SPgi^.^"!*— ;^v.4f.:*i-^^> i''.3CE'F—r-I::c"- -----— * - ■ *: •"■' :i£r.aaifeS?T-:,---t---,.— ■■ v-'"~ ■v-Vifel-Zg-.-i--- ... '■-?■;••'?.-.■:■■ &4^MSla^i^r.«-r^.Ta-Sr5- -Try1---:-"-: "&F- alji-Kr-lfm-jn-.^■"'■--,', •■'•.; -r: i\*- ■ . :v .: ,;..; Jri''"'/.-. '>»?-vr-■ '"""> Jf'','~.-,' .'- -- ■"?' .. c^t:i^- k- —>■ *>V * ... >.■•-. ..-■«!■ " .'3 ,s: • UNITED STATES OF AMERICA ^ * . FOUNDED 1836 WASHINGTON, D. C, Bl9574 ON THE USE AND EFFECT OF APPLICATIONS OF NITRATE OF SILVER TO THE THROAT, EITHER IN LOCAL OR GENERAL DISEASE. By HORACE GREEN, M.D., LL.D., (chairman of the committee,) PRESIDENT OF THE FACULTY, AND EMERITUS PROFESSOR OF THE THEORY AND PRACTICE OF MEDICINE IN THE NEW YORK MEDICAL COLLEGE ; CORRESPONDING FELLOW OF THE LONDON MED- ICAL SOCIETY J MEMBER OF THE AMERICAN MEDICAL ASSOCIATION, ETC. FROM THE TRANSACTIONS OF THE AMERICAN MEDICAL ASSOCIATION. NEW YORK: EDWARD P. ALLEN, No. 9 SPRUCE STREET. 1855. \ j % \NVB Fil^ n* ?'-V5 #; EEPORT USE AND EFFECT OF APPLICATIONS OF NITRATE OF SILVER TO THE THROAT, LOCAL OR GENERAL DISEASE. By HORACE GREEN, M.D., LL.D., CHAIRMAN OF THE COMMITTEE. [From the Transactions of tlie American Medical Association.] Many years ago the celebrated Abernethy published to the world his treatise " On the Constitutional Origin of Local Diseases." His views have been pronounced enlightened and philosophical; and perhaps justly so. Certainly they were eminently suggestive, for they contributed, more than those of any other writer of that period, to awaken among both sur- geons and physicians a spirit of enlightened inquiry with regard to primary diseased action. But the great work needed now more than any other, by both branches of the profession, and which might be termed, perhaps, the converse of that of Mr. Abernethy, is one which would embrace a full, enlightened, and philosophical history of the Local Origin of Constitutional Diseases. Until this neg- lected portion of the history of Medicine shall have been written by some second Abernethy, thoroughly enlightened and imbued with the vast importance of his subject, the value of topical medication, its effects and utility, cannot be fully appreciated by the profession. i 3 1 * 6 5*3 4 A brief history, only, of the therapeutic effects of a single agent locally employed in the treatment of disease, is doubt- less the one expected by those from whom the appointment to report on this subject emanated; and yet the diseases in which topical medication has been already successfuly employ- ed, embrace a wide range, and include many of the most im- portant affections which the physician is called upon to treat. Besides all that has been written in this country on the topical employment of nitrate of silver, several works of some magni- tude, besides many monographs, have been published in Europe within a few years, which are devoted wholly or in part, to the history of the effects of this therapeutic agent in the treatment of disease. In reporting, therefore, on this sub- ject, I shall refer primarily and mainly to the views and con- clusions of others—to those which appear to be based on care- fully recorded observations—believing that the value of my own views and opinions will be enhanced when these are sustained by the experience and the corroborative testi- mony of distinguished observers of my own and of other countries. Among the works which have been published on topical treatment, or in which the use of nitrate of silver as a local therapeutic agent is discussed, are the following : uDysphonia Clericorum, or Clergyman's Sore Throat, its Pathology and Treat- ment. By James Mackness, M.D., member of the College of Physicians, London, &c, published in London, 1848." "A Treatise on Diseases of the Larynx and Trachea, and their Treat- ment by the Local Application of Caustics. By John Hastings, M.D., Licentiate of the Royal College of Physicians, London &c, 1850." A work on the Medication of the Larynx and Trachea, by S. Scott Alison, M.D., Member of the Royal College of Phy- sicians, London, was published in 1853. And in the same year, Prof. Bennett of Edinburgh, published his work on Tu- berculosis and on the Local Medication of Pharyngeal and Laryngeal Diseases. But the most comprehensive and valuable publication on this subject, is the recent work of Dr. Watson, of Glasgow, Pro- fessor of the Institutes of Medicine in the Andersonian Uni- 5 versity, in which he declares his object has been to explain the rationale, and to recommend the practice of topical medica- tion to the larynx, not only in those diseases which affect that organ simply and alone, but also in others during the progress of which it is secondarily involved in morbid action.* There are two other foreign works, having reference to diseases of the air-passages and their topical treatment, of which I might speak, both of which were published in London in 1851. The one by a member of the Royal College of Sur- geons of England, the other by a Fellow of the Medical Society of London, &c. But as these volumes contain nothing on this subject, not recorded in my own work on Diseases of the Air-passages, published in 1846, I shall only allude to them in order to say, that however just the English may have been in accusing American writers of " pirating " and of borrow- ing largely from English authors, they are themselves not alto- gether immaculate in this respect. One of these authors has taken copiously from the above work, without the ordinary acknowledgment ; whilst the other has made up a good-look- ing volume of nearly two hundred pages, on Diseases of the Mucous Membrane of the Throat and their Treatment by Topical Medication, a large proportion of which in its chapters on pa- thology, etiology, and treatment, is abstracted from my work ; page after page of matter having been copied literally, with- out any intimation whatever as to its true paternity, and that too without those revisions and improvements which might have been made advantageously, with almost every sentence purloined. Although many brief articles on the treatment of several of the diseases of the air-passages by means of cauterization, have from time to time appeared in our Medical Journals, yet no work, nor even a monograph, especially devoted to this subject, has ever been published by any one among my own countrymen. Among the diseases, in the treatment of which the preced- * The Topical Medication of the Larynx in Certain Diseases of the Respira- tory and Vocal Organs. By Eben Watson, A.M., M.D., &c, &c. 6 ing authors have recommended the employment of application of nitrate of silver, are the following : Follicular disease ot the pharyngo-laryngcal mucous membrane, acute and chronic laryngitis, croup, oedema of the glottis, aphonia, hooping- cough, spasmodic asthma, chronic bronchitis, laryngismus, and tuberculosis, especially when the latter affection is consequent on or complicated with laryngeal disease. Now, the question very appropriately presents itself, on what principle in rational or scientific medicine, is that practice founded by which several diseases, diverse in their indications, can be successfully treated by the employment of a single topi- cal remedy ? Dr. Watson, in his recent valuable work, to which I have alluded, in considering the modus operandi of this local stimu- lant, in the treatment of inflammations of the mucous mem- brane, offers an interesting rationale of that treatment, show- ing its applicability to many diseases, which at first sight are essentially different; " as different, for example, as hooping- cough and laryngitis, or as either of these and aphonia." All practitioners who have used this local remedy to any extent, have found it highly important to vary the strength of the solution in different cases, and also according to the condi- tion of the diseased membrane. When a solution of nitrate of silver of moderate strength is applied to the mucous mem- brane, it acts chemically on the mucus with which it comes in contact, and throws down a copious white deposit that coats the membrane beneath. " In erosion and ulceration of the mucous membrane," says Dr. Watson, " the deposit of the white substance before al- luded to. from the caustic solution, is thickened by coagulation of the albumen of the liquor sanguinis, which transudes from the exposed vessels, and thus protection is afforded to the deli- cate and inflamed parts beneath."