tongue, pharynx, larynx and trachea. The ton- sils were healthy; the tongue was enormously tumefied. At the base of this organ, on the sides of the epiglottis, the mucous crypts were larger and more rounded than natural. Examining the posterior part of the larynx, externally, we found the epiglottis erect, swelled, hard, and the submucous cellular tis- sue cedematous and hard, as in the oedema of new-born infants. It looked like adipocire. The colour of the mucous membrane was rosy white. The epiglottis was curved towards its inferior face. On the edge of the right aryteno-epiglottic ligament there were superficial ulcerations, continuous with those within the larynx. All the lining mucous membrane of the larynx was ulcerated and scattered over with prominent pimples. The ventricles were scarcely perceptible, and only marked by an uneven line. Probing these ulcerations with the bistoury, prominent bony particles were found, which checked the instrument. There were also numerous superficial ulcerations along the trachea The mucous membrane was decidedly swollen, and of a diffuse rose colour. There were many points of ossification in the cartilaginous rings, sometimes opposite the ulcerations and sometimes separate from them. After having the parts delineated by M. Chazal, we boiled them, the better to examine the cartilages. The epiglottis was not altered- the thyroid was completely ossified posteriorly and infe- rior y cauLginous above and before, but friable, the cartilaginous insensibly mingling with the ossified parts. Anteriorly and on the eft sde, th™ tfssue, which remained cartilaginous yielded under the least pressure, and was raised by fragments with the submu- C°TVetty^?Pe"it'ies, which we have mentioned in the midst of theUlcerations™ the internal surface of the larynx, were inti- mated united with the cellular tissue, in the mids of which they seemed to take their origin, rather appertaining to the perichon- drium than to the thyroid cartilage. 90 TROUSSEAU AND BELLOC ON LARYNGEAL PHTHISIS. The cricoid cartilage was completely ossified, except its lower border, and in front; so that the ring was closed anteriorly by an isthmus of cartilaginous friable tissue. The parts which remained cartilaginous were locked between the bony plates of the ossified parts, and after boiling they separated just like epiphyses, and left an uneven and rough indenture. Many of the tracheal cartilages were completely ossified. Bonnet regarded scirrhous induration of the epiglottis as the cause of this extreme difficulty of deglutition. Epiglottidem adeo quandoque induratam, deprehendi, ut non solum,, loquelai aboli- tionem inferat, verum etiam non nisi frusta magna deglutire aigrum posse efficiat. Potits et omnia quai cochleari exhibentur, tracheam intrant, rigidiore ab epiglottide non satis clausam. (Sepulcretum, lib. 3, sect. 4, Obs. VI.) This opinion appears to us quite as admissible as that which attributes the difficulty of deglutition to destruction of the whole or part of the epiglottis. The symptoms enumerated by M. Louis are as follows:—Fixed pain in the upper part of the thyroid cartilage or immediately above it; difficulty of deglutition and rejection of drinks by the nose, the pharynx and tonsils being perfectly healthy. These signs, collected by M. Louis from eighteen patients affected with ulcerations of the epiglottis, are sometimes incorrect, as we have proved, since they may all be present without our finding ulceration of the epiglottis, (Obs. 25,) and all may be wanting when the epiglottis is destroyed (Obs. 24.) We regret exceedingly that so exact and minute an observer as M. Louis should have made no observations upon the introduction of food into the larynx, confining himself to its rejection by the nasal fossae. In the midst of the uncertainty which exists respecting the causes of food falling into the larynx during the act of deglutition, we shall not attempt to give an explanation of the phenomenon; for it appears to us impossible to refer it to any constant lesion. Of the differences of symptoms according to the species of laryn- geal phthisis.—We have mentioned the general symptoms of simple laryngeal phthisis ; with a few exceptions they are found in all the species. The tone of the voice, the cough, the local swelling, the mode of respiration and deglutition, are precisely the same, whatever may be the species, because they depend upon an organic modification common to all—to wit: the inflammation, ulceration, and narrow- ing of the larynx. But each species also offers some peculiar symptoms which it is interesting to observe, and which we shall pass in rapid review. Syphilitic laryngeal phthisis.—When speaking of pain, we said there was very little in simple laryngeal phthisis. In this form it is sometimes very acute, especially in the act of deglutition, rather than when you press upon the upper part of the larynx. This SYMPTOMS. 91 pain is explained by the pathological condition of the pharynx and tonsils, which are generally covered with ulcers, or are deeply furrowed with cicatrices; the veil of the palate is sometimes ulcerated. There is always a considerable erythema of the mucous membrane, and frequently more or less swelling of the submucous cellular tissue. There is sometimes oedema of the uvula and of the anterior pillars of the veil of the palate. Touch- ing, which we have shown to be so unimportant in our diagnosis of simple laryngeal phthisis, is here often of great importance, and should never be neglected. Thus, in the case of M. P. (No. 49,) the introduction of the finger into the back of the mouth proved the existence of enormous syphilitic vegetations on the pharynx and over the superior opening of the larynx itself. It is true that when the syphilitic ulceration is seated in the ventricles alone, or within the larynx, it cannot be distinguished by any peculiar sign, and can only be recognised by the previous history, and the collateral symptoms that may exist on the skin, the bones, &c. The course of the syphilitic form is different from that of simple laryngeal phthisis. In the latter, the disease generally begins in the larynx or trachea, whilst in most cases the former is an exten- sion of the lesions of the pharynx or nasal fossae, so common in syphilis. It is therefore necessary to pay especial attention to this peculiarity ; for experience shows that the larynx is ordinarily the seat of lesions analogous to those previously observed in the throat. Thus a syphilitic erythema of the nasal fossae and pharynx is followed by laryngitis without ulceration ; and, on the contrary, we may presume that syphilitic ulcers and necrosis exist in the larynx when an analogous lesion has been observed in the nasal fossae, and when the tonsils and veil of the palate have been deeply ulcerated. Tubercular laryngeal phthisis.—We admit the existence of this form whenever there is, at the same time, confirmed pulmonary phthisis. Hence we find in this species the signs of pulmonary consumption added to those of simple laryngitis. It is, then, by stethoscopic signs, by the nature and abundance of the expectora- tion, and by the rapidity of the emaciation, that we distinguish this species. In another place we shall state the manner in which we conceive simple laryngeal phthisis may give rise to tubercular pul- monary consumption. When tubercles are once developed, the laryngeal affections will progress more rapidly. Indeed, in tuberculous patients we find the simplest phlegmasia? have a fatal tendency to be aggravated, and to take on unmanageable characters. Thus, the slightest sprain occasionally becomes the cause of a white swelling, and the mildest affection of the larynx may occasionally cause laryngeal phthisis. Hence, when making our prognosis of the diseases of this organ, we should pay the closest attention to the slightest signs of pulmo- nary tuberculisation, and not anticipate a cure, when we can only 92 TROUSSEAU AND BELLOC ON LARYNGEAL PHTHISIS. palliate the disease temporarily. The case of M. L. of Dunkirk, (No. 25,) is demonstrative of this. The following history is analo- gous; in it we obtained only an apparent cure. OBSERVATION XXVI. Tuberculous laryngeal phthisis at the onset—Thirty-seven years old—Born of a consumptive mother—Laryngeal hemorrhage—Hoarseness—Signs of tubercle—Apparent cure. M. F. S., a lawyer, in the month of March, 1833, experienced an acute pain in the region of the larynx ; for eight days there were fever and bloody sputa, which evidently came from the larynx. Active antiphlogistic measures were employed, and all the symp- toms yielded in a week. The voice was at first a little hoarse, but became perfectly restored. M. S. occasionally took colds, but they never lasted more than three or four days. He got along very well until the beginning of 1835, when a slight, clry cough came on, and a sense of pricking in the larynx. The voice was clear and sonorous. In June, 1835, the same symp- toms as those of 1833 were renewed, after a violent diarrhoea, and lasted four days; they reappeared after a fortnight, but with less intensity. As the bloody sputa continued, M. S. came to Paris for our advice. The voice was very weak and hoarse, the respiration rather short. The region of the larynx was rather painful, conveying the sensation of heat and pricking. Two or three times a day the patient experienced an obstruction in the larynx, and by hawking, rather than by a cough, he raised a semi-bloody, semi-purulent sputum, the size of a five-sous piece, which was all that he expec- torated. We called MM. Andral and Louis in consultation, who examined the chest carefully; there was a little dulness in the right posterior region, and resonance of the voice, without any sign of tubercular softening. Still we decided that he had tubercles in the lungs, and feared that laryngeal ulcerations would soon be developed if they did not already exist. The patient was ordered to maintain silence, to drink asses' milk and artificial Bonnes waters during the autumn, to insufflate the subnitrate of bismuth, and afterwards a powder of one part of acetate of lead to seven parts of powdered sugar candy. These measures were carefully followed, and we recently received a letter from M. S. in which he mentions his complete recovery; we do not believe that the tubercles were cured, but they do not manifest themselves by any symptoms. Here we have evidently cured a laryngeal phthisis, which was tuberculous, in the commencement, and we have done in the larynx what is so often effected in the intestine. Indeed, when pulmonary ubercle has not advanced too far, it is easy to cure the diarrhoea TERMINATIONS. 93 which depends upon incipient alteration of the glands of Peyer and Bruner. But when the tubercular cachexia has made any progress, the least irritation of these intestinal crypts immediately acquires an uncontrollable tendency to ulceration. In the case we have just mentioned, it is probable that were the pulmonary tubercles to become softened, the commencing laryngeal phthisis which we had once so easily cured, would resist all our medications, however energetic and thorough they might be, and that it would go on, with the disease of the lung, to a fatal termi- nation. Cancerous laryngeal phthisis.—The symptoms of this form do not really differ from those of simple laryngitis; as may be seen by referring to case No. 18. We should suppose from analogy that the character of the pain would be important; but on consult- ing the only fact of this kind that we have met with, we find that the tumour never caused any lancinating pains, nor did the patient complain of any other difficulty than that inseparable from such a lesion as her case presented. The presence of the fully developed tumour alone can aid us in the diagnosis, for in the early stages it would be impossible to dis- tinguish it from any other tumour. In the chapter on the different species, we said we might be justi- fied in making a dartrous laryngeal phthisis—we will adduce our reasons. It is a fact, which cannot have escaped those who have studied the pathology of the larynx, that persons who have long suffered a chronic affection of the Schneiderian mucous membrane, often have phlegmasia? of the larynx and pharynx, which alternate with the disease of the nose, or appear to be an extension of it. We have quoted a case (No. 44.) Many similar might be presented. But as these chronic phlegmasiae of the nasal mucous membrane are generally chronic eczema, is it unreasonable to admit something of the same kind in the larynx ? We leave our readers to decide the question. . . Differential diagnosis.—There are three diseases with which it might be possible to confound laryngeal phthisis;—tracheal phthisis, cedematous laryngeal angina, and asthma. ' The first we do not consider separable or distinguishable trom laryngeal phthisis, with which it is almost always united, as we have shown in Chapter II. M Cayol, who sustained a thesis on tracheal phthisis in 13IU, thinks, on the contrary, that this disease has characters peculiar to itself but the symptoms he has indicated are so precisely those of laryngeal phthisis, that it would be utterly impossible to distinguish them We have his thesis in our hand, and after having attentively revised his observations, we are convinced that the larynx had been superficially examined; our readers will no doubt unite with our opinion when they read of M. Cayol's patients dying generally with fits of orthopnoea, having the larynx healthy, and in the trachea ulcerations which did not diminish its calibre. 