A CASE OF ATRESIA LARYNGIS FROM CATARRHAL 
LARYNGITIS, WITH PRESENTATION OF PATIENT, 
FOLLOWED BY INTUBATION. . 
By DR. A. W. DE ROALDES, 
Surgeon in charge of Eye, Ear, Nose and Throat Hospital.* 
Reprinted prom the February, i8gs, number of the New Orleans Medical and Surgical ’Journal. 
Gentlemen of the Parish Medical Society: It is al- 
most without preparation that I appear before you this even- 
ing, as I was approached by your worthy secretary only three 
days ago with the pressing request that I should take the place 
of the designated essayist. Previous engagements and the 
short limit of time induced me to resort to an exhibition of an 
interesting case which is now under my treatment, rather than 
to write an essay. 
The clinical history of this patient, whom I have to-night 
brought before you, is such as, I hope, will compensate to some 
extent for the regrettable change in your programme. 
I now refer to a case of almost complete synechia of the 
rima glottidis, the result of chronic catarrhal ulcerations. Her 
observation, as taken by Dr. C. J. Landfried, was as follows: 
About eleven years ago, during high water in the suburbs of 
the city, Mrs. G., a native of New Orleans, aged 41 years, 
was accidently thrown from a skiff, getting her head and body 
soaking wet. That same day she noticed a little huskiness of 
the voice, which gradually became worse, until finally she was 
so hoarse that she could not be understood (the voice not 
amounting to more than a mere whisper). The patient has 
had a marked aphonia from that time to this, due, however, for 
nine years to, presumably, a catarrhal laryngitis, and for the 
* Read before the Orleans Parish Medical Society, December 26, 1891, 2 
last two years to a synechia or adhesion between the vocal 
cords, causing at first slight dyspnoea, but which became so 
aggravated in the short space of three months as to require a 
tracheotomy. The dyspnoea was continual, i. e., night and 
day, and not paroxysmal; during rest as well as upon slight 
exertion, patient always experienced a sense of suffocation. 
The dyspnoea was aggravated by the least exertion, such 
as sweeping, going up steps, etc., and showed no tendency to 
ameliorate, but, on the contrary, became gradually worse. A 
few months after the accident (falling]from skiff) above men- 
tioned, patient had recourse to a medical gentleman for her 
hoarseness. He treated her for several years with electricity 
applied to the neck in the region of the larynx and by sprays, 
inhalations, etc. At the end of that time (five years), her hoarse- 
ness not being any better, she concluded to go to the Charity 
Hospital, where she was examined by a physician of the visit- 
ing staff, who made an application to the pharynx (she says of 
something black) and ordered her to put one teaspoonful of tur- 
pentine in a pint of steaming water, to he used by inhalation, and 
also to go to the piney woods or a place not near water. She 
followed those instructions, and came to the city every third or 
fourth week, for the purpose of reporting. After one year of 
such treatment, she was just about the same ; no better nor 
no worse. She next went to another public institution. 
The surgeon in charge there ordered a mixture to be taken 
internally, and inhalations, which she followed for about nine 
months, but with no result. At the end of that tirrte the 
breathing commenced to become embarrassed, dysponoea in- 
creased, and the disease pursued the course outlined above. 
In this condition she applied to the Eye,Ear, Nose and Throat 
Hospital on the 29th of December, 1889, just two years ago. 
Before the accident, which occurred eleven years ago, 
from which she dates her trouble, patient was perfectly well. 
She had no cough, and her general health was good. Father 
died of apoplexy eighteen years ago, at the age of 68. He 
was a stout, robust man. Mother is living, 72 years of age, 
and, for her age, very active. Patient had four children; one 
died at the age of 9 days, and the other three, living, are per- 
fectly healthy. Has three sisters living, who are robust and 3 
remarkably healthy. Two brothers, also living, and well. No 
history of any skin eruption, no alopecia, no sore throat that 
could be suspected as specific, no sore eyes, and, in fact, 
nothing that would lead to a suspicion of syphilis. 
Upon examination of the larynx I found a marked stenosis 
of the glottis, with appoximation and almost complete immo- 
bility of the arytenoid cartilages. The respiration was car- 
ried through a small aperture of the size of a goose quill, 
and located near the posterior commissure. 