* The therapeutic effect which follows the stimulation produced in the vessels of the parts, by the application of the argentine solution, he explains by a reference to the action of this remedy, on the different degrees and stages of that inflammatory process, which is artifi- * Op. citat., p. 32 eially produced in the web of a frog's foot, stretched out under a microscope. When, for example, he says, " a red-hot needle is passed through the web, the following are the phenomena observed : A spot in the centre of the inflamed part is sphacelated, de- stroyed by the passage of the needle through it; a circle around the spot is usually found in a state of complete conges- tion, the vessels being dilated and the corpuscles almost per- fectly stationary within them, while in the part beyond this circle, the vessels are not so much dilated, and the stasis of their contents is not so complete. The stream is seen passing slowly away into the collateral circulation of the unaffected parts of the web." " Now these two circles represent two degrees of inflamma- tion, which it is important to distinguish wherever they occur, and perhaps especially when the seat of morbid action is the mucous membrane of the larynx or trachea. That part of the web of the frog's foot in which the stasis was complete, repre- sents the most intense, or sthenic degree ; the other, in which the stasis was not so complete, represents what is usually called the subacute, and perhaps chronic varieties. And the effects of the solution of caustic on each of these parts, is markedly and importantly different. In the part which is most intensely inflamed, the solution in the direct ratio of its strength in- creases the stasis of the blood within the vessels. The latter seem to be unable to dilate further, and are, therefore, little changed, but the nitrate of silver acts through the coats upon the blood which they contain by causing its partial coagula- tion, and likewise by withdrawing water from the serum for the crystals of the nitrate which begin partially to form if the solution is strong. In that part of the web, on the other hand, which had been less intensely inflamed, the stimulant solution causes a renewed and increased dilatation of the blood vessels, and the retarded current moves on in them more freely than before ; a cure being thus speedily effected if the exciting cause of the inflammation has ceased to act."* From these experiments Dr. Watson believes we are war- * Op. citat., pp. 32-3. 8 ranted in concluding that the purely stimulant action of this remedy is beneficial, in all varieties of the inflammatory pro- cess, except the most intense ; and that a strong solution not only stimulates the vessels, but tends, as in the different varie- ties of oedema, to remove the watery part of their contents, on the laws of exosmose and endosmose. Prof. Bennett of Edinburgh, on the other hand, declares in his recent work on Pulmonary Tuberculosis, that " the action ol the nitrate of silver solution is not that of a stimulant, but rather that of a calmative or sedative. It acts chemically on the mucus, pus, or other albuminous fluids it comes in contact with, throws down a copious white precipitate, in the form of a molecular membrane, which defends, for a time, the tender mucous surface, or irritable ulcer, and leaves the passage free for acts of respiration. Hence the feeling of relief almost always occasioned ; that diminution of irritation in the parts, which is so favorable to cure, and why it is that strong solutions of the salt are much more efficacious than weak ones."* Dr. S. Scott Alison, in his work on the Medication of the Larynx and Trachea, expresses the opinion that the nitrate of silver, when applied to an acutely inflamed organ, is an irri- tant, and may aggravate the morbid condition. " To a part affected with chronic inflammation," he says, " it is a tonic and a .stimulant, and therefore is likely to be beneficial. To a tissue, the subject of irritation, it is a sedative. Applied to a membrane, which for some time has been the seat of excessive and unhealthy secretion, it abates and corrects it." * These are the opinions of a few of the distinguished members of the profession—men who have had the largest experience in the use of the remedy—of the therapeutic action of the nitrate of silver solution, in the treatment of diseases of the lining membrane of the air-tubes. I shall now proceed, in as brief a manner as possible, to * The Pathology and Treatment of Pulmonary Tuberculosis ; and on the Local Medication of Pharyngeal and Laryngeal Diseases, frequently mistaken for, or associated with, Phthisis. By John Hughes Bennett, M.D., F.R.S.E., &c, &c., p. 140. * The Medication of the Larynx and Trachea. By S. Scott Alison, M.D. &c, pp. 10, 11. 9 specify some of the most important of the local and general diseases which have been enumerated, in the treatment of which the Use and Effect of Nitrate of Silver have been observed and recorded. 1st. The Effect of Nitrate of Silver in the Treatment of Fol- licular Pharyngo-laryngeal Disease. In advocating the employment of topical medication, in the treatment of diseases of the air-passages, in the work to which I have alluded, I state that, " in the simple and uncomplicated form of follicular pharyngo-laryngeal disease, however severe the local affection may have been, this remedy alone, namely, the crystals of nitrate of silver topically applied, has proved in my hands a specific in a large number of cases." * This opinion of the efficacy of the remedy in this disease, has been fully sustained by subsequent experience, in the practice of many distinguished physicians in this and in other countries. It is well known that Prof. Bennett, of the University of Edin- burgh, has adopted extensively topical medication in the treat- ment of laryngeal and kindred diseases, in the Royal Infirmary, and in his private practice. In his treatise on Pulmonary Tuberculosis and Laryngeal Affec- tions, much valuable information on this subject, and many in- teresting cases, successfully treated by the applications of nitrate of silver, are given. I shall take the liberty of noting the following Case.