94 TROUSSEAU AND BELLOC ON LARYNGEAL PHTHISIS. (Edematous laryngeal ansina is in nearly the same predica- ment. When this affection fs acute, it can only be confounded with croup; when chronic, which is most frequently the case, it is oftener one of the terminations of laryngeal phthisis, and, therefore, merely a symptom of this affection. This is not the place to dis- cuss the relations which exist between the two diseases; this im- portant point in pathology will be treated at length in our chapter on terminations. Asthma.—By this term, we do not mean the habitual difficulty of respiration which is observed in patients with disease of the heart or lungs. It appears impossible to confound this form of dyspnoea with that produced by laryngeal phthisis ; we shall, therefore, say nothing about the differential signs. The only asthma about which there can be any doubt, is that singular ner- vous affection of the respiratory apparatus, characterised by pa- roxysms of orthopnoea, followed by more or less perfect calm in the respiration. When you witness two cases, one caused by asthma, the other by narrowing of the larynx, you will be struck with the strong similarity of the phenomena. The attitude, expression, and mus- cular efforts are all alike; but one pathognomonic sign estab- lishes an immense interval between the two diseases: in asthma, the voice is sonorous; in laryngeal phthisis, it is extinct. Without considering the period of the fit, if we compare the other symp- toms, we shall see in what they differ. The oppression of asthma comes on suddenly, without warning, or appreciable cause; after a few hours, it ceases; and as it attacked its victim in the midst of full health, so it leaves him with no other symptom than a little fatigue. These fits of asthma have been preceded and are followed by others of a similar character. But, in a large majority of cases of laryngeal phthisis, the orthop- noea comes on gradually, and has generally been introduced by a palpable difficulty of respiration, and by an alteration in the vo- lume of the voice. When the paroxysm has ceased, the respiration is far from being clear ; and the fits go on increasing in their intensity, until at last the patient reaches such a degree of asphyxia, that death is threatened, or is only averted by a surgical operation. We, therefore, think it impossible to confound two diseases, whose course and form are so different. CHAPTER VI. TERMINATIONS. § 1st. Before we explain how simple laryngeal phthisis causes death, it may be well to enquire into the usual termination of con- sumption. TERMINATIONS. 95 Death may be produced by tubercular pulmonary consump- tion ;—this proposition, sustained by the highest authorities, ap- peared so evident, at first sight, that no one has taken the trouble to examine it, and it had almost become an axiom in pathology. We hope, nevertheless, to advance some opinions which have hitherto been considered paradoxical, though they are now begin- ning to be generally acknowledged and received by the profession. The phthisis (consumption) would not be truly pulmonary, in the strict and literal sense of the term, unless the suppuration of the respiratory organ, its chronic inflammation, and its tubercular softening, had gradually carried the patient through all the stages of marasmus, until life was extinguished, without any other organ of the economy having been attacked. But this is rarely the case: life is ordinarily destroyed by a host of sympathies, that have been awakened by the pulmonary phleg- masia, or by the absorption of morbid products. And, without speaking of functional lesions, such as the acceleration of the pulse, increase of heat, &c, we have many organic lesions, which, though secondary, are nevertheless often more immediately fatal than the primary affection itself. Thus, the colliquative diarrhoea of consumptives, which is the symptomatic expression of a phleg- masia in the alimentary canal, induces death more rapidly than the most extensive suppuration of softened tubercles. The secondary symptom has here more value than the primary lesion, if we re- gard only danger. It being well established, that, in pulmonary phthisis, although the first disorder is evidently in the lungs, death is usually caused by more serious organic lesions foreign to the respiratory appa- ratus, we think it will be easy to assign the true nosological position of tubercular laryngeal phthisis. If, indeed, the chronic disease of the larynx have long been the principal affection, it may be considered the cause of death; and, when alterations of other organs, more or less nearly associated with it, are also present, we must not deny the existence of laryn- geal phthisis. In this case, the well-established priority of lesions would be our chief reason for naming the disease. If the luncr be first attacked, and if the mesentery and follicles of the intestine°afterwards become the seat of disorders, which are more immediately mortal, we should, nevertheless, call the disease pulmonary phthisis. If, on the contrary, the tuberculous swellings of the mesenteric ganglia had marked the onset of the attack, and the ulceration of the small intestine had followed; and, finally, in the last stage of existence, pulmonary tubercles had been deve- loped, and softened; we should say, (according to the expression of our predecessors,) that our patient had a mesenteric phthisis, upon the same principle that, in the other case, we decided upon pulmo- nary phthisis. For the same reason, when the series of local and general phenomena has clearly commenced in the larynx, and when while the laryngeal lesion is still progressing, the lungs, the 96 TROUSSEAU AND BELLOC ON LARYNGEAL PHTHISIS. intestines, and the mesentery present signs of tuberculisation, we should still say that the patient had laryngeal phthisis. You may say, if you choose, that he had laryngeal phthisis, then pulmonary phthisis, then tubercular enteritis, then mesenteric atrophy; but, at last, it was laryngeal phthisis. Nevertheless, we admit there is an immense difference between laryngeal and pulmonary phthisis. This consists less in their cause (for both are considered tuberculous) than in the extent and importance of the diseased organ, and in the number of sympathies either may awaken. It appears that a chronic disease of the larynx would require a long time to cause death by consumption ; whereas we all know the frightful rapidity with which it occurs in gallop- ing consumption, as it is called. We do not wish to assimilate these species, but merely to show their points of contact. Hitherto we have confined our comparisons to tuberculous affec- tions, and we confess that our reasoning may be rather defective; indeed, tubercle is a general fact in the economy, and if the lungs be most frequently affected, it is no less true that almost all the organs may participate; the same is true of cancer. Hence it follows that the coincidence of lesions in different parts of the body does not by any means prove that there was a necessary connection between the primitive lesion, or rather between the organ first affected, and those which afterwards suffered. When, therefore, tubercles exist simultaneously in the lungs, the larynx, the intestine, the mesenteric ganglions, and in the various parenchymata, we are not bound to say that the patient suffered from pulmonary or laryngeal phthisis, but that he had a tubercular phthisis, which is quite another affair; but custom prevails, and the species of phthisis is named from the organ most severely affected; we shall conform to this usage, always observing the order of priority more than that of severity. From ail that has been said it results, that in tubercular laryn- geal phthisis, death by consumption is less due to the lesion of the larynx itself than to the other accompanying lesions which are rather concomitant than consecutive. In fact this form is only the expression of a general morbid constitution. Let us study simple laryngeal phthisis and ascertain how it may produce death. We have never seen a single case of chronic dis- ease of the larynx which caused death by consumption; but other practitioners, whose testimony is unimpeachable, have seen what a long acquaintance with the hospitals and an extensive private prac- tice has not exhibited to us. The cases which we have given under Nos. 8, 9, 10, 11, 12, 13, and 14, and which are annexed to the chapter on species, as types of simple laryngeal phthisis, suffici- ently prove that the lesion of the larynx may alone produce death by consumption. But we, as well as our predecessors, have observed chronic dis- eases of the larynx, causing a fever very like hectic, and producing considerable emaciation and debility; and, if the swelling of the TERMINATIONS. 97 mucous membrane and the consequent suffocation did at last cause death, it is no less true, that decided consumption had commenced before the orthopnoea occurred. From this degree of consumption to that which characterises confirmed phthisis there is truly but a single step. But how does death occur in the simple form of laryngeal phthisis ? By consulting the cases we have cited it will be seen in an instant, that the hectic, the abundance of expectoration, the violence of the cough, the pervigilium, and finally the various derangements of digestion, have gradually destroyed the patient, while' the autopsy discovered nothing to explain these secondary symptoms but the alterations of the larynx. Here we may truly attribute death to laryngeal phthisis, in the strictest sense of the word. But these cases are very rare, as M. Andral1 has observed. Under ordinary circumstances, the affection of the larynx, when not far advanced, and when unaccompanied by an obstinate cough, or fever, or oppression, scarcely ever causes emaciation ; but when these symptoms occur, the patients soon fall into a bad situation. Dyspnoea advances, and death supervenes on asphyxia. This is the most frequent mode of termination. Here there is not, properly speaking, any laryngeal phthisis, for there is no consumption ; but custom prevails, and this name is left attached to the disease, because the patient would have passed gradually through all the stages of consumption, had not his life been destroyed by the obliteration of the air-passages. It seems difficult indeed, at first sight, to comprehend how a chronic ulcerative phlegmasia of the larynx could by itself bring on consumption. The surface of the mucous membrane is so limited, the suppuration is generally in so small amount, the pains so trifling, the sympathetic relations of the organ of so little im- portance, that it needs the imposing names we have cited in the chapter on species, to support belief in the existence of simple laryngeal phthisis. . We can readily understand how chronic inflammation, ulcera- tion and suppuration of the kidneys, intestine, bladder, or a large portion of the cellular tissue, might gradually interfere with the circulation, excite febrile reaction and bring on marasmus. But here another circumstance must be taken into the account; the continuance of the cough which fatigues both the lungs and the expiratory muscles, and which prevents the patient's enjoying a moment's rest: the frequently considerable difficulty of deglutition, the impracticability sometimes of swallowing the least portion of food without being instantly seized with convulsive cough and suffocation ; in a word, pervigilium and inanition suffice, we thins, to explain the marasmus and death. Simple laryngeal phthisis, then, generally destroys the patient 1 Clinique Medicale, torn. ii. p. 220. 98 TROUSSEAU AND BELLOC ON LARYNGEAL PHTHISIS. differently from the two other forms, or from continuous suppura- tion in other organs, independent of tubercular lesion. Pulmonary phthisis is a very frequent termination of laryngeal phthisis. We have already stated that it often produces serious disorders in organs more or less removed from the lungs ; we can suppose that it may itself be provoked by an analogous cause and be con- secutive. We have given some cases which show the justness of this view, and refer the reader to them. (Obs. 23 and 33.) One of these cases is much more conclusive than the others in favour of this opinion, it is quoted from M. Bulliard.1 (Obs. 33, bis.) The subject of this observation, after having been tracheoto- mised on account of an acute laryngeal angina, wore the canula constantly for fifteen months. Eight months before death, a care- ful auscultation indicated no tubercles in the lungs, and autopsy showed many that were suppurated ; hence it is difficult to believe that the phlegmasia of the larynx did not cause the development of these morbid products. If we compare this case with that of Mme. Petit, (No. 18, Chap. Species,) we shall see the same cause producing a similar result. When this lady was carefully ausculted by M. Louis and our- selves, she presented no symptom of pulmonary tubercle ; a canula was worn in the trachea, and besides the cancerous tumour in the larynx, partially softened pulmonary tubercles were found after death. In these cases the conditions of the patients were very different. One was affected with a simple chronic phlegmasia of the larynx; he was a drunkard and debauched: his profession frequently exposed him to the inclemency of the weather; the other lived in comfortable style, had always led a regular life, and had a cancer- ous tumour of the larynx. So there was nothing in common between them, except that both wore a silver canula. Still, though in both the lungs appeared sound at first,.they were found after death loaded with partially softened tubercles. The same observations will apply to the case of Mme. Morin; when we first saw this patient, the larynx appeared the exclusive seat of morbid action, and the little haemoptysis which occurred might well be attributed to the urgency of the cough. The most careful auscultation did not indicate any modification in the reso- nance of the thorax or in the respiratory sounds. The complex- ion was good, with considerable embonpoint. Some months later, however, the pulmonary affection broke out with much violence, and the patient died with purulent expectoration, and all the symp- ioms of pulmonary phthisis. The following observation appears still more conclusive:__Miss 1 Journal Hebdomadaire de Medecine, 1827. J TERMINATrONS. 