Compliments of the Author 25 E. 31st ST„ THE HEALING OF ULCERS IN LARYN- GEAL PHTHISIS \/ j / Dr. WM. C. JARVIS LECTURER ON LARYNGOLOGY AND DISEASES OP THE THROAT IN THE MEDICAL DEPARTMENT OF THE UNIVERSITY OP NEW YORK ; CONSULTING PHYSICIAN TO THE NEW YORK UNIVERSITY DISPENSARY ; FELLOW OF THE AMERICAN LARYNGOLOGICAL (THROAT) ASSOCIATION ; MEMBER OF THE NEW YORK LARYNGOLOGI- CAL SOCIETY, OF THE MEDICAL SOCIETY OF THE COUNTY OF NEW YORK, ETC. • ' r. }*, \ I ,'',**"■*" \ f '>. ' 1 READ BEFORE THE AMERICAN CONGRESS OF LARYNGOLOGY, MAY 21, 1883 [Reprinted from the Archives of Laryngology, Vol. iv, No. 3, July, 1883] THE HEALING OF ULCERS IN LARYNGEAL PHTHISIS./ By WM. C. JARVIS, M.D. THE cure of phthisical ulcers in the larynx is still doubted by many, and there is much disagreement on the question of their treatment. The difference of opinion held by eminent authorities, concerning the nature of these ulcers, may have helped to encourage a natural disinclination to be convinced of their cure. Conscious of this popular prejudice, I would have hesitated to present my case and views did I not feel that the evidence of others, the clear history, lesions, symptoms, and remarkable results, completely confirmed my claims. Miss C, aged forty-five, consulted me on May 22, 1882. In the preceding February she had been confined to bed with what her physician called the pleurisy. Several weeks afterward, during convalescence, she experienced pain in the throat. The medicine prescribed could not be swallowed without severe pain, and was therefore abandoned. She consulted a well-known specialist, who, upon being interrogated by the patient's aunt, pro- nounced the disease consumption of the throat and incurable. The inquisitive lady promptly fainted, and was only restored to consciousness to be confined to her bed. I learned this physician's diagnosis several months after the patient called. Her appear- ance when first seen by me was extremely pitiful. Pale, emaciated, and, peculiar to phthisis, the general signs were distinct from the beginning. Though anxious to speak, her hoarse whisper was soon silenced by suffering. A painful cough racked her unsteady nerves. Accumulations of mucus irritated the windpipe and renewed the paroxysms. Swallowing was al- most impossible. Even liquids produced pain in deglutition. She was anxious to finish her meagre meal, and contemplated with horror the return of another. Words, she said, could not describe her suffering. Reprinted from the Archives of Laryngology, Vol. iv, No. 3, July, 1883. 2 Wm. C. Jarvis. A laryngoscopic examination showed the laryngeal mucous membrane to be anaemic and irregular. Two pale, puffy projec- tions over the arytenoid prominences gave the characteristic ap- pearance of the pyriform tumefaction in laryngeal phthisis. The mucous membrane over one arytenoid was slightly abraded. The ventricular bands and vocal cords were thickened, and the lumen of the larynx was narrowed by the general tumefaction. A pale, irregular grayish ulcer had eroded the margin of the right vocal cord. All the structures were smeared with sticky muco-purulent discharges. The lungs were examined by Dr. W. H. Snow, of the University Medical College, who wrote : " The following is the result of a careful examination: Phthisis second stage going on to third at left apex, as shown by the large and small rales and the presence of a small cavity, etc." My opinion being demanded on the question of a cure, I, from past experience, could only answer in the nega- tive. I promised relief, and no more. My local treatment was in many respects similar to the mild methods proposed by Dr. Bosworth. I was convinced that the parts would not tolerate the slightest irritation, and that local anaesthesia was necessary to relieve the tort- ured larynx. Acrid muco-purulent accumulations were carefully removed by means of alkaline sprays. Spraying was stopped when coughing seemed imminent or occurred. The cleansed structures were then bathed in a spray of Magendie's solution of morphia. Pulverized iodoform was finally thrown upon the part by means of a home-made powder-blower, working on the Ely principle. No tannic acid, acacia, morphia, or other substances were added to the iodoform. Persuaded by experiment that iodoform is the only pow- der that can be comfortably borne by the nasal mucous membrane, I used it pure in the larynx. Applications were made every day. Constitutional treatment was considered almost as neces- sary as local. A harassing nervous erethism was quieted by the administration of the bromides. Continued doses of the United States solution of morphia prevented the pain- ful cough. The Healing of Ulcers in Laryngeal Phthisis. 