—" I was requested by an assurance office, in July, 1850, to examine the chest of Mr. M----, a merchant, aged about 30, who said he labored under no kind of complaint, with the exception of occasional sore throat, and expectoration of mucus tinged with blood. He was tolerably stout, took long walks without uneasiness, and suffered from no difficulty of respiration or from cough. Repeated examination of his chest failed to elicit any physical sign indicative of pulmonary disease. I therefore certified that his lungs were healthy. In October, 1851, this gentleman called upon me again for advice, under the following circumstances. The soreness of the throat had lat- * A Treatise on Diseases of the Air-Passages, &c., p. 213. 10 terly increased, and considerable cough was induced, after which he spat up mouthfuls of purulent matter, frequently tinged of a red color. He brought me some of this sputum to examine, which consisted of mixed blood and pus, of a dirty brick-red color. Examination of his chest again convinced me that the lungs were unaffected ; but in the interval I had paid attention to the writings and practice of Dr. Horace Green, of New York ; and I now examined his throat, when the cause of his symp- toms was at once apparent. The fauces and upper part of the pharynx were studded over with nodular swellings, varying in size from a pin-head to that of a pea. Many of them were bright red, and fungoid in character, probably the origin of the extravasated blood, whilst considerable patches of purulent matter adhered to several parts of the mucous membrane. I applied a sponge, saturated with a strong solution of the nitrate of silver, to the affected parts. In three days he returned, having been much relieved, when the application was repeated. I have not seen him since. " These two cases (a second case being recorded by Dr. B., not quoted) convinced me that certain symptoms which have hith- erto been considered as indicative of phthisis, might have their origin entirely in the fauces, pharynx, and upper part of the larynx. The cough, so occasioned, with the purulent expecto- ration, often tinged with blood, frequently so resembles that occasioned by phthisis, as not only to induce alarm in the minds of the patients, but frequently to mislead the medical practi- tioner. I have now met with many such cases, which have been mistaken for phthisis, and which have been treated for that dis- ease without any effect, until local remedies were applied when they, for the most part, disappeared or became much better." * Dr. Bennett enumerates other cases of follicular disease where all the symptoms of phthisis pulmonalis were present including emaciation, profuse sweating, cough, expectoration of pus mingled with blood, bad appetite, hectic ; and, in conse- quence, cod-liver oil. cough mixtures, acid drops, wine and good diet were administered, and all without effect; " but which in many instances were cured by the topical applications." * Op. citat., p. 128. 11 2d. The Effect of Mtrate of Silver in the Treatment of Acute and Chronic Laryngitis. Dr. Hastings, in his excellent Treatise on Diseases of the Lar- ynx and Trachea, expresses great confidence in the use of the nitrate of silver, as a local remedy in the treatment of these affections ; and he also details many cases of much interest, in which topical medication proved effectual in arresting the dis- ease, after other measures had failed. Under the head of " Fol- licular Laryngitis," Dr. Hastings alludes to a pathological con- dition of the larynx and trachea, which, as an independent affection, is very generally overlooked by the profession, or, is considered the sequel—not, as it often is, the antecedent of tuberculosis. " I am satisfied," says Dr. Hastings, " that cases presenting the morbid appearances in the pharynx and arch of the fauces just described, form but a small proportion of those denominated follicular laryngitis."* * * * * " I have repeatedly met with cases in which the disease was confined to those parts, and the back of the velum, where nothing more was required than to carry the solution of the nitrate of silver behind the uvula into the posterior nares, and over the pharynx and fauces, in order to remove a very trouble- some cough ; whilst in others, and by far the greater number, the disease exists in the larynx and trachea, the fauces and pharynx at the same time presenting a healthy appearance. " Such cases are, generally, most puzzling tothe practitioner. The patient is troubled with cough, the expectoration is muco- purulent, occasionally streaked with blood, to a considerable amount; pains are felt in the chest below the clavicles, he wastes a little, or he may not lose flesh. His chest is examined again and again, but no disease can be discovered; his mouth and throat are inspected without anything being found there to account for the symptoms; at length the disease is regarded as an obscure case of phthisis; he gets treated with sedatives, expectorants, and cod-liver oil, until the ensuing Winter, when all his former symptoms return in an aggravated degree, whilst as the warm season comes on, they improve." * A Treatise on Diseases of the Larynx and Trachea. By John Hastings, M.D., &c. London, pp. 115. 12 " Much pain and suffering might be spared in these cases, were a stethoscopic examination of the windpipe resorted to, which in most cases would point out the nature, situation, and extent of the disease; and the practitioner would have that satisfaction in treating the case, which an imperfect knowledge or an entire ignorance of it can never give." ' Such cases are reported by Dr. Hastings as having been suc- cessfully treated by the repeated application of the sponge, sat- urated with a solution of the nitrate of silver, and which was " carried down the windpipe," he says, " as low as the bifurca- tion of the bronchi."t In speaking of the practicability of this operation, and of the benefit to be derived from topical medication in disease of the larynx, Prof. Bennett declares, that if the probang be pro- perly prepared, and the operation well performed, the sponge saturated with the solution of nitrate of silver may be rapidly thrust through the rima into the larynx and frequently into the trachea. " I am persuaded," he continues, " that on many occa- sions, I have passed it pretty deep into the trachea, not only from the length of the probang which has disappeared, but also from the sensations of the patient. | * * * In this first part of the operation, the rima glottidis is, as it were, taken by surprise, and the sponge enters, if the right direction be given to it, without difficulty ; the rima glottidis immediately contracts by reflex action, so that on withdrawing the instrument you feel the contraction." " This also squeezes out the solution, which is diffused over the laryngeal and tracheal mucous membrane. Now if the sponge be a fine one, it will be found capable of holding about half a drachm of fluid, the effect of which upon the secretions and mucous surfaces, almost always produces temporary relief to the symptoms, and strengthens the tone of the voice ; results at once apparent after the momentary spasm has abated." In the treatment of both varieties of chronic laryngitis the idiopathic and the tubercular, topical applications of the nitrate of silver solution have proved, in the hands of many practi- tioners, a most efficient and valuable remedy. * Op. citat., pp. 116-7. t Op. citat., p. 119. { ft,., pp. 139) l4Q 13 Dr. Cott' a, one of the physicians of Brompton Hospital, in the work to which I have alluded, in speaking of topical medica- tion in chronic laryngitis and laryngeal phthisis, candidly admits his previous unbelief in, and changed views with regard to the practicability or propriety of