99 Longet, aged thirty-two years, took a violent cold in the winter of 1834-35. There was fever, with emaciation, and an aphonia which lasted six weeks. A well-directed regimen and moderate antiphlo- gistic treatment quelled the symptoms, and at the end of two months health was perfectly restored. A year afterwards she took cold coming from a ball; the same symptoms were developed ; fever, abundant expectoration, and loss of voice. An application of leeches and the continued use of emollients again stopped the fever and expectoration, but the aphonia and cough continued. Six months afterward, the respiration became hissing and labo- rious ; every thing indicated a considerable narrowing of the larynx. Death by suffocation was threatening; mercurial fric- tions to the front of the neck stopped the oppression. We then ausculted the patient with care; and M. Louis, called in consulta- tion, examined her himself. We found a little obscurity of the sound, and bronchial respiration anteriorly and posteriorly. It was evident there were tubercles, but we heard neither gur- gling nor moist crepitus ; there was not the least expectoration. This case is precisely analogous to that of a woman who was tracheotomised by M. Fournet, under M. Andral, and who, at her entrance, offered no signs of pulmonary phthisis, but only an op- pression which was so great that bronchotomy had to be practised. Some time after the operation, phthisis developed itself, and she died consumptive. May we say of these patients that the lesion of the lungs was the cause of the laryngeal affection, which had existed long before the former developed itself; when the serious derangements were pre- sent in the larynx, and the most careful exploration of the thorax did not indicate the softening of tubercular matter? These facts would go to support the opinion of Borsieri and Portal, who regarded laryngeal as a frequent cause of pulmonary phthisis. At any rate they are directly opposed to that of M. Louis; who considers the ulcerations of the trachea and larynx caused by the passage of pus, which could not have been the case in the instances just cited, since the tubercles were not softened. M. Louis considers the irritation of the pus from the lungs, as the very probable cause, but he is not absolutely convinced of it. In the absence of this explanation, so generally satisfactory, may we not attribute it to diathesis, and admit the simple coincidence of the pulmonary and laryngeal lesions without regarding them as causes one of the other ? We often see a joint become the seat of white swelling, and pulmonary phthisis shortly after developed; in other cases, a chronic diarrhoea persists for several months, owing to the tubercu- lar ulceration of the glands of Peyer, and the lungs remain a long time unaffected. It is generally the tuberculous softening of the luno- which continues and the intestinal lesion that follows. To us these alterations do not appear to be causes of one another, but only the product of the tubercular diathesis, which generally 100 TROUSSEAU AND BELLOC ON LARYNGEAL PHTHISIS. attacks the lungs first, but which, in some rare instances, affects some other organ, and only attacks the lungs secondarily ; and besides, it will be readily understood that there is a more intimate bond of connection between the larynx and lungs than between the latter and any other part of the system. It is not, then, as Borsieri thought, laryngeal which caused pul- monary phthisis, any more than the pulmonary lesion, which, according to M. Louis, causes the laryngeal disorders. The ques- tion is simply, whether the lung or the larynx have been first affected; and this problem is difficult to solve. Before Laennec discovered auscultation, the opinion of Borsieri necessarily prevailed ; indeed the presence of pulmonary tubercles could not be determined until they were far advanced, while all were struck with the symptoms of disease in the larynx. But in our day, the exploration of the chest may be so precise, that the alterations of the lungs are often revealed before the cough, hemop- tysis, and purulent expectoration proclaim tubercular phthisis. It is not every one, however, who can detect the early stages of disease in the parenchyma of the lungs ; great practice of auscul- tation, and constant attendance on the hospitals, are necessary to distinguish these changes in the intensity of the respiratory sounds, and the resonance of the voice, which have so great a diagnostic value. Even where an appreciable alteration in the resonance of a part of the lung, in the respiratory murmur, or in the voice exists, we must not always decide upon the existence of tubercles ; but by frequently repeating the examination of the patient, and by watch- ing the progress of the signs furnished by auscultation, we learn to decide with certainty. The aphonia, the narrowing of the larynx and consequent op- pression, are the grand obstacles to auscultation. On one hand, we cannot explore the resonance of the voice, which furnishes such valuable diagnostic means; on the other, the hissing in the larynx so masks the noise of respiration that it becomes impossible to detect the slight changes of which we have been speaking. This we found to be the case with Mr. L. of Dunkirk, whose case we have given in No. 25. The sound was less clear without being obscure, and as this semi-obscurity was observed in the whole chest, it would not serve to decide the relative predominance of the pul- monary lesion (the autopsy, indeed, showed that the lungs were equally loaded with tubercles in their whole extent.) The respira- tory sounds disappeared entirely in the midst of the bronchial and laryngeal gurgling, and the complete aphonia did not permit us to examine the resonance of the voice. Still the tubercular pulmonary phthisis was palpable: the abundance of purulent expectoration, the hectic fever, the diarrhoea, the emaciation, and night sweats, all concurred in leading us to this diagnosis, which we could not establish by stethoscopic signs. It was exactly the same with M. Prevot, a relation of Dr. Honored He was affected with pulmonary and laryngeal phthisis in the last stages, and neither percussion nor TERMINATIONS. 101 auscultation enabled us to recognise the presence and softening of tubercles from the same causes which operated in Mr. L. of Dun- kirk. We conclude, 1st, that, in most cases, tubercular pulmonary phthisis is first established, and that the larynx is afterwards affected. 2d. In some rare cases the tubercular lesion commences in the larynx, and only iuvades the lungs secondarily. 3d. That sometimes both exist and progress simultaneously. 4th. That in this case the lesion sometimes seems to exist ex- clusively in the larynx because of the predominance of the laryn- geal symptoms, and the difficulty of ascertaining the pulmonary lesion by stethoscopic signs. We have said that marasmus was rarely caused by laryngeal phthisis. Among the causes which induce death before marasmus comes on, we mentioned the swelling of the mucous membrane of the larynx, produced by its ulceration or chronic inflammation. As this is one of the. most frequent and serious causes of death*, we shall devote a paragraph to the study of the connections that exist between this swelling of the mucous membrane, which has been made a special disease, and the acute or chronic phlegmasia of the parts which compose the larynx. § 2. The relation which osdematous laryngeal angina bears to laryngeal phthisis.—Our object, in this paragraph, will be to prove that cedematous laryngeal angina scarcely ever1 differs in its cha- racters from the inflammatory cedematous laryngeal angina de- scribed by authors, and of which Boerhave has left us so faithful an account in the following aphorisms. • ... Aph. 801. "Si sola laborat pulmonalis fistula, illaesis alhs, in interna membrana sua* musculosa tunc oritur ibi tumor, calor, dolor, febris acuta calida, ceterum externa signa nulla; vox acuta, clangosa, sibilans; inspiratio acute dolens; respiratio parva, frequens, crecta, cum summo molimine; hinc circulatio sanguinis per pul- mones difficilis; pulsus mire et cito vacillans, angustiae summae; cita mors. Est que haec una ex iis quae funestissimae nee externa dant signa: qu6 vero proprius glottidi et epiglottidi malum, eo sane magis lethale." . , Aph 802 "Si larynx imprimis acute inflammatur, et sedem habuerit malum in musculo albo glottidis et simul in carnosis ei claudendse inservientibus, oritur dirissima, subito strangulans, ' We say scarcely ever, because in the numerous examples of diseases of the larynx which have fallen under our own observation, or of which we haveread itTaithors, we have found but one which could fairly be considered as belon-in" fo trous 10 134 TROUSSEAU AND BELLOC ON LARYNGEAL PHTHISIS. OBSERVATION XL. Simple chronic laryngitis, lasting three years—Four applications of the cautery in three months—Decided melioration—Treatment laid aside, return of the symptoms—Probability of tubercles. Madame V., aged twenty-four, was a woman of active mind and great nervous susceptibility, who enjoyed general good health. She was an excellent musician. Every morning when she awoke she had a violent pain in the throat, which hindered deglutition, but insensibly disappeared in a few hours. She perceived with morti- fication that her voice had lost its clear sound and power. On the 1st of August, 1835, we practised a first cauterisation of the pharynx and larynx, with a solution of the nitrate of silver (one dram to the ounce.) The operation caused such violent nausea and vomiting, that, disgusted with the remedy, she renounced all hope of recovering her voice. We prescribed a gargle of one ounce of alum to two pounds of water. In a few days she begged ns to repeat the cautery; her voice was already stronger, and had gained a note. Wishing the first appli- cation to have its full effect, we waited until the third week had elapsed before we repeated it. The nausea was less troublesome, and the voice was somewhat improved. The cautery was twice practised at intervals of three weeks, and the voice could reach fa. A severe cold, subsequent to a chill, forced us to suspend the treatment, to the great regret of the patient, who waited impatiently for its resumption, hoping to obtain the desired object. But the cold took an alarming form ; unequivocal signs of pul- monary tuberculisation were manifested, and the voice was again altered ; we did not feel justified in having recourse to the remedy which had before succeeded so well. Our readers will remark that the cautery of the larynx effected a decided improvement, though the tubercular diathesis probably existed from the first. The same remark will hold in the next two observations. OBSERVATION XLI. Aphonia gradually developed in the course of a chronic inflammation of the larynx—Cautery of the throat—Unsuccessful. A young woman of twenty, with a sanguine temperament, entered the royal hospital of faubourg Saint Denis, to be treated for chronic aphonia of several months' standing. She was placed under the care of Professor Dumeril, who called us in to the case. She had the appearance of perfect health ; for eighteen months that she has been married, she never felt any other trouble than that for which she claimed our attention ; for a year she has had a pain in the larynx, which was decidedly increased whenever she spoke much. Her TREATMENT. 