3 Relief, slow at first, steadily increased under the local treatment and artificially acquired rest. Advantage was taken of the increased toleration of the larynx, to admin- ister a very palatable emulsion of cod-liver oil, pepsin, and pancreatin.1 The continuation of her method of communi- cating by writing, which she had been compelled to adopt before seeing me, was insisted upon. Though averse to eating, she craved the crushed strawberry, and soon suc- ceded in eating one with but little discomfort. Thus en- couraged, she drank and enjoyed light wines. I was compelled to leave the city at this stage of her im- provement. She was advised to provide herself with medi- cine and spend the summer in the country. I feared the ground gained would be lost by the interruption of local treatment. She went to the Catskill Mountains. Several months passed, and the patient, not appearing, was given up as dead. In the early part of last January, she surprised me by a call. Her changed appearance prevented immediate recog- nition. The hollowed cheeks were replaced by a full face, and the painful whisper by a distinct voice. She said out- door life soon improved her appetite. She ate heartily, relished her meals, and steadily gained in weight. I examined the larynx, and found an irregular crescentic excavation on the right vocal cord, composed of smooth cicatricial tissue. The lumen of the larynx was still small, and the arytenoid prominences large and smooth. Although the laryngeal structures were distorted, they were clean and compact. Phonation and respiration showed free movement of the cords. The voice was low-pitched and sometimes rough. This was evidently due to defi- cient vibration of the eroded cord. The patient pronounced herself well, and was making arrangements to return to Europe.2 Dr. Alfred L. Loomis discovered signs of fibrous phthisis. 1 Made by S. J. Bendinir, No. 47 Third Avenue, New York City. 2 At this date, August, 1883, Miss C. is reported as travelling through Germany. 4 Wm. C. Jarvis. Conclusions. A case of this kind, carefully studied, naturally suggests many thoughts. The appearance and progress of the ulcer exclude the probability of its being tuberculous. Tuberculous ulcers, as a rule, do not commence at the true cord's edge and from this point erode the structure.1 The existence of the ulcer may be inferentially accounted for by observing the production and course of superficial sores in the mouth. I have learned, from personal experience that, at certain times, one may with impunity lacerate the buccal mucous membrane and expect the torn tissues to quickly heal. The same amount of injury, however, may at another time result in a pro- tracted superficial sore, though the health is apparently un- impaired. Perversion of the buccal secretions invariably preceded or existed with the last-mentioned wound. If covered with shellac varnish, or a metal albuminate, they rapidly healed under the protective pellicle.2 They also repaired slowly if treated locally with iodoform. When lo- cated upon a portion of the mouth in frequent motion, as the palatine folds, and left untreated, they degenerated into painful superficial ulcers, causing much discomfort in deg- lutition, an annoying nervous erethism, headache, and gen- eral debility. There is but little wanting, besides the degree, to create an analogy between this lesion with its peculiar symptoms and the condition of the phthisical patient. As the lesion upon the palatine fold was caused by direct injury, and similar lesions cannot occur spontaneously, so we infer that the ulcer in the phthisical patient originated from an injury. It may have been produced by a cough, or any violence of a similar nature applied to the friable and infiltrated laryngeal tissues. Acrid discharges and con- stant motion more than meet the analogy and complete the result. 