topical medication to the mucous membrane of the respiratory passages. The admission is hon- orable to himself, and worthy of imitation. " I should here remark," he observes, " that my own views upon this subject differ from those I formerly held and have even expressed ; and that I owe this change to the kindness of Dr. Horace Green of New York, the justly celebrated advocate of this treatment. who, during a recent visit to our metropolis, convinced myself and others, not only of the possibility, but of the safety and usefulness of the practice. " I had long been in the habit of using a solution of nitrate of silver to the pharynx and upper surface of the epiglottis, by means of a soft brush, in all the early cases, both of pharyngeal and laryngeal complication ; and had frequently witnessed its good effects, not only upon the part to which it was immedi- ately applied, but upon the laryngeal structures also, attributing it in the latter case to an action excited in the upper respira- tory passages from continuity. But I had never ventured to apply anything directly to the larynx itself; not from misgiv- ings as to its effects, but from apprehensions of its danger. For some months past, however, I have done so, extensively in cases of chronic laryngitis, whether idiopathic or tubercular, and very frequently with marked success. " At the commencement of the laryngeal symptoms, a solution of the crystals of nitrate of silver, varying in strength from ten grains to half a drachm to the ounce of distilled water, passed by means of the instrument recommended by Dr. Green, into the opening of the larynx, is often productive of great relief. I have known the voice regained, the irritable cough removed, and the tenderness and difficulty of swallowing dissi- pated entirely by it; indeed, I think we might almost speak of its curative effects, so far, at least, as the larynx is concerned, in some very early cases." * * Op. citat., pp. 236-7. 14 "In the treatment of acute laryngitis," says Dr. Hastings, i: the topical application of a solution of the nitrate of silver may sometimes be employed with great advantage; indeed, unaided, it will not unfrequently remove the disease, but then the patient must be seen sufficiently early. " If the inflammation has not penetrated into the trachea, but is confined to the larynx, we may safely and successfully ven- ture to employ this topical application ; for although a small spot of intense inflammation may be safely and successfully treated in this way, a large surface is irritated by the same means. " This treatment would not interfere or prevent the use of any additional remedies, such as calomel, opium, aperients," &c. " But it is in the chronic form of laryngitis," Dr. Hastings con- tinues, " that this treatment is remarkably useful. Many such cases improve rapidly under local treatment applied to the larynx and trachea, which, if neglected for months, or it may be for years, not unfrequently lead to permanent changes." * In this connection Dr. Hastings relates some most interesting cases of chronic laryngitis, attended with hoarseness, cough, emaciation, " expectoration streaked with blood," difficulty of breathing, night-sweats, and most of the ordinary symptoms of phthisis—all of which were promptly and permanently relieved by a solution of nitrate of silver of the ordinary strength applied to the larynx and trachea.f With regard to the treat- ment of tubercular laryngitis, Dr. Hastings remarks, " I know of no means so capable of arresting and removing it, as spong- ing the windpipe with a solution of the nitrate of silver." % In the treatment of the non-exudative variety of chronic laryngitis, Dr. Watson has employed and recommends the application of the nitrate of silver to the inflamed mucous membrane ; but he considers that a great amount of discrimi- nation is necessary in the adaptation of the strength of the solution to the severity of the inflammation which may be present; as well as in the preparation for commencing the topical measures. In the severe forms of the affection, he believes that depletion of some kind will at first be necessary * Op. citat., pp. 79, 80, 81. f lb., p. 85 et seq. % lb., p. 130. 15 to check the violence of the inflammation before the applica- tions of the caustic solution are made to the laryngeal mem- brane ;* and with regard to the strength of the remedy employed, he maintains that the more intense the degree of inflammation of the laryngeal lining, the weaker ought to be the solution of the nitrate of silver applied to it.t After the intensity of the primary inflammation has been subdued by appropriate treatment, a stronger solution may be used with advantage. " Its first effect," he continues, " when thus judiciously applied will be to coagulate the albuminous film upon the surface of the membrane which had been stripped of its epithelium, and to secrete new mucus, and thus the arti- ficial film of coagulated albumen is by and by replaced by a more natural covering, and the surface is lubricated by its appropriate moisture. " If, then, a renewal of the morbid process could be prevented, a cure would already have been effected, but this is seldom or never the case. The good effects of the topical application wear off in a few hours, and the former abnormal phenomena may even in that time have reappeared in nearly equal severity. The treatment must therefore be continued ; the touching of the larynx must be repeated frequently for some days ; and indeed, until all the symptoms of laryngitis have completely disappeared."t Many practitioners both in this country and in Europe, differ entirely from Dr. Watson, with regard to the strength of the solution to be employed in the treatment of different degrees of inflammation of the mucous membrane. The weaker solu- tions, they believe, those for example of the strength of five, ten, or fifteen grains to the ounce of water, act as a stimulant, or as an irritant when applied to a highly inflamed membrane ; while a strong solution, by the chemical changes it effects, will prove a sedative, and thus tend directly to subdue the violence of the inflammatory action. On this point, as we have seen, Prof. Bennett expresses the decided opinion, after much observation and experience in the topical use of the nitrate of silver solution in the treatment of * Op. citat., p. 40. t lb-, P- 41. t Op. citat., p. 41. 16 inflammations of the lining membrane of the larynx and trachea, that strong solutions of the salt, by acting as a calma- tive or sedative, diminish the irritability of the inflamed parts, and are therefore much more efficacious than weak ones. Dr. Watson, in his treatise, has devoted many pages to the consideration of chronic laryngitis. " In the treatment of chronic disease of the laryngeal mucous membrane," he remarks, " I place my chief reliance on topical applications to the parts affected, but I do not undervalue or neglect more general measures." The strength of the solution, he adds, " should vary with the requirements of the case, and it should be applied every day, or every second day, according to the patient's feelings."t Dr. Alison, in the work to which I have referred, on the Medication of the Larynx and Trachea, details his experience in the employment of other agents beside nitrate of silver, for the treatment of local diseases; such as Atrophine, Daturine, Iodine, &c, but he gives the preference to the first named rem- edy, as the one most efficient. " I had so frequently found," he remarks, " in the treatment of local disease, and local com- plications, that many remedies were far more efficacious, when applied immediately to the part affected or to its vicinity, than at a distance, that I was glad to learn that a sponge loaded with the solution of the nitrate of silver, and affixed to a probang, could, not only without injury, but with manifest advantage, be passed through the glottis and the larynx down into the trachea."