135 voice easily grew hoarse, and became more and more grave ; about the fourth month of the disease the larynx was swelled and painful, and occasionally, in the evening, the voice was completely lost. The disease grew worse, and six weeks before she came to the hospital, she had entirely lost her voice. Still there was little cough, and no external sign or general symptom which indicated pulmonary tubercular lesion. The sound was similar under both clavicles, the respiratory murmur feeble, the inspiration full, and without mucous rattle. There had been no haemoptysis, no disposition to diarrhoea, fever, or emacia- tion. We supposed there was a chronic phlegmasia of the mucous membrane of the larynx, and as there was much pain, we should certainly have applied leeches and used emollients had not these means already proved fruitless. We therefore applied a saturated solution of the nitrate of silver to the throat and upper part of the larynx. Vomiting immediately followed, and deglutition was difficult for two days; but after seventy-two hours the voice became more sonorous, it was still very hoarse, but could be easily heard at the distance of ten yards. We prescribed a saturated solution of alum as a gargle, and fric- tions of the alcoholic extract of stramonium to the front of the neck. Still, as the voice did not improve decidedly, we renewed the cautery a fortnight after the first application. The improvement was now evident, and one month from the commencement of the treatment, the voice was restored; but she could not long speak aloud without pain and hoarseness. Our efforts to combat the pain with frictions of belladonna, and the application of morphia to blisters on the front of the neck were useless. W7e then thought that the obstinacy of the inflammatory symptoms was chiefly owing to a constitutional syphilitic affection, and therefore commenced a mercurial treatment; and under the influence of this new medica- tion there was some improvement. There was still pain in the laryngeal region, and a troublesome disposition to get hoarse from the sl?ghtestecause, but the more alarming symptoms of laryngeal phthisis were dissipated, or perhaps rather masked. OBSERVATION XLII. Aphonia after a hoarseness that had lasted a long while.—Very frequent cauterisation.-Incomplete re-establishment of the voice.-Five months after, threatened suffocation, tracheotomy, death.—Tuberculous and poly- pous tumour in the larynx. M de Serry was directed to us in January 1835 by Dr. Paradis of Auxerre For a year past he has occasionally observed his voice at first a little cracked, and soon permanently hoarse; by de- 136 TROUSSEAU AND BELLOC ON LARYNGEAL PHTHISIS. grees, the timbre became more grave and less sonorous ; and at last, for two months it has been entirely lost; there was no pain or swelling in the laryngeal region. He has never had catarrhs or haemoptysis; no organic lesion of the pulmonary tissue could be detected by the most thorough auscultation and percussion. He seemed to enjoy the fullest health, all the functions except that of the larynx were perfectly executed. We need scarcely say that the antiphlogistic and revulsive treatment with mild and debilitat- ing regimen had been used without success. We determined to employ the cautery, which was used daily for a week, then three times a week for a fortnight, afterwards twice a week for the same period, and then only once a week for a month ; neither pain nor inflammation ensued. For a week there was no melioration, then there were some very hoarse sounds ; at the end of a month the voice had some character, but was very hoarse; finally, at the end of two months and a half, the patient spoke with a cracked voice, and at last he could make himself heard in a large hall, in the midst of a crowd of persons speaking aloud. M. Serry then left Paris. The rest of his history may be found in the first observation. Notwithstanding the condition of the mu- cous membrane, we were able to modify it to some extent, as the character of the voice was restored. Pulverulent topical remedies.—We were led by that sure guide, analogy, to apply irritants to the larynx. We observed that col- lyria of corrosive sublimate, sulphate of copper, nitrate of silver, and sulphate of zinc modified the chronic phlegmasia of the mucous membrane in ophthalmia both rapidly and happily.—Similar re- sults were observed in the nasal fossae, and we supposed it would be the same with the larynx: experience proved that our conjec- tures were well founded. It cannot be denied that the introduction of liquids into the larynx is attended with difficulty; the operation is unpleasant for the patient, and the sudden constriction of the glottis always pre- vents the medicine from penetrating far. We want, then, some method of applying therapeutic agents to the whole of the larynx and even to the upper part of the trachea. Aretaens had already prescribed insufflations of powdered alum to the larynx in malignant angina, and it must be confessed that at the present day, this medicine, which has been introduced by M. Bretonneau of Tours, is one of the most, powerful agents we have, to check the extension of false membranes from the pharynx into the air passages.—Aretaeus's instrument was a simple reed. M. Breton- neau used a tube with a bulb in its course, traversed by gauze. These instruments were always employed by the physician or at- tendants when the patients were children ; the patient should make his inspirations coincide with the insufflation ; still the pow- der may fall into the pharynx, and upon the tongue, and provoke sffcr'.s c:" vomiting or a spasmodic constriction of the gullet, which may defeat our object. TREATMENT. 137 It appears to us much better to confide the insufflation to the pa- tient himself. The apparatus is in fact the reed of Aretaeus, a glass tube being substituted for it. This tube should be two lines in diameter, and eight or ten inches long. Three or four grains of the powder is to be put into one end of the tube, the other extremity is to be placed as deeply in the mouth as possible. After emptying his lungs by a strong expiration, the patient closes his lips upon the tube, and then by a quick effort of the diaphragm, takes breath rapidly. The column of air, in traversing the tube, divides and hurries along the powder towards the pharynx, but a part, suspended in the air, penetrates the larynx and upper part of the trachea. We are advised of its having entered the larynx by fits of coughing, which the patient should repress as much as possible so as to pre- serve the medicine in contact with the affected tissue. These inspirations are repeated more or less frequently every day, ac- cording to the state of the larynx, the nature of the powder, and the manner in which it is borne. We have in this manner introduced pulverulent collyria into the larynx, as easily as into the eyes. We use powdered sugar, the subnitrate of bismuth, calomel, red precipitate, the sulphate of zinc, sulphate of copper, alum, acetate of lead, and especially nitrate of silver. Sugar and subnitrate of bismuth, may be used pure, the calomel, mixed with twelve times its weight of sugar; red precipitate, sul- phates of zinc and copper, with thirty-six times their weight, alum with twice, acetate of lead with seven times its weight, and the nitrate of silver, with seventy-two, thirty-six or twenty-four times its weight of sugar. These are the proportions we generally adopt, but they may be varied ad infinitum, and must be regulated by the state of the larynx and the susceptibility of the patients. The apothecary should be directed to prepare these powders on a porphyry slab, otherwise, small crystalline asperities remain, which act as irritants and provoke repeated efforts of coughing, which do not allow the patient to retain the powder When the laryngeal affection is not serious, we use the subni- trate of bismuth. Observation XXVI proves its efficacy, even where the disease from its commencement was owing to crude tubercles in the lungs. The following case will afford further evidence of the innocuity and utility of this substance. OBSERVATION XLIII. Scrofulous constitution.—Aphthous eruption in the mouth and throat.—Acute catarrh.—Cure.—Continued hoarseness and pain in the larynx -Inspira- tions of the subnitrate of bismuth.—Rapid recovery. Mr. d'H. while growing up, had some enlarged cervical glands, 138 TROUSSEAU AND BELLOC ON LARYNGEAL PHTHISIS. a few of which suppurated. His whole appearance is scrofulous. At the school of Saint Cyr, where he was in 1827, he had an apn- thous affection which invaded the whole of the mouth and pha- rynx, and continued a long while. The disease re-appeared in 1833, and was easily cured.w From this time he was free from pain in the throat. At the commencement of the winter of 1835, he went hunting, took cold, became hoarse and had a pain in the larynx to which he paid no attention. The cold was cured in a few days, but the pain irt the larynx continued and was accompa- nied with a dry cough and hoarseness. The obstinacy of this ap- parently slight affection induced M. d'H. to claim our attention. We directed four grains of bismuth to be taken by inspiration four times a day—five days sufficed to dissipate the cough and hoarse- ness. As some swelling remained in the tonsils we touched them twice with the pencil of nitrate of silver, and the cure was com- plete. , We use insufflations with acetate of lead, alum, the sulphates ot zinc and copper, and nitrate of silver, in cases of laryngitis without ulceration, when sugar and sub-nitrate ot bismuth have proved in- effectual. We always begin with alum, when we suspect the pre- sence of swelling of the mucous membrane without a high grade of inflammation. Such was the case with the child cured of croup by tracheotomy, recorded in Obs. XV. We consider insufflations with nitrate of silver always indicated, not only when there is a simple erythema of the mucous membrane, but even when erosions or ulcerations exist; it is the article we generally use. The insufflation is made twice or thrice a week, or even every night, according to the susceptibility of the larynx, and strength of the powder. We never use calomel and red precipitate, which are so powerful in chronic, syphilitic, or other ulcerations, except when we have reason to believe that ulcerations exist in the mucous membrane. Such was our diagnosis with Mme. G., Obs. XXXIX. But we should make one important remark in regard to these medicines. Prac- titioners have no doubt observed that when calomel or red precipi- tate mixed with sugar, in the proportions above mentioned, is blown into the eyes, a slight irritation follows, which lasts some hours, and if the insufflation be repeated two or three times a day, an acute phlegmasia will ensue. The same holds with the indis- criminate use of mercurial unguents. What we see occurring in the ophthalmic, occurs equally in the laryngeal mucous membrane. We therefore, at first, only advise two or three applications a week ; experience has proved, that the symptoms grow worse if they be repeated once or twice a day at the beginning. But, as the patient becomes accustomed to them, we may and should repeat them more frequently, and also increase the proportion of the mercurials in the powder. We repeat, we advise mercurial insufflations in laryngeal phthisis, consequent upon a common inflammation, as well as in TREATMENT. 139 those of a syphilitic character. They are equally applicable to both. Mercurial medication.—A reference to the ponderous tomes on the use of mercury, and an impartial examination of the cases published to prove its efficacy, will convince us that many of the most acute and serious inflammations, many chronic engorgements and ulcerations in various situations, have been cured by this class of remedies; and, perhaps, their chief efficacy in syphilitic affec- tions depends upon their power of modifying the general, and, consequently, the local condition of the organism, rather than upon any specific virtue, as many of our cotemporaries have contended. Living in a country where mercury is given profusely, and, we may add, with little discretion, we have had an opportunity of wit- nessing its effects on most diseases. In this way, chance has, perhaps, shown, that the mercurial plan has often effected cures in laryngeal phthisis, when so far advanced that no hope of recovery was entertained. M. Pravas, in his thesis on laryngeal phthisis, in 1824, called the attention of the profession to this important point of therapeutics. The four following cases will impress our readers better than any explanations. OBSERVATION XLIV. Hoarseness for fifteen years.—Coryza, with scurfy secretions, for five years.—Intense cough.—Croup.—Fever.—Emaciation.—Complete apho- nia.—No signs of tubercle.—Mercurial treatment.—Cure.—Relapse.— Treatment resumed.—Effectual cure. Mrs. B____is thirty-four years old; she married at eighteen, prior to which she had enjoyed excellent health. Her husband was a libertine, and debauched in his habits. Still, she never expe- rienced the least leucorrhoeal discharge, nor the slightest symptom of disease in the parts. Could she have had a chancre at the neck of the uterus? It is impossible to say. Shortly after her marriage, when eighteen and a half years old, she travelled to England, where she contracted what a physician of that country called a disease of the liver; she was treated with larae doses of calomel, and in six months her hair and eyelashes felfoff entirely; about the same time she began to have pains in the throat and ear, which were exacerbated at the menstrual period. From this period, the voice, which had been sweet and sonorous, occasionally became hoarse, especially during the heat of summer. Nine years afterwards, in 1829, she felt lancinating pains in the frontal sinuses, with a considerable flow of mucus from the nose, then loss of smell, permanent coryza, swelling of the nose, scurfs, superficial ulcerations, and foetor. The olfactory membrane was a bright red. , . a Sometimes the coryza was moderated, when active inflammation occurred, and the throat, nose, larynx, and intestines were succes- sively and separately affected. 