1 M. Mackenzie in his work " Diseases of the Throat and Nose," 1880, p. 360, writes, according to Heinze, "the destructive process commences from within not from without." a N. Y. Medical Record, vol. 23, No. 24, p. 668. The Healing of Ulcers in Laryngeal Phthisis. $ Although the above history does not warrant the physi- cian in extending hope to the majority of patients suffering with phthisical ulceration of the larynx, it demonstrates the curability of certain forms found in this disease. The de- pendence of the reparative power of ulcers upon depth, as shown in superficial and deep syphilitic lesions, is rendered as proportionately greater in phthisical ulcers as the pain, poor nutrition, and lowered vitality exceed that of syphilis. To expect good results where extensive phthisical erosions involve the laryngeal skeleton, is to over-estimate human endurance. I have not considered many points of interest, and have intentionally omitted to compare and temper my views, since, to do so, would require more time than the occasion affords. A NEW LARYNGEAL POWDER-BLOWER. A thorough application of pulverized iodoform to laryn- geal ulcers is sometimes rendered extremely difficult on account of their situation, mal-position of the epiglottis, and other obstacles familiar to the experienced operator. An instrument devised by me and shown in the figure re- duced to one third its size, has satisfactorily overcome these difficulties. It is manipulated like an ordinary laryn- goscope. The powder is directed as in the familiar ex- periment of sighting a gun in a mirror. The compressed 6 Wm. C. Jarvis. air, obtained either by rubber bulbs or the pneumatic pump, is controlled by a trigger, s, connected with the valve, v. The mirror is carried into the throat and as soon as the diseased part appears in its centre, the air, let into the chamber by pushing the slide valve, s, disturbs the powder which escapes at the orifice, o. When the image is properly sighted, the orifice is inclined in a direction, which when followed by the powder must cause it to strike the point pictured in the mirror. The advantages of this instrument are : that the powder is evenly distributed over the diseased structures with ease and precision, and its dis- tribution can be watched in the mirror and nicely regulated, thus avoiding irritation from massing of the powder, securing the local anaesthetic effect of the drug, and preventing iodoform eructations and poisoning from wastage. a ARCHIVES OF LARYNGOLOGY EDITED BY LOUIS ELSBERG, M.D., NEW YORK, J. SOLIS COHEN, M.D., FREDERICK J. KNIGHT, M.D., PHILADELPHIA, BOSTON, GEORGE M. LEFFERTS, M.D., NEW YORK, IN CONJUNCTION WITH Dr. J. Boeckel, Strasbtirg; Prof. Burow, Konigsberg; Prof. Gerhardt, Wttrzburg; Dr. Heinze, Leipzig; Dr. Koch, Luxembourg; Prof. Krishaber, Paris; Prof. Labus, Milan; Dr. Massei, Naples; Dr. Morell Mackenzie, London ; Prof. Oertel, Munich ; Dr. FelixSemon, London ; Dr. Smyly, Dublin ; Prof. Voltolini, Breslau ; and Prof. Zawerthal, Rome. It is believed that the time has come for the publication of a journal devoted to the specialty of Laryngology. So much has been achieved in this department of medicine during the last twenty years, that in the regard of both the profe?.- sion and the lay public it has acquired recognition and a certain amount of inde- pendence. In the further advance in every right direction the Archives is in- tended to give important aid. None of the existing medical journals can occupy its place ; it competes with none, and supplements alL It is to be a bond of union between the specialists themselves, and also between them and the general profession. Such a means of communication and interchange of ideas, constitut- ing at the same time a depository of contributions of permanent merit and a mirror of the progress of the specialty as reflected in a comprehensive digest of periodical and other literature in every part of the world, cannot fail to be of value from a scientific as well as a practical point of view. The scope of the Archives embraces Human and Comparative Morphology and Physiology of the Throat, and Pathology and Therapeutics of Throat Diseases, in the widest signification of these terms. All contributions are original. The contents are arranged in three departments, which are : I. New Contributions to Literature, viz., a. Leading Articles, comprising Monographs and accounts of cases with re- marks. b. Clinical Notes, being a briefer record of interesting cases. c. Society Transactions, /.