! In acute inflammation of the glottis, Dr. Alison has hesitated to apply the solution, lest " the presence of the stimulant on parts suffering from such attacks," might aggravate the disease • but in chronic inflammations of the larynx, " and of the upper portion of the trachea, the solution of the nitrate of silver he observes, has in my hands as in others, been very useful in bringing the disease to a conclusion ; and where that has not been accomplished by reason of its dependence upon incurable disease of the lungs, it has almost invariably afforded verv considerable relief, by rendering the cough less violent and fre- * lb., p. 140. t lb., p. 85 et seq. { Op. citat., pp. 23. 17 quent, and removing much of the tickling and uneasy sensations, at the upper portion of the larynx." * * * * " In some cases of disease of the larynx and trachea," he continues, " in which the symptoms inclined to the suspicion that ulceration existed, the same local application of a solution of the nitrate of silver has been very useful."* Abundant testimony from many other sources might be gathered, if necessary, to prove the great advantage to be obtained from the topical use of this remedy, in the treatment of laryngeal and tracheal disease. 3d. The Effect of the Application of Nitrate of Silver in the Treatment of Membranous Croup. As a difference of opinion obtains, to some extent, among the profession, with regard to the propriety of employing top- ical applications of the nitrate of silver in exudative laryngitis, or croup, I shall examine with some care the opinions and observations of those who have had extensive opportunities to test its efficacy in the treatment of this often fatal malady. According to the testimony furnished by Prof. Trousseau, of Paris, M. Bretonneau, the preceptor of Trousseau, was the first to employ topical medication in the treatment of membranous croup. Prof. Trousseau, in a letter which I received from him, and which was published in the January number of the Amer- ican Medical Monthly, thus writes: "As early as 1818, M. Bretonneau, in the treatment of croup, carried over the aryteno- epiglottic ligaments, several times a day, a sponge fastened to the extremity of a piece of whalebone and charged either with pure chlorohydric acid, or with a saturated solution of nitrate of silver. He expressed the fluid from the sponge at the entrance of the larynx, and the patient in the convulsive move- ments of respiration caused a certain quantity of the caustic solution to enter therein."t In 1830, M. Trousseau employed for the first time caustic applications in the treatment of diseases of the larynx. " I made use," says M. Trousseau, " precisely of the same process which I have pointed out above, in the treatment of croup, and *°Ib„ pp. 7 and 8. t American Medical Monthly, Jan. 1855, p. 9. 2 18 I endeavored to express the caustic solution into the cavity of the larynx." In this coanection Prof. Trousseau asserts, " that never, either before or since the publication of your labors, have I attempted to introduce into the larynx or trachea, a sponge saturated with a caustic solution," * * "and consequently," he continues, "the direct introduction of the sponge saturated with a caustic solution, into the larynx and into the bronchial tubes, does not belong to me in any respect whatever." * This local agent has also been employed after the manner of Bretonneau, in the treatment of pseudo-membranous croup, by MM. Dupuytren, Guersant, Guiet, Bouchut, Berton, and other French practitioners, but no one of the number made any attempt to pass the sponge probang into the larynx. M. Bouchut, whose work on Diseases of Children was pub- lished in 1845, advises the employment of cauterizations, in the treatment of the disease, but he observes and recommends great caution in making the applications to the pharynx, and over the glottis, lest too large a quantity of the fluid should drop into the larynx, and produce suffocation and death, or at least render it necessary to practice immediate tracheotomy. The follow- ing are M. Bouchut's remarks on this subject: " Si la cauteri- zation de l'arridre—bouche et de la partie sup^rieure du larynx est avantageuse, elle a aussi ses inconvenients qu'il faut con- naitre pour tacher do les e>iter. La suffocation immediate peut en etre la consequence, si Ton a laisse" trop long temps l^ponge sur la glotte, et si une trop grande quantitd de liquide a pe^tre* dans la larynx. Cet accident est fort grave, car il peut determiner la mort, ou au moins la ndcessite" de pratiquer aussitot la trache'otomie."t A late number of the Archives Generates de Medecine contains an interesting Memoir, by M. Vauthier, on the history of Croup as it occurred in an epidemic form, in L'Hopital des Enfants Malacks de Paris. In this paper are the details of several well marked cases of membranous croup, which were treated suc- cessfully by " emetics and cauterizations;" and although in these * See American Med. Monthly, Vol. HI, pp. 9-10. Mam^Cp. 2^^ *" Malad''e8 *" Nott™^-N*, et des Enfants a la 19 distances, the argentine solution was not conveyed into the larynx, but was applied only to the fauces and pharynx, yet the patients recovered perfectly under the treatment* Although the cases thus treated are characterized as having been very severe—" tr6s intense"—yet, as the treatment was early adopted, it is probable that the exudative process had not extended into the larynx; for, in the same paper is a history given, of five other cases of membranous croup, in which the disease, having reached the larynx, was not arrested by cauterizations. This method was employed, as in the other cases, but no attempt was made to pass the instrument below the epiglottis. Tracheot- omy, however, was resorted to in all these five cases, but every patient died. Efficient cauterization of the larynx, we main- tain, would have saved three, if not more of these last cases. Among the English practitioners, of whose works, on topi- cal medication, we have spoken, a few only appear to have employed this remedy in the treatment of true exudative croup. Dr. Watson's exudative experience, in the treatment of the few cases he has reported in his work, has led him to the con- clusion, " that the topical treatment is unsuitable during the acute stage of exudative croup." Having been unsuccessful in the management of a single case of membranous croup,t in which he employed the treatment through the acute or inflammatory stage of the disease, Dr. Watson adopts and promulgates the above opinion. In the commencement of the disease, or in that stage of the affection denominated by him " the pre-exudative stage of croup," Dr. Watson highly recommends the application of the solution of nitrate of silver to the throat and larynx. Omitting the appli- cations during the acute stage of the disease, he renews the topical measures, as soon as the inflammatory process has been * Archives Gnierales de Medecine, tome xix., art. 1st. t The only other case mentioned by Dr. Watson, as one not benefited by the topical treatment, is that of a gentleman past the middle period of life, " who on a Winter evening," was suddenly seized with difficult respiration, tightness in the throat, harsh, dry, whistling cough, and high fever, "whilst the phys- ical signs were : Inspiration long in the trachea, and accompanied by a harsh sound of the air passing along the dry and narrowed tube." Symptoms, man- ifestly indicative of acute laryngitis, and not as Dr. Watson supposed, of " acutb tbacueal croit, accompanied by exudation."