140 TROUSSEAU AND BELLOC ON LARYNGEAL PHTHISIS. In 1831, there was complete aphonia, which lasted two months and a half, accompanied with pain in the laryngeal region, and decided remission in the coryza. From this time the voice was always nearly extinct; jt became hoarse again whenever the in- flammation of the nose grew worse. In January, 1835, after the fatigue of a round of balls, while dressing for an assembly, Mrs. B. was seized with great oppression, which rapidly increased; the orthopnoea soon became extreme, repeated fits of croupy cough occurred, and in four hours she had all the symptoms of fully developed croup. Dr. J., her usual attendant, recognised acute laryngitis, or rather, what has been improperly considered oedema of the glottis, and controlled the alarming symptoms by applying leeches to the neck, sinapisms and bleeding. The voice was now completely lost; the larynx painful. We were called in consultation, in the end of April, 1835. The character of the disease of the nose, the scurfy secretion constantly arising from it, the nearly permanent pain in the throat, the falling off of "the hair fifteen years previously, and, above all, the bad habits of the husband, induced us to believe it was a syphi- litic affection that had never been revealed by a local symptom. The case was becoming urgent; there was constant cough, fre- quent fever, and emaciation ; in a word, phthisis seemed ad- vancing. Still, the thorax presented no abnormal sounds. We determined to employ a local and general mercurial course. Every third day the patient took a bath, in which half an ounce of corrosive sublimate had been dissolved. Thrice a day she in- spired into the nostrils a powder composed of two drams of sugar and twelve grains of calomel and red oxide of mercury. After pursuing this plan for two months the cough ceased, the disease of the nose was entirely dissipated, the voice re-established, embonpoint increased, and everything went on well until the begin- ning of the winter of 1835 and 1836, when the voice was altered, but the symptoms again disappeared in a few days, after touching the pharynx and upper part of the larynx with a solution of nitrate of silver, and insufflating a little sugar and calomel, at the same time that some baths of the bi-chloride were administered. OBSERVATION XLV. Dr. Thomann has published the history of a laryngeal phthisis that was successfully treated. A miller,1 aged thirty-three, enjoying good health, though not robust, fell twenty-four feet with a sack of meal on his shoulder; His thorax struck a log of wood, and he was senseless for three or four minutes. When he recovered, he continued three or four 1 Annales lnstituti Medico-clinici Wirceburgensis, 1799. TREATMENT. 141 hours in a state of great anxiety, with a violent cough, spitting blood, at first bright, afterwards black and grumous. Cold lotions were applied to the head and chest, and he soon felt a pain in the thorax, which was increased by respiration and pressure; this passed off in about nine days, and he felt no other inconvenience than lassitude. But, after this, his voice was gradually lost, so that he could only speak in a very low tone. He" came to the hospital of Wurtzburg on the 15th of September, 1799, when he was un- able to utter a word distinctly; he coughed badly, and expectorated < viscid and purulent matter. Little ulcers, of a lardaceous appearance, were found in the gullet: he complained of lassitude in his limbs, of emaciation, and of a slight pain in the laryngeal region, which was increased by deglutition. Gentle pressure caused a sound like that of a fracture of the hyoid bone, or of a cartilage ; the cough was increased by it, and the patient felt as though there was a foreign body in the larynx. The pulse was feeble and frequent; the other functions were well performed, and there was no symptom of pulmonary phthisis. Thomann prescribed a powder composed of henbane, golden sulphuret of antimony, and sugar, to be taken in three doses during the day; and a decoction of lichen islandicus for drink. The diet was mildly nourishing, on account of the patient's debility. From the day of his entrance until the 18th there was no change in the symptoms. The same powder1 was continued, the whole dose being given, and wine and water for drink, to which two spoonfuls of the following mixture were added :—Decoction of cinchona f gviij., honey f §j. This treatment was continued until the 24th, without much im- provement. A blister was then applied around the neck, and a mixture of infusion of the flowers of arnica, extract of cinchona, and honey. These means having been continued until the 1st ot Uctober, the voice was still suppressed, but the cough and lassitude had disappeared. The embonpoint returned, and there was less diffi- culty in respiration. Calomel, with opium and sugar, were given to cure the ulcers of the throat, though there was no symptom of syphilis. The neck was anointed with camphorated volatile liniment. , r On the 8th of October, the ulcerations presented a more favour- able aspect, and daily progressed towards a cure ; on the 15th they were contracted, and on"the 20th entirely cured ; the voice was more distinct, and the other functions well performed. On the 2*d the patient left the hospital in a state of convalescence; he resumed his laborious occupations, the voice gradually regained its natural tone, and there was no relapse. 1 We are left to conjecture the dose.—Translator. 142 TROUSSEAU AND BELLOC ON LARYNGEAL PHTHISIS. OBSERVATION XLV. bis.1 A baker, forty years old, who was of small stature, thin, and very irascible, and had never suffered any serious indisposition, in the winter of 1815 took a journey, during which he was much exposed to wet and cold, and in 1816 was much affected with indisposition. When M. Henning saw the patient he had a very hoarse voice; acute pain in the throat; almost constant cough and irritation, with a sense of heat and pricking in the oesophagus; there was also insomnolence, anxiety, difficulty of swallowing solids, and, five or six times a day, a transient lancinating pain in the right cheek above the zygomatic bone. This pain passed to the pharynx, becoming more violent, and causing a violent attack of coughing. There was constant dryness of the throat and burn- ing fever. After the appearance of these symptoms an inflamma- tion of the joints, with pain and swelling, had entirely disappeared. On examining the mouth nothing was discovered but a bright red- ness behind the palate. The neck was decidedly swelled about the thyroid gland, and when this part was touched, it was found better than the neighbouring region, and the patient felt acute pain extending into the trachea; and if he made an effort of deglutition at this time, all the parts interested in the function were called into action, and there was strong pulsation of the arteries. Nothing was observed in the neuralgic cheek; all the buccal cavity, espe- cially near the epiglottis, was covered with viscid mucus; the pulse beat 100 in a minute. M. Henning recognised in all these symptoms an inflammation of the larynx, in which the com- mencement of the oesophagus participated ; and, as it had lasted nearly three months, it had greatly enfeebled the patient. Eight leeches were immediately applied to the neighbourhood of the larynx, and followed by frictions of equal parts of volatile liniment and mercurial ointment, which were repeated every two hours, and after each application the surface was covered with an emollient poultice. A dose of nitre was taken internally. The cheek was simi- larly rubbed, and pediluvia were frequently used, in which elder and camomile flowers had been steeped. Two days of this treatment had effected no melioration, and the patient continued constipated. A blister was applied between the shoulders, an enema was admi- nistered, and as the pulse continued the same, leeches were applied to the arms and calves of the legs. Abundant sweats, and improve- ment of all the symptoms followed. Calomel, and extract of aconite were administered, and afterwards camphor and opium. All the symptoms of inflammation of the larynx ceased, and the facial pain alone remained, and even increased in frequency and intensity. It would be useless to repeat all the means that were unsuccessfully employed to combat it. Some time afterwards, the « Bibliotheque Medicale, torn. lxix. TREATMENT. 143 patient died suddenly of apoplexy, and we could not obtain permis- sion to examine the body. We are here presented with a phlegmasia, occupying the mucous membrane of the larynx, trachea, pharynx, and oesophagus. The mercurial frictions were probably used because of the attendant neuralgia. The history of the treatment clearly proves that no appreciable benefit was derived from the local bleedings. The first application of leeches to the neck diminished none of the symp- toms. No melioration was observed until the mercury began to act upon the system. We cannot believe that the leeches applied to the limbs could have diminished the erethism; general bleeding would have been better calculated to fulfil this indication. OBSERVATION XLVI. Chronic laryngitis after a sharp cry-Hamioptyses-Slight pricking pain in the larynx-Alteration of the voice-Seton-Mercurials-Stnct silence- Emollient fumigations-Decided improvement-Mineral waters ot Mt. d'Or—Cure. In June, 1811, Madame C. lost an only and darling son ; in her despair she uttered so shrill a cry that she felt something tear in her throat. From this epoch she had haemoptyses in the mornings; at the moment of waking she felt a little mass separate from the painful point, this was expectorated with some drops of blood. At the lower part of the larynx, there was a constant pricking sensa- tion, which induced her to place her hand to the part. 1 hese symptoms continued without much increase until the summer ot 1813, when, being one day overheated by a ride on horseback, she spat much blood at intervals; the pain was more acute, and was aggravated by spiced food, or by food too hot or too cold. She felt although there was an open wound. As the disease was advan- cing, her husband, from whom she had long concealed her sufiei- ingf determined to consult a physician ; but, whether indifferent to her lot, she had not given a correct statement of her condition, or the physician did not pay sufficient attent.on to it, the disease was mistaken. Tonics and stimulants were prescribed such ias wine of cinchona, and the concentrated essences of meat, which exasperated all the symptoms. She had very acute sympathetic pafns n the superio/ extremities and in the back, her voice was aTtered and the fever continued. A second physician prognos i- cated that she had reached the last stage of pulmonary phthisis. MCbi" justly alarmed, brought his wife to Pans, that she mUt enjoy°the advice of the most celebrated men. Dr. Itard, to whom he was introduced, immediately recognised the character of die disease, which he judged very serious from its dura ion the emaSon^and the extrem! debility of the patient; he called Pro- i Pravaz, Recherches pour servir a l'Histoire de la Phthisie Laryngee. These, Paris, 1824, 4to. 144 TROUSSEAU AND BELLOC ON LARYNGEAL PHTHISIS. fessor Halle in consultation, who made an equally unfavourable prognosis. It was agreed that little moxas should be burnt in the neighbourhood of the painful point. M. Itard, who continued to take charge of the case, had already applied a pitch plaster, sprinkled with tartar emetic, with the inten- tion of exciting revulsive action. The moxas, which produced little effect, were followed by a seton, which was worn a year. Various mercurial preparations were long employed to combat a lymphatic predisposition of the system. Soothing and mild regi- men was prescribed, and silence recommended; to these means were added inspirations of emollient vapours. The patient shut herself up in a large closet every morning, so arranged that she could read while breathing the vapour of a quart of milk, produced by the heat of a spirit-lamp. Leaving this sort of stove, she passed into a moist atmosphere and mild temperature in her chamber, pro- duced by boiling the flowers of marsh mallows, violets, and other mucilaginous plants. If she left this, she took care to breathe from a retort with two tubulatures, in which was a mixture of ether and balsam of tolu, so arranged that the air should be impregnated with the medicines. When the symptoms of irritation had disappeared, aromatic fumigations were prescribed, procured from the combustion of balsam of tolu, which was to be applied to the throat for some moments. This rational treatment, seconded by the most delicate offices of friendship and conjugal affection, induced a considerable amendment in all the symptoms. M. Itard thought that the ther- mal waters of Mont d'Or might suit the patient and conduce to her convalescence; she was therefore sent in the month of May, to Clermont, to accustom herself to the mountain air. She still spat some blood, but this symptom disappeared while using the waters. She regained her embonpoint and was cured. A little sensibility of the larynx remained ; and for some months after her return, she continued to sleep in a very clean stable. She was next year sent back to Mont d'Or, to confirm the happy cure, which has continued permanent. We shall cite, hereafter, some observations in which laryngeal phthisis, so far advanced that tracheotomy was deemed necessary, has been cured by an active mercurial treatment, even when the patients had no syphilitic taint. How does the mercury act in these cases 1 By what therapeu- tic avenues can it modify so serious alterations as those we usually find ? We shall not attempt to answer, confident that we should only hazard hypotheses which a thorough investigation might not support. Iodine.