—Op. citat., p. 51. 20 su'vlued by appropriate reducing measures. But his view on this subject will be best understood from the following brief extract'from his work : " There is a large class of cases, in which the croup commences by a longer or shorter stage of simple, though severe inflammation of the laryngeal membrane. This inflammation differs in nothing from the most intense degree of catarrh, formerly described; but it speedily ends either in exudation upon the surface of the membrane, or in serous effusions beneath it, " The suddenness of the attack, the anxiety of the patient, the severity of the constitutional fever, and above all, the stetho: scopic signs of a dry and tense glottis, never fairly released at any stage of respiration, are the chief diagnostic marks of the danger to be expected in the next stage of the disease. No one who has ever listened attentively to the peculiarly harsh sounds transmitted through the stethoscope placed over the thyroid cartilage of a patient in the critical state we are now consider- ing, can either forget or mistake the prolonged and dry, but vibratory sound during inspiration, immediately followed by less noisy, though still grating murmur of obstructed expiration by which it is characterized. Then the stifling and painful cough, without expectoration, and the whispering, not hoarse voice, are equally characteristic. " In children, or in adults predisposed to the disease, such a ?roup of symptoms as that just referred to, may be considered is certainly indicative of the first stage of exudative croup. But no exudation has yet been poured out, and according to my experience, the disease may here be checked by the application )f an appropriately strong solution of the nitrate of silver ; and [ will venture to assert, it is in the treatment of this pre-exuda- tive stage of croup, if I may be allowed so to name it for sake of brevity, that Dr. Horace Green has also been successful."* This abortive treatment of croup by topical applications, is further illustrated by Dr. Watson, in his relation of the sub- joined case : " It is that of a family of young children," he says " all of whom are remarkably subject to croup, and,' notwith- standing the utmost care in their management, some of them * Op. citat, pp. 49, 50. 21 have suffered once or twice from the disease during the Win- ter, for some years past. In the beginning of the present year, I attended two of them, and, within the last few days, a third, when attacked by this disagreeable visitant. " Whenever a croupy cough is heard in this family, the throat and larynx are at once touched with the solution of caustic. A warm bath, a few drops of antimonial wine, and, if necessary, a dose of laxative medicine, are next had recourse to, and very little else is generally required. The throat is touched for the two or three succeeding days, by which time the child is usu- ally quite well. " Only once that I remember did this abortive treatment fail in my hands, and it was in the case of a member of the family here referred to. The weather was at the time very severe, and the subject of the disease, a strong little boy about six years of age. For some reason or other, it was longer than usual, too, before the topical application was made to the larynx, and it failed. Exudation was thrown out, and the boy pa^scd through a critical illness, during the intensity of which I laid aside the topical treatment, and employed leeches, calomel, and antimony. But when, as happily occurred in this case, the exu- dation had separated in due time, I renewed the stimulant applications to the windpipe, with marked benefit, and the child made a speedy and perfect recovery."* In one other respect Dr. Watson differs from most practi- tioners in this country, namely, in the strength of the solution which he employs in the treatment of croup. He has found in practice, he says, that a solution "of fifteen or twenty grains to the ounce of water, is abundantly successful in fulfilling the indications of the disease."t Althouoh a prejudice against the local treatment is still entertained by many practitioners, applications of the nitrate of silver in the treatment of membranous crowphave been employ- ed, with more or less success, by physicians inevi-ry part of this country. Contributions from the profession have been made from time to time to most of our medical journals, during the last ten rears, in which cases successfully treated by this agent * Op. citat., pp. 51, 52. t lb., p. 51. 22 are detailed. I will refer only to the opinion and observations of one of these writers, a distinguished permanent member of of this Association ; it is well known to the reading members of the profession, that several years ago, Dr. Ware, of Boston, published his contributions to the "History and Diagnosis of Croup"-—a work evincing more scientific research, and contain- ing more information with regard to the true pathology of mem- branous croup, than all that had previously been written in America. In these papers, Dr. Ware refers to thirty-nine cases of what he denominates membranous croup, which were noticed in his own, or in the practice of his friends. Of these cases the state of the fauces was observed in thirty-three instances, and " in thirty-two, a false membrane was present; most frequently, and sometimes only, on the tonsils, sometimes on other parts also, as the palate, uvula, and pharynx. In one case no such membrane was present; but it was found to exist in the larynx after death. These thirty-three cases were treated by the ordinary therapeutic measures ; and of the whole number three only recovered ; in thirty the disease proved fatal." It is not at all surprising that, under these circum- stances, Dr. Ware, eminent for his careful investigation and conscientious inquiry after truth, should have become " confirm- ed in the opinion," as he subsequently declares himself to have been, " that the methods of treating this disease, in common use, require a careful reconsideration ;" nor, that he should have propounded the question : " If the mode of treating croup com- monly adopted, does no good, are we sure that it does no hurt ?" Having concluded after the experience to which we have referred, to treat the disease " without the preserving use of the heroic remedies," Dr. Ware subsequently adopted a method in which the treatment consisted— ' 1. "In the absence of all reducing, depleting, and disturbing remedies. b 2. " Keeping the patient under the full influence of opium combined with calomel. 3. " Constant external application of warmth and mois ture (to the neck), and of mercurial liniment, slio-lltlv stj lating. a " mu" 4. *' Constant inhalation of watery vapor." 23 In March, 1850, Dr. Ware read before the Suffolk District Medical Society, "Additional Remarks on the Treatment of Croup," in which paper he refers to five cases of membranous croup, three of which were treated on the method indicated in the pre- ceding propositions ; and in the other two cases, in addition to these general measures, applications of a solution of nitrate of silver were made into the larynx. The first three cases which received general treatment only, proved fatal ; yet they " ex- hibited," says Dr. Ware, " certain differences from the common course of this disease which indicated a favorable influence from difference of treatment." " In all of them the membrane was thrown up in consider- able quantities. " In all of them the disease was attended by very much less distress than is usual in croup ; and, in two, there was so deci- ded a mitigation of symptoms following the separation of the membrane, as to lead to considerable hope of a favorable ter- mination. " In two, at least, the disease was prolonged to at least twice its average duration under the usual treatment. "In the other two cases, to which reference was made, the same general course of treatment was followed, with the addi- tion of the introduction of the sponge, wet with a solution of the nitrate of silver, into the larynx. In each of these cases the application was made as early in the disease as I became satisfied of its distinct character. It was repeated morning and evening. It decidedly gave relief to the breathing, soon after each application, and both cases ultimately recovered per- fectly. For the suggestion and adoption of this valuable addi- tion to our means of treating this formidable disease, we are indebted, as is well known, to the enterprise of Dr. Horace Green, of New York. The profession, I think, owe to him a lar^e debt of gratitude, for the energy and perseverance mani- fested in the introduction of this remedy, and I am the more disposed to render this tribute, to him, because so many at- tempts have been made to detract from his merit in relation to it." " I am well satisfied from what I have now seen of this method of treating croup, as compared with that which has been follow- 24 edforso many years, that it has the advantages which were pointed out in one of the preceding papers. It is a disease which I would treat without depletion, except, perhaps, by a few leeches—without vomiting, without purging, without blis- ters, without antimonials, ipecac, and all those other nauseous remedies which have been usually resorted to. I would trust to opiates, perhaps calomel, emollients, and the local applica tion of the nitrate of silver." " I ought to add that many of my friends in the profession have informed me of cases in their prac- tice, treated on these principles, which have recovered in a favorable manner."* Since the publication of Dr. Ware's papers, cauterization of the larynx, in the treatment of membranous croup, has been adopted by large numbers of medical men in New England, as well as in other places in the United States, from many of whom we have received communications on this subject, expressing their full confidence in this therapeutic agent, when timely and appropriately employed in the management of croup. Should we give the history of a tithe of these cases, which have been thus reported to us, they Avould occupy a much larger space than can be appropriated to this subject. In 1848 the chairman of this committee published a small treatise "On the Pathology of Croup, and its Treatment by Topical Mi dlcations" in which the declaration was made that '■ the practice of making topical applications of medicinal agents into the larynges of young children, for the treatment of membran- ous croup, is a plan entirely practicable, safe, and when judi- ciously employed, in the highest degree efficacious." This method of treating a disease hitherto so unmanageable was founded, among others, upon the following propositions (which were then advanced, with regard to the pathology of the disease), namely : " that the essential characteristics of true croup consist in an inflammation of the secreting surfaces of the fauces, larynx, and trachea which is always productive of a membranaceous or an albuminous exudation." " 2. That the membranaceous concretion, which is found coating the inflamed mucous surface of the parts in croup, is an * Boston Med. and Surgical Journal, vol. xlii. pp. 267-8. 25 exudation, not from the membrane itself, but is secreted by the muciparous glands, which so abundantly stud the larynx and trachea. " 3. That the exudative inflammation commences, invariably, in the superior portion of the respiratory passages, and extends from above downwards, never in the opposite direction." * Since the publication of the work in which this mode of treat- ment is advocated, the author has had the opportunity of treat- ing many cases of croup on the plan deduced from this view of its pathology, viz : by means of topical medication, not only in his own practice, but in the practice of, and in conjunction with, other members of the medical profession ; and with an amount of success that has afforded a high degree of encouragement and satisfaction. He has also received from medical men, in different parts of the United States, as well as from numbers in Europe, the his- tory of many cases of membranous croup, wherein topical measures, in their hands, have proved effectual in arresting the disease. 4th. The Effects of the Applications of the JYitrate of Silver in the Treatment of GZdema of the Glottis. In 1852, a work " On the Surgical Tnatmcnt of Polypi of the Larynx, and QZdcma of the Glottis" was published by the author, in which cases of the latter disease are reported as having been successfully treated, as early as 1849, by means of a solution of the nitrate of silver to the affected parts. The happy result which had followed its employment, encouraged the author to commend with much confidence, this method of treating one of the most formidable, and hitherto one of the most fatal of all the diseases of the larynx. In a paper read before the Edinburgh Medico-Chirurgical Society, bv Dr. John Scott, one of the oldest and most dis- tinguished physicians of Edinburgh—a paper which was after- wards published in the Monthly Journal of Mtdical Science for 1850—many interesting cases of laryngeal diseases, success- fully treated by topical treatment, arc recorded. Among the * Observations on the Pathology of Croup, with Remarks on its Treatment by Topical Medications, «fcc. 26 cases reported by Dr. Scott is one, the particulars of which were furnished him by his friend, Dr. Brown of Edinburgh ; which appears to have been a case of oedema of the glottis, following, or being complicated with inflammation of the mucous membrane of the parts. The patient was recovering from an attack of erysipelatous sore throat, when Dr. Brown was sent for, the message being that the patient was dying. " Meeting fortunately with Dr. Scott," says Dr. B., " he accom- panied me. The patient had all the appearance of imminent death ; his face expressive of extreme terror and anguish; the extremities cold ; the pulse hardly to be counted from its rapidity and weakness ; the breathing all but impossible, apparently from some affection at the top of the windpipe ; the voice was gone. On looking deeply into the throat, the pharynx and top of the larynx were seen of a deep red. " The patient being too weak for bloodletting, and too ill for any slower measures of relief, Dr. Scott applied the solu- tion of the nitrate of