—The same will not hold of the action of iodine, which, if no better known than that of mercury, at least produces more constant effects, that we may compare with analogous results observed in other parts of the economy. We see large doses of tincture of iodine cure secondary symptoms of syphilis, resolve bony tumours, glandular engorgements, &c. &c. Its most striking TREATMENT. 145 effects are the atrophy of indurated and sound tissues, therefore it is not extraordinary that this medicine should also discuss chronic engorgements of the larynx. This article was rather spoken of than tried by the Germans, and has only been used by us in laryngeal phthisis; once without success, at another time with decided advantage. OBSERVATION XLVII. A locksmith, living in Paris, came to consult us, two years ago, for a serious affection of the pharynx and larynx. He told us that he had had syphilis, which was followed by angina. He then consulted M. Biett who prescribed pills of the proto-iodide of mer- cury; and after this treatment all the syphilitic symptoms disap- peared, leaving only a great susceptibility of the pharyngeal mu- cous membrane. The pains soon became more acute and were extended to the larynx; these symptoms having alarmed him he again consulted M. Biett, who advised a second mercurial course, but without advantage. M. Marjolin, also thought the disease had a syphilitic origin, and various mercurials, and sudontics were vainly administered. M. X. then came to claim our care. The tonsils, the veil of the palate, and the uvula were much swelled and of a bright red ; the epiglottis, which was plainly seen when the tongue was depressed, was very red and much tumefied. Deglu- tition was painful; there was a sense of burning in the larynx when M. X. ate or spoke. The voice was not much altered. We be*an by cauterising the tonsils and epiglottis with nitrate of silver, "twice a week. This simple and easy treatment dispersed the swelling and redness of the gullet in one month, but the larynx continued as bad as ever. We were about introducing the caustic into the entrance of the glottis, or directing inspirations of the pow- der of alum, when it occurred to us to try iodine. We prescribed the tincture in doses often drops night and morning, in half a glass of sweetened water. In one week there was decided improvement, in another the patient seemed cured; and has continued to be so. We have not had sufficient experience in the use of this medicine to speak confidently of its virtues from an isolated fact, and should not have mentioned it, had not the journals frequently adverted to its efficacy in the treatment of chronic diseases of the pharynx and ^Tdphur; sulphurous mineral waters. Many physicians chiefly those who have embraced the opinions of the new French school, consider as almost fabulous the cases of cure reported by Bordet and many others, effected by the waters of Bonnes and Cauterets But they who have studied the effects of the Pyrenean water's upon the spot, they who haveoften sent to them their patients, cedent y-attacked[with pulmonary tubercles, will acknowledge the admirabte cures which have been annually effected by this pow- erfu means. Therefore we should never neglect the use of sul- 146 TROUSSEAU AND BELLOC ON LARYNGEAL PHTHISIS. phurous mineral waters, whether natural or artificial, in the treat- ment of various forms of laryngeal phthisis. Although secondary, they may unaided effect a cure in the early stages of the disease. We select the following case from a host of others. OBSERVATION XLV1II. Hoarseness.—Aphonia.—Gargles of alum without advantage.—Milk diet and Bonnes waters.—Cure.—Relapse after imprudence.—Return to milk diet and Bonnes waters.—Cure in five weeks. Mr. D. captain of artillery, thirty-four years old, was born of tuberculous parents. His voice is rather grave, and not very strong, except in the high notes. He attended balls and soirees and was much in the world, for three months, when he perceived that his voice was hoarse, and complete aphonia soon followed.1 There was no expectoration or pain in the larynx, and the general health continued excellent, only he was extremely fatigued by the great efforts that were necessary to make himself understood. There was nothing to induce a suspicion of disease in his lungs, he had never had haemoptysis, catarrhs, or angina. He used a gargle of one ounce of alum to a pound of water for a fortnight without amendment. Milk diet was then prescribed with some advantage ; to this was added one bottle of Bonnes waters per day. This soon effected an improvement and a complete cure at the end of two months. He went into Normandy to spend the summer; one day, after having taken a very hot bath, he walked on the sea shore, and re- turned to Paris with a violent pharyngeal angina and complete aphonia. He was again put upon the use of warm milk. Tartar emetic ointment was rubbed into the neck morning and night; the Bonnes waters were resumed, and after five weeks of this treatment, his voice had regained its natural tone. A curious remark, which confirms what physiologists say of the intimate relation which exists between the organs of generation and those of phonation, is, that M. D. was always better when his wife was unwell, and he abstained from intercourse. Treatment by topical applications to the pharynx.—We have seen that chronic inflammation of the larynx, and laryngeal phthi- sis resulting therefrom, have originated from a phlegmasia of the mucous membrane of the tonsils and veil of the palate, and some- times even the simple tumefaction and procidence of the uvula. Caries of one or two teeth often keeps up a constant fluxion to the throat and consequently chronic laryngitis. One of our greatest singers, Madame Mainveille-Fodor, is said to have lost her voice in this way. ' It should be mentioned that he had thrown aside his flannel. TREATMENT. 147 It would seem that in this case, the inflammation is propagated by continuity of tissue, as we see vaginal catarrh succeed inflam- mation or ulceration of the neck of the uterus ; or, a fistulous ulcer from caries becoming the cause of chronic inflammation and indu- ration of the surrounding cellular tissue. In this case, the cure of the original disease, if we may be allowed the expression, dissi- pates the secondary symptoms. Thus, the excision of the uvula, or tonsils, and the extraction of a tooth, may effect the cure of in- cipient laryngeal phthisis, caused by the disease of the throat. Bennati, who had some success and great reputation in the treat- ment of laryngeal affections, attached great importance to topical applications to the tonsils and base of the tongue. He prescribed almost exclusively aluminous gargles. The solution should be strong, a scruple, half a dram, and even a dram to the ounce of water. The gargles should be frequently repeated every day. Bennati employed sulphate of zinc in the same proportions. We prefer the nitrate of silver. When the pharynx and larynx are simultaneously affected, we touch the tonsils and veil of the palate two or three times a week with a stick of nitrate of silver, with a sponge soaked in a saturated solution, or we introduce with the finger, a powder composed of six or eight grains of the nitrate of silver to a dram of sugar candy. A saturated solution of the sulphate of copper, or zinc, or of corrosive sublimate, equally an- swers this therapeutic indication. But we may combat laryngitis by these means with equal suc- cess, even when there is no chronic phlegmasia of the mucous membrane of the fauces. It is difficult to explain how an appli- cation to the tonsils can modify a laryngeal phlegmasia, but such is the fact, and analogy shows us that such a result ought to follow. In the beginning of this chapter, we have seen that caute- risation of the superior part of the larynx cured inflammation which was often seated beyond the immediate influence of the caustic ; it is not more surprising that cauterisation of the base of the epiglottis and tonsils should produce the same results. Physicians who treat diseases of the ear well know that cauteri- sation of the tonsils alone sometimes effects a cure of catarrh of the Eustachian tube ; it is not more remarkable that the same remedy should have a parallel influence upon catarrh of the larvnx It may be said that this is done by revulsion, and that the irritant acts as a vesicatory, and concentrates at this point the inflammatory congestion ; which is not an improbable explanation ; we must ad- mit however, that the organic modification impressed upon the tonsil is transmitted to the mucous membrane of the ear and larynx: This is a question of little importance which we shall not &UTreatment of syphilitic laryngeal phthisis.—When we have every reason to suspect the syphilitic character of a case of laryn- 148 TROUSSEAU AND BELLOC ON LARYNGEAL PHTHISIS. geal phthisis, many indications are presented according to the alterations of the pharynx, which indeed sometimes claim our principal attention, provided the inflammation and swelling of the mucous membrane of the air passages be owing to an extension of that in the back of the mouth; in the same way that the inflam- matory procidence of the uvula is often evidently caused by an organic alteration of the nasal fossae or of the tonsils. If then this form of laryngeal phthisis is only an extension of the pharyngeal inflammation, we should always direct our remedies, whether general or local, to this affection. But when laryngeal phthisis is idiopathic, and the organic lesion confined to the larynx, besides the means generally indicated to combat the usual inflammatory symptoms, we should also attend to touching the throat with a solution of the bichloride of mercury, and to inspirations of calomel and red precipitate in the proportions we have specified.—See Observations XX, XXI, XLIX, XLIX bis, XLIX ter. The general treatment is just what all enlightened physicians would advise in constitutional venereal disease. The five following observations, which we select from many analogous cases, will show the happy influence of anti-syphilitic treatment in this affection. The first three, and Nos. XX and XXI, which are taken from our own practice, will give our readers an idea of the treatment we have adopted in similar cases. OBSERVATION XLIX. Syphilitic laryngeal phthisis. Mr. P. aged fifty years, had contracted syphilitic chancres in 1828. He was cured by a short, local, and mercurial treatment. A year afterwards, without having been again exposed to contagion, he had violent pain in the throat. His physician recognised an ulcerative syphilitic angina, and prescribed a thorough course of mercury. The disease was cured, but the throat was soon sore again. It was filled with hard rounded vegetations; the veil of the palate adhered to the posterior and superior part of the pharynx, the voice was altered, became hoarse, was afterwards extinct, and at last habitual dyspnoea supervened. These alarming symptoms were combated by the local applica- tion of nitrate of mercury,1 (nitrate acide de mercure,) by all sorts of gargles, by repeated applications of leeches, by blisters loco dolenti, by seton to the muchae, and internally by repeated mer- 1 This is supposed to be a solution of nitrate of mercury in nitric acid, highly recommended by MM. Cloquet and Recamier as a caustic in obstinate syphilitic and scrofulous ulcers, &c. Vide Ratier'j Formulary, p. 231, et seq. TREATMENT. 149 curials, by the tisan of Feltz,1 by the biscuits of Ollivier, and by the muriate of gold. A temporary melioration was obtained during the summer; but the symptoms returned with new force in the winter, and from the beginning of 1835 M. P. obtained no relief, and seemed likely to die of asphyxia. In the month of May he consulted M. Marjolin, who sent him to us. We have already mentioned the appearances presented by open- ing the mouth. But by introducing the finger to the epiglottis a mass of irregular and uneven tumours was felt in the larynx and aimost closing the oesophagus. The sensation received was like that of a deeply ulcerated uterine cancer. The voice was extinct, but became hoarse and cavernous when he made great efforts. Respiration was so very laborious that when he reached our office, (which is on the second floor.) he had to wait five minutes to take breath before he could speak. The air, as it passed the larynx, produced a sharp hissing in the inspira- tion ; the expiration, thougli not braying, was painful, so that the expiratory muscles were called into active exercise. No trace of pulmonary lesion was discovered in the sounds of the thorax. The patient, who was naturally fat and florid, had lost more than twenty pounds, was weak, and had no appetite. Still we did not despair of effecting a cure, and directed the following course:— 1 st. To avoid, as much as possible, speaking, coughing, or spitting. 2d. To avoid exposure to the morning and evening air. 3d. Every four days to cauterise the pharynx and upper part of the larynx, either with a solution of nitrate of mercury, of nitrate of silver or with chloride of gold, dissolved in nitro-muriatic acid. 4th'. To use a gargle daily of a saturated solution of alum. 5th. To insufflate the following powder twice a day :— B<. Hydr. chlor. mit. 9ij. Pulv. sacch. crystal. £ss. M. To be followed in five minutes by a gargle of water. 1 Tisan of Feltz. 