silver, which he happened to have with him. He got the sponge completely into the larynx. Mr. S. almost instantly expressed, by signs, his relief. In the even- ing he could speak a little, and was able to lie down in bed, and was in all respects better. He was blistered, and had calomel and opium. " Next morning he was much better. The sponge was again applied without any difficulty. He recovered rapidly, and has been for more than two years in perfect health, attributing without any hesitation, the saving of his life to the sponge and the caustic." The valuable work of Dr. Watson contains his views with regard to the effects of nitrate of silver in the oedematous glottis, together with a record of several cases successfully treated by this remedy ; and he expresses the gratification that he has been able to " come to precisely the same conclusions with myself, as to the strength and mode of application of the solution," in the management of this disease. He therefore quotes from my work the following directions, which are to be pursued in the employment of this remedy. " The first application with the sponge-probang should be made to the pharynx and top of the epiglottis ; and after a 27 delay of ten or fifteen minutes, the measure may be repeated, and the sponge, wet with the solution, be freely applied to the base of the epiglottis and over the oedematous lips of the glottis. The application should be repeated every hour or two hours, according to the urgency of the disease, and the effect produced by the operation ; and an attempt should be made each time to carry the sponge between the lips of the glottis. As the oedema at the opening of the larynx subsides, this may be done, and the application of the caustic solution be made to the interior of the glottis. "I am inclined to think that the benefit arising from such a practice is brought about by the powerful stimulation of the relaxed vessels of the oedematous organ. Such a condition of the bloodvessels permits a continual increase of the morbid state, whereas, by their contracting under the stimulation, the current of blood within them is quickened, and the effused fluid is partly absorbed into the circulating fluid, partly re- moved by the new layer of epithelium, which is rapidly found to replace what had perished during the inactivity of the base- ment membrane, coincident with, and produced by the oedema of its subjacent tissue. Every touch of the probang renews the impulse already given to these restorative processes, and thus the benefit increases in a geometrical ratio, till the cure is finally accomplished."* " The action of a solution of caustic," says Dr. W., on another page, "applied to a sub-acutely inflamed mucous mem- brane, might, a priori, be expected to produce a beneficial effect on the oedematous glottis ; and this expectation has been re- markably fulfilled in my experience." t 5th. Of the Effects of .Kitrate of Silver in the Treatment of IL)a/)i»g-(1ough. To Professor Watson, of Glasgow, belongs the honor of having been the first to employ topical medication for the treatment of Hooping-Cough. His original paper on hooping- cough, in which he describes, " a new method of treating that disease," was read before the Medical Society of Glasgow, in * Watson, pp. 57, 58. f lb., pp. 54, 55. 28 1840. and was first published in the Edinburgh Monthly Journal in December of the same year. Five years later—after h. ing treated many other cases by this new method, Dr. Watson publishes, in his work on Topical Medication, the results of his experience; and these practical results have been considered in the highest degree encouraging. He has also given us, in this chapter on the laryngeal treatment of hooping-cough, the experience of M. Joubert, of France, who has employed, with great success, this topical method of treatment, in a large num- ber of cases of hooping-cough. His memoir on the subject was published in a French journal, in 1851* In the opinion of Dr. Watson the indications for the topical treatment of hooping-cough are founded upon what is consid- ered by him the true pathology of the disease. The morbific agent, he thinks, whatever that poison may be, "in the cases of hooping-cough commences its operations by producing inflam- mation of the pharyngo-laryngeal mucous membrane; and secondarily, irritation of the pneumogastric nerves." t And hence the declaration of his belief that topical treatment alone " is founded on the true pathology of the disease, and is fitted to counteract, the most speedily and effectually of all known means, the results of the mysterious poison which originates the malady." | In the early stage of the disease, when the inflammatory action is high, Dr. Watson recommends, for children, the em- ployment of a solution of the nitrate of silver, of the strength of about fifteen grains to the ounce of water. " Afterwards, when the nervous symptoms predominate, the solution may with advantage be strengthened ; but it is impos- sible to lay down rules that will universally apply to different cases, or even to the same case on different days. This must be left to the judgment of the practitioner." § It is recom- mended that the applications should be made at least every second day, first to the pharyngo-laryngeal membrane, then to the parts above the glottis, and to the opening of the glottis. " But after the general inflammatory state has been got rid of," * Recueil des Travaux de la Socie'te' Mddicale de l'Indre et Loire. 1851. t Op. citat., p. 107. % lb., p. 106. § lb., p. 116. 29 says Dr. Watson, " and when the disease has come to its height, the larynx must be entered, in order that the caustic may be brought into contact with the nerves, upon the excitement of which the continuance of the hoop depends."* The following favorable numerical account is given by Dr. Watson, of the results of the treatment in question, in his own cases, and in those of M. Joubcrt; the number of patients treat- ed amounts to 134 in all:— Cured within Cured within Resisted a fortnight 3 or 4 weeks. treatment. Total. Dr. Watson's cases . . . 46 20 0 66 M. Joubert's " . . . 40 20 8 68 86 40 8 134 During the Spring of 1854, hooping-cough prevailed in Glas- gow as an epidemic, and Dr. Watson had an opportunity of treating a large number of cases. In the most of these the dis- ease was very severe ; and yet the result as given is as follows : cured in a fortnight ten cases ; in three weeks sixteen ; in four weeks five ; one resisted the treatment; and one died. The whole number treated being therefore 167, the propor- tions stand thus:— fared in two weeks .... 96 cases, or 54.4 per cent. " three to four weeks . . 61 " or 36.5 " Resisted treatment .... 9 " Died........ 1 case, or nearly 0.06 " In contrast with the preceding results of the topical treat- ment of hooping-cough, Dr. Watson subjoins a table of the ordinary duration of the disease when treated in the usual man- ner, as stated by some of the best and most recent authorities, such as Williams, Copland, Walsh, West, and a few others ; and the average of all the statements of these authors, is from one and a half to three and a half months. The deaths from hooping-cough in London (and the percentage appears to be about the same in other parts of Great Britain), according to the reports of the Registrar-General, are in the proportio°n of 8.9 per cent, among females, and 6.2 per cent. among males to the deaths from all causes under ten years of a