5,. Radicis sarsap. concisae |iij. Ichthyocollse jfss. Pulv. antim. crud. %iv. Aq. f'ontanae Kvj. M. Boil down to one half; strain. Take half a pound three limes a day. Formula for the Tisan. &. Rad. sarsaparil. ^ij. Rad. chinsegj. Sulphur, antimon. §iv. Ichthyocol. Cort. buxi Cort. hederae aa. ^iss. Aq. puree ftxij. M. Fnclose the sulnhuret of antimony in a linen bag, and boil the whole until half the iquor ha^evaporated ; strain through a sieve, allow it to settle and Secant, dissolve in it hydr. bichlor. grs. iij. Dose: a pint a^ ^ 150 TROUSSEAU AND BELLOC ON LARYNGEAL PHTHISIS. Gth. To use fumigations of cinnabar as follows :—throw a small portion of powdered cinnabar on a hot chafing dish, and receive the vapour in a funnel placed in the mouth; this to be repeated five or six times successively if it caused no pulmonary irritation. 7th. Take Bonnes water, either in Paris or in the Pyrenees. Our patient has been at Paris for two years, with re-established health. Before publishing this case we wished to have sonie further account, and we therefore present the statement of his physician, M. Collin. " Respected sir,—Mr. P. is doing well; the cough, expectoration, and difficulty of deglutition have ceased ; his rotundity of figure and strength have returned; and, except the change in the quality of his voice, which he has had seven years, there is no trace of the disease." This cure, which is truly remarkable, considering the gravity of the organic derangements, recalls the following relation of Mor- gagni,"Letter 44, § 15. "Senex decrepitus lue venerea plurimos jam annos male mulc- tatus, ut quae loqueretur vix intelligeres, urinaj autem difficultate, et gonorrhea denique a duodecim annis laboraret, his malis, et ipsa" astato, lente confectus, vita cesserat ante medium Januarium anni 1717. Cadaveris, quasdarn partes in nosocomio dissecantes, base quae ad propositos morbos spectarent, animadvertimus. Uvula, cujus pars deerat, linguae superior postrema superficies, et annexa olim per ligamenta epiglottis cnrtilago itaerani cicatricosae, ut nihil magis. Itaque ea cartilago inaequaliter contracta, in triangularem propemodum veraticem desinebat, multo caninae similior quam humanae. Q,uin vitium in laryngem reliquam, et huic proximum asperae arteriae truncum se propagabat: eratque arytenoidum altera quasi luxata, non compari parallela. Intra illam autem arteriam inaequales magnique prominebant quasi lacerti, &c." OBSERVATION XLIX bis. Thirty-four years of age—Syphilitic disease for eight years—Mercurial treatment—Cure—Six years afterward, angina, at first in the pharynx, then in the larynx; cough, aphonia, pain in the larynx—Orthopnoea, mer- curial treatment, salivation—Rapid recovery. M. aged thirty-four, a lace maker, came to the hospital on the 19th of July, 1836. In 1828 she had the venereal disease, with chancres, that disap- peared in one month, and buboes that lasted three months. The treatment consisted in the use of the liquor of Van Sweiten. which was used six weeks. The cure seemed complete until the 12th of November, 1834, when she had a happy accouchement. The fifth day after delivery a slight pharyngeal angina occurred, which lasted a month, and was followed by pricking pain in the larynx, and frequent fits of cough. At the same time there was TREATMENT. 151 acute pain in the larynx, and a hoarseness which, after a month, became complete aphonia. All these symptoms continued. In the course of May, 1835, she was bled four times, seventy-five leeches were successively applied to the throat, and three blisters in front and at the sides of the larynx; these measures effected nothing, the patient even affirmed that the cough became more frequent and severe. Three months after birth, the infant had pustules on the genitals and nates, which the physician pronounced syphilitic. The mother and child were admitted into the venereal hospital, where M. Ricord confirmed the diagnosis that had been made ot the child's disease. The pustules were powdered with calomel; lotions of the chloride of soda were eaiployed. The cure was effected in three weeks, and from that time he continued well. The mother employed no treatment at this time. Present state, (July 19, 1836.) Complete aphonia for twenty months. When she speaks or takes breath, a hissing sound is heard in the larynx, as though the air passage was too small. Walking, even slowly, occasions great difficulty in breathing, and considerable laryngeal hissing. The region of the larynx is rather painful; cough frequent; expectoration ropy; mucus clear. No pain in the pharynx; no difficulty of deglutition. For three months the neck has been swollen, so that she has been obliged to lengthen her collar three inches. The thorax offers no sign of disease. The general health appears pretty good, but there is constantly some fever. Treatment.—Tvrne a day the neck is to be rubbed with Nea- politan ointment' eight parts, extract of belladonna two parts. July 22d. There is some amendment; the frictions are laid aside. We prescribed, morning and night, a pill of one-sixteenth of a grain of proto-iodide of mercury; frictions to the arms and thighs, with four drams of Neapolitan ointment; a bath, with an ounce of corrosive sublimate. 25th. The cough has almost ceased. The gums begin to be touched. The frictions are discontinued. 26th The patient can walk without oppression : the inflamma- tion of the gums induces us to lay aside the active mercur.al treat- ment : the pills alone are to be continued. 27th. She spoke for half an hour without getting out of breath; without cough or wheezing. Same treatment ■ 28th. The voice is clearer; at our desire she gave a strong and clear shout. She could walk easily without losing breath; the ' Neapolitan ointment; or, mild mercurial ointment. p.. Adipis suillae, Ibj. Hydrargyr. pur. £ij. M. Ratier's Formulary, p. 108. 152 TROUSSEAU AND BELLOC ON LARYNGEAL PHTHISIS. cough has entirely disappeared ; salivation continues. Same treat- ment. 29th. Same state. Two ounces of castor oil. August 1st. There is a diminution of one inch in the circum- ference of her neck. Yesterday she could run up one flight of stairs without suffering oppression. The infant has no symptom that would induce a suspicion of a syphilitic taint. 5th. The voice is quite natural. 7th. Every thing looks well, except the gums, which continue painful. Before the eud of the month, she left the hospital perfectly cured. OBSERVATION XLIX. ter. Chronic disease of the larynx, probably syphilitic. Mile. Basinet, aged twenty-four years, was born at St. M£ne- hould, where she has since lived. When seven years old, she had an exostosis on the left leg, which she attributed to a blow. En- largement of the bone, without suppuration or redness of the skin, continued seven years. The pain was worse at night than in the daytime: she remembers, that as soon as she was in bed she had to get up again, because the pain was so acute. At fourteen she menstruated, and the pain ceased; but the exos- tosis continued. The only treatment consisted of a hemlock plaster, which she wore for a year without benefit. Excepting the exostosis, which was not painful, she enjoyed good health until she was twenty-two, when she had an obstinate chronic diarrhoea for two years; this was followed by a pain in the throat, which continued eighteen months, by spells of a month, with intervals of a fortnight, during which time no treatment was addressed to it. In December, 1833, it became permanent, and much more vio- lent. She saw no physician, nor consented to adopt any treatment until April 10th, 1834. There was then a round ulceration of the palate. A month later, there was a new ulceration in the veil of the palate which threatened its complete destruction. Alkaline chlorides, nitrate of silver, and iodine, were prescribed without any improvement. July 28th, 1834. She consulted another physician, who advised mercurial frictions to the neck, and touching the ulcers with creosote. After pursuing this treatment for a fortnight, the gums were swelled, and so continued six months. There was a decided im- provement, which lasted a fortnight, when all the symptoms returned with increased violence. She consulted another physician in November, 1S34, who cauterised the throat with nitrate of mer- cury, (nitrate acide de mercure;') after six weeks the cure was 1 See note p. 148. TREATMENT. 153 completed. No general treatment was adopted. As the mense6 had been suppressed for five months, preparations of iron were given, and the flow was re-established in January, 1835. The health was then very good until September. In April, the first day that she took the iron, she perceived that her voice was hoarse; this insensibly increased until December, when there was complete aphonia. At this period deglutition was again painful, though no alteiation was observed in the tonsils. She began to cough, and this symp- tom continued. There was also a fit of suffocation for three days which yielded to bleeding, a blister to the neck, and purgatives. She continued better for six weeks. In May 1836, frictions of chloride of gold were applied to the tongue, which treatment was continued thirty-nine days, but it ha- rassed the patient so much that she could not endure it any longer. The suffocation re-appeared on the 20th of June, and increased so much, that on the 18th of July she seemed likely to perish from asphyxia. The fit was calmed by bleeding and a pediluvium with hydrochloric acid. Still, the throat was touched with nitrate of sil- ver, which only alleviated the symptoms for two days. As the suffocation continued to increase, Dr. Carre, seeing no resource but tracheotomy, sent her to consult us in Paris, where she arrived on the 22d of July. When she entered our office she had hissing, difficult, slow, deep respiration, and seemed to be threatened with impending asphyxia. We immediately directed her to M. Pinel's Maison de Sante at Chaillot. . . 23d. Same state. A pill, morning and night of an eighth ot a grain of proto-iodide of mercury; friction on the thighs with four drams of double Neapolitan ointment. 24th. No change. Same treatment. 25th. Rather less difficulty of respiration, the gums begin to be painful. Same treatment. Insufflation with a powder composed of one grain of nitrate of silver and one dram of sugar. T he gums to be rubbed with powdered alum. To take a mixture of six grains of red precipitate to a dram ot sucrar in powder, for the disease that has existed in her nose for a velr and a half. The sense of smell had been lost for a year. 26th Same treatment. Respiration is much easier in the morn- in- but embarrassed in the evening, though better than it has been C»' 1 fOI27th. decided improvement; deglutition much easier; the gums arp more painful : same treatment. 28th The gums are rather less swollen than yesterday, the ton- sils are rather painful. The hissing in the larynx is even less than vesterdav. Continue the same treatment. 30th Respiration has been completely re-established since yes- terday morning ; the hissing has entirely ceased. The patient can waltow liquid's 'without coughing, which she could not do hereto- 154 TROUSSEAU AND BELLOC ON LARYNGEAL PHTHISIS. fore. The gums are much swollen and very painful. No saliva- tion. No cough since the 28th ; an occasional hoarse sound for a few minutes. Stop the frictions, continue the pills and insuffla- tions. August 1st. The nostrils are almost free. Respiration is easy, even during violent exercise. The salivation decreases, though the gums are still painful. The exostosis has diminished. Continue the insufflations and pills. 10th. The proto-iodide has been continued alone. The gums are not swelled, the tongue is no longer painful. For the last four days, especially in the mornings, there has been occasional phonation, which was dull and hoarse, but it did not last long, particularly when the patient endeavoured to increase its intensity. There is no more oppression, and the menstrual flux appeared yesterday at two o'clock. Continue the pills ; make one insufflation to-day. 28th. No change, except that the cough and expectoration have disappeared for a week ; we cauterised the epiglottis and upper part of the larynx with a solution of the nitrate of silver. One day, while performing this operation, and depressing the tongue with a spoon, we discovered that the epiglottis was deeply cleft from top to bottom by a considerable ulcer, it was crenated on its edges like a cock's comb. The ulcer, if not cured, was at least in a very fair way; we cauterised it repeatedly. Continue the pills of proto-iodide. There is no pain whatever in deglutition. She no longer swal- lows awry, and considers herself cured. Still we advised her to persist in the use of the mercurials. It is not long since we heard from her that she continued to do well. OBSERVATION L.' Hoarseness.—Pricking in the larynx, then pain in this organ.—Purulent sputa.—Antiphlogistic treatment.—Improvement.—Relapse.—Appearance of syphilitic pustules.—Mercurial treatment.—Cure. Adelaide G., aged thirty-seven, of a lymphatic temperament, after delivery, fifteen months ago, experienced hoarseness, prickings in the larynx, dysphagia, anorexia and cough. Since then, these symptoms have frequently appeared and disappeared. ' In the spring of 1820, the pain became fixed, the cough habitual, headach almost constant. Constipation obstinate, and abundant expectoration of sero-purulent sputa. The pharynx seemed in- flamed and the epiglottis ulcerated. M. Cloquet administered purgatives, mustard pediluvia, emol- lient gargles, refreshing drinks. Some local bleedings were prac- 1 Papillon, Recherches sur la phthisie laryngee. Paris, 19 Mai, 1821, in 4to. TREATMENT. 155 tised, and ten blisters were successively applied in front of the neck. Rigid diet. There was great improvement after five weeks of this treatment ; the pain, cough, dysphagia and anorexia ceased. Expectoration was less abundant and not more purulent; the epiglottis resumed its natural aspect; but the hoarseness continued, and night sweats prevented the re-establishment of her strength. She left the hospital, but, eight days*afterwards, all the symp- toms re-appeared, and she returned. Pervigilium and hectic fever were added to her other sufferings. M. Fouquier, who now had charge of the hospital, used the same means that M. Cloquet had prescribed, but all efforts were fruitless. After eight months, the vulva and other parts of the body pre- sented syphilitic pustules. Fractional doses of mercurial ointment were then administered internally, and at the end of three months the patient left the hospital perfectly cured. OBSERVATION LI.1 Pain in the larynx—Hoarseness—-Dyspnoea, then aphonia—Dysphagia— Emollient treatment without success—Threatened suffocation—Trache- otomy— Cure—Relapse after ten days—Appearance of a syphilitic pustule —Mercurial treatment—Lasting cure. Emily Baiily, a dressmaker, aged twenty-three years, was admit- ted into the Hopital de la Charite, on the 31st of December, 1821. She had long enjoyed good health, except some irregularities in menstruationr But for some years she has had a dry cough, which became more troublesome whenever she took unwonted exercise. Three months have elapsed since the commencement of the disease, which obliged her to come to the hospital. She says that, after sleeping*by an open window, she awoke with consider- able hoarseness and fever. She used an infusion of mallows and gum-water. The hoarseness and catarrhal symptoms disappeared after fifteen days of this treatment, only the voice was hard, and soon after became weak. It should be observed that she then worked on cotton fabrics. With the aphonia the cough became more frequent, and fatigued her more than before, but it was still without expectoration. At intervals there was a sense of oppres- sion, especially on going up stairs, after active exercise, or when her mind was excited. Respiration was braying during the inspi- ration. Leeches and cataplasms were applied to the throat, and various other remedies employed, with some benefit. On the 30th of December, the oppression increased, sinapisms, and antispasmo- dics were used, and a blister applied to the front of the neck. Abundant bilious vomitings occurred, which relieved the chest and seemed to facilitate respiration ; the same night some traces of blood were seen in the expectoration. ■ Pravaz, Recherches pour servir a l'histoiw de la phthisie laryngee. Paris, 6 Avril, 1824. 155 TROUSSEAU AND BELLOC ON LARYNGEAL PHTHISIS. Hitherto the sputa have been thick and brownish. The last menstruation was on the 27th of December, and lasted two days. Since the invasion of the disease, the powers have gradually dimi- nished; an emaciated condition had supplied the place of her usual embonpoint. At the visit of the 1st of January, 1822, she offered the following symptoms :—Pain, referred to the sides of the neck, opposite to the great horns of the hyoid bone ; slighter pain behind the sternum, and deep in the dorsal region, between the shoulders ; increase of this pain when she coughs, swallows, or speaks, which last act is reduced to a whisper. Nothing was observed on the examination of the interior of the mouth, except some inequalities in the walls of the pharynx, without ulceration ; respiration laborious and bray- ing; greater facility in respiration when she is up, than when lying down ^ deglutition, accompanied by a sound like hiccough. Cough frequent, recurring almost every quarter of an hour, in- creased by drinks and eflbrts to speak, and producing a viscid, limpid matter, in which floated some masses of opaque mucus, streaked with blood; it was accompanied by a peculiar sound, which M. Fouquier compared to croup; so that by this character alone we should have been led to suspect an alteration of the larynx; there was pain in the ears and head; dyspnoea, amounting sometimes to suffocation, from the slightest causes ; frequent, small, and hard pulse; night sweats; loss of appetite, and imperfect digestion. For the first three days, barley water, milk, and soothing gargles were prescribed, with an opiate julep and pediluvia; suppuration was induced in the vesiccated surface in front of the neck; the constipation was obstinate. On the 4th the blister was suppressed that another might be placed over the sternum ; no change in the symptoms. 5th. Respiration is more difficult and hissing; con- striction of the larynx; same prescription. 6th. Constipation con- tinues, the dyspnoea increases, the larynx seems more constricted; sixteen leeches to be applied under the jaw. 7th. Bilious vomit- ing ; some stools during the night; a grain of tartar emetic, gum water, and pediluvia were prescribed. Under this treatment, re- spiration became slower, easier, and less braying. There was a calm during the night. On the 8th, there was considerable op- pression, pain behind the sternum, and redness of the face. The leeching was repeated; the diet consisted of four bouillons and a lait de poule; vomiting at night. 9th. The occlusion of the larynx is almost complete; inspiration is very difficult and noisy, orthopnoea, cough, extreme anxiety, and aphonia ; at night, threat- ened suffocation and extreme agitation; all the symptoms increase. On the 10th, they had reached their greatest intensity ; MM. Fou- quier and Roux proposed tracheotomy, as the only resource. The trachea was scarcely opened, when a quantity of blood entered the canula, and prevented the access of the air to the lungs; the patient TREATMENT. 157 fell senseless, the arteries ceased their pulsations, the countenance was pale, and the whole body cold; respiration was interrupted, the beating of the heart was no longer felt. The surgeon intro- duced an elastic tube into the trachea, and by repeated inspirations he succeeded in withdrawing part of the blood which obstructed the air-passages. The respiration was thus restored, and the cir- culation established, but the patient was still unconscious. The catheter was fixed by a riband round the neck, and the sufferer carried to bed. The rest of the day was passed with little hope; it was frequently necessary to clear the tube of viscid mucus. There were many fits of coughing. In the evening there was high fever, but respiration was less painful than before the operation. The 11th, she had not yet recovered her consciousness; her drinks were given with a sick-cup (bibcron). A silver canula was substituted for the elastic tube, but it gave the patient pain, and did not afford so good a passage to the air. On the 12th, the respira- tion was more free; she began to recognise persons around her; there was less fever; part of the air passed through the larynx ; there was thirst and constipation. Gummed barley water and diet were prescribed. The 13th and 14th, less fever; respiration easier, and more by the glottis than the canula. Prescription: Bailey water with milk, gum water, opiate julep, demi-creme de riz, a lait de poule, and three bouillons. The 15th. The wound began to contract, and no mucus passed; respiration was performed by the mouth; no more night sweats; sleep undisturbed. On the 16th, the pulse was rather frequent. The 17th, the speech was restored, when the finger was applied to the wound. 18th : pulse weaker, small, and not frequent: return of appetite: the wound is healing, and she can speak so as to be understood, without applying the finger. 19th; pulse scarcely frequent, respiration easy. 20th; some cough. 21st; scarcely any fever, constipation combated by injections : some nourishment was allowed. 22d; neither cough nor expectoration. 23d; the aphonia diminishing. After this, the pain in the throat disappeared, the strength returned, and cicatrisation progressed. 31st; very little air passed by the wound : the granulations were touched with nitrate of silver. She has appetite, the respiration is perfectly free and she improves from day to day. On the 6th of lebruary, the 'wound was nearly healed; the quantity of food was increased without any detriment. On the 14th, the fistula was closed, and the voice restored, but more dull than heretofore. She left the hospital with instructions to return occasionally, that a relapse might be observed. Emily Bailly remained eight or ten days without any symptoms of disease: every thing induced the belief that the cure was per- manent She then came to M. Fouquier, complaining of difficulty of respiration, pain in the throat, pricking in this region, and 153 TROUSSEAU AND BELLOC ON LARYNGEAL PHTHISIS. cough, general indisposition, and restlessness at night. She re- turned a second time, and as the symptoms were increasing, she was advised to come back to the hospital, which she did on the 1st of March. She then had a large pustule on the left commis- sure of her lips, partly ulcerated and partly covered with a crust which led to the suspicion of a syphilitic virus. Many other pus- tules were scattered over the scalp. From an investigation into the history of the case, it appeared that she had the venereal dis- ease five years before, when she consulted M. Cullerier; that she had followed an appropriate treatment for some weeks, and until she supposed herself cured. These facts, in connection with the symptoms present, left no doubt of the nature of the diseasr, or that the laryngeal affection might be connected with it. The liquor of Van Swieten and the sudorific syrup were, therefore, adminis- tered. During the first week she was pretty well; on the 8th, she seemed to have recovered her voice partially, and the difficulty of respiration was diminished. On the 16th, the liquor and syrup were suspended on account of an increase in the cough: pills of Neapolitan ointment were substituted. This treatment seemed to suit very well at first. The pustule on the lip insensibly dimi- nished, assumed a better aspect, and contracted. On the 18th, the voice reappeared, the oppression diminished, and there was less hissing during the inspiration. 20th. The voice was restored ; there was a swelling of the right cheek, incipient salivation : twenty leeches under the jaw, cata- plasms, gargles of marshmallow tea, gum potion,1 and five bouil- lons. 22d. A purgative of manna; the ptyalism is excessive, with ulcerations in the mouth. 23d; vapour baths for the salivation. 25th; a purgative enema was added to the other remedies: the venereal symptoms had disappeared. 26th; the happy effects of the vapour bath on salivation were manifest. 28th; the swelling of the cheek had diminished. 29th ; the salivation was subdued, she scarcely feels it, and on the 31st it was entirely arrested. On the 5th of April the voice was re-established ; she was able to 1 Gum potion. ;v. Gummi acaciae arab. grs. xviij. Infus. althsese comp. f Jiv. Aquae flor. aurant. Jij. Syrupi althaeae f Jiij. M. Vid. Ratter's Formulary, Am. edit. p. 149. Or, 9<. Gum. acac. 3j. Aquae f Jiij. Syr. simp. 3j. Aq. flor. aurant. 3ij. M. Vid. Ratier, p. 152. TREATMENT. 159 resume the liquor of Van Swieten,' and the syrup of Cuisinier: she continued to do very well. The symptoms of venereal infec- tion and those of laryngeal alteration have disappeared. There was no cough or expectoration, no fever or sweats. Sleep was tranquil, the digestive functions resumed their activity, and her strength increased from day to day. On the 12th of April, the menses appeared after an interval of many months. On the 13th, she would leave the hospital despite the representations which were made her of the uncertainty of her entire recovery. She promised to continue the use of mercurials for some time. Since this period, M. Truchon has frequently seen her. She has enjoyed uninterrupted good health. Cancerous and tubercular laryngeal phthisis.—We shall not hazard any remarks upon the treatment of these species, which are evidently beyond the resources of our art. The only object we can propose, is to afford some palliation, and we are often bbliged to practise tracheotomy upon the unfortunate patients, though it be only to prolong their sufferings. . Tracheotomy.—Whatever may be the form of laryngeal phthisis, when the tumefaction of the mucous membrane and submucous cellular tissue has gone so far as to prevent the entrance of a sum- cient quantity of air into the lungs, death is threatened, if we do not open a passage to the air. Catheterism is the first mode which suggests itself to the mind, and Hippocrates3 proposed the introduc- tion of tubes by the mouth. This plan was exclusively followed by physicians until Asclepiades, who first proposed the incision ot the trachea, according to the method we shall presently describe. Desault* revived the plan of Hippocrates, which had fallen into disuse; but he asserts, that it is only practicable in, cases of pha- ryngeal angina, when the inflammation has not invaded the larynx or trachea; for, besides the difficulty of introducing the tube throucrh swollen tissues, its presence would cause an increased irritation. Boyer* was therefore wrong in blaming this practice ' *. 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