The right arytenoid cartilage seemed to be on a more an- 
terior plane than the left one. A shallow groove could be seen ex- 
tending from the above mentioned aperture to anterior thyroid 
angle. When the laryngeal sound was used this groove was 
found to be lined not by a depressible membrane, but by a 
resisting tissue, the opposing edges of the rima glottidis be- 
ing, as it were, firmly glued together. The line of union was 
imperfectly straight. No granulation tissue could be found to 
allow of removal for microscopical examination. The pa- 
tient’s general appearance was miserable. She was pale, weak 
and very much emaciated. The examination of the 
chest gave negative results. Her expectoration was difficult 
and generally froth}’, occasionally spotted with thick secretion; 
no bacilli were found. After reporting a few times, the patient 
was advised to enter the hospital in order to be tracheotom- 
ized. The operation though was hurried on by anydarming attack 
of dyspnoea. During 1890 numerous attempts were made with 
Whistler’s instrument to dilate the opening in the larynx, which 
had contracted still more after the introduction of the cannula. 
Whilst in Berlin I ordered a special set of laryngeal knives, 
hoping, on my return home, to incise the synechia ; I could then 
scarcely introduce a very slender laryngeal probe. In 1891 I 
was forced for several months to abandon all attempts, by rea- 
son of a deep phlegmon of the neck, the result of lymphangitis 
caused by the introduction of the sound, which determined 
probably a traumatic infection. Upon my return from Europe 
this year I found the larynx air-tight, the opening being closed 
by a large granuloma. After removing it with the laryngeal 
forceps, I succeeded in introducing this very slender sound 
hrough the tracheal wound, from below upward. After push- 4 
ing it up into the pharynx I managed to throw around the end 
a knot of ligature thread, which I drew down through the tra- 
cheal wound, the extremities being tied over the chin. The 
next day, by means of this thread, I pulled through the strict- 
ure a double thread, then four, six, eight, etc., until I had to 
stop on accountof an ulceration of the epiglottis and inner sur- 
face of arytenoids, caused by continuous pressure and friction 
during deglutition. Still I had managed, by that time, to have 
an opening sufficiently large to admit the No. i of Schrotter’s 
hard rubber tubes. This, on the first day, remained in the 
larynx for about half an hour. 
The next day the same number was again introduced, and 
remained about the same length of time. On the third day 
No. 3 was introduced without difficulty, and remained in place 
a little longer than the preceding numbers, say about one hour. 
The same number was introduced on the two succeeding days, 
and remained about the same length of time. Then No. 4 was 
introduced, and allowed to remain one hour. This number 
was reintroduced each day for about eight days, when I com- 
menced introducing O’Dwyer’s tubes for infants, first the size 
next to the largest and to-day the largest size. As soon as I 
receive a box of O’Dwyer’s tubes for adults I will incise the 
stenosed parts if necessary and proceed to use much larger 
tubes, and hope to be able, in the course of a few months, to 
dispense with the tracheotomy tube when the canula wound 
can be closed, and the patient considered as cured. 
Now, gentlemen, I wish to call your attention to a point in the 
etiology of the case which is certainly a most interesting one, 
and might be the subject of a spirited controversy. The fact is 
that, leaving aside the different forms of acute stenosis of the 
larynx, such as acute oedema of the glottis, erysipelatous inflam- 
mation, laryngeal diphtheria, perichondritis, etc., most cases of 
chronic stenosis of this organ can be classified under the head 
of tuberculosis or svphilis. Of course, this statement does 
not apply to those cases in which the stenosis is the result of 
neoplasm or of the cicatrical adhesions which follow some of 
the acute infectious diseases, such as variola, typhoid fever, 
glanders; nor does it include cases of rhinoscleroma, of lupus 
or of paralysis of the abductor muscles. 5 
In a general way, it is true that most cases of chronic ste- 
nosis of the larynx are or a tubercular or syphilitic origin. A 
careful study of the present case makes it evident that it can- 
not be classified under either one of these two headings. The 
absence of any specific infection, the duration of the disease, 
the negative result of the examination of the sputa at the 
time, the absence of cough or of expectoration, compels me to 
abandon all idea of tuberculosis or of syphilis. I must, there- 
fore, considert his as a case of laryngitis a frigore, which 
led to an ulcerative process, and finally to an almost complete 
synechia of the glottis. 
I am aware that the existence of catarrhal ulcerations, and 
especially leading to such a result, has been contested by 
most specialists. Schnitzler, of Vienna, and Heryng, of War- 
saw, with a few others, are the only ones who admit 
their existence. In fact, I have failed in my researches 
(hurried, it is true,) on that subject to find a case of chronic 
cicatrical stenosis of the larynx which was ascribed to purely 
catarrhal ulceration. 
The case of Schrotter is the only one which presents 
such points of great similarity with the one I bring before you 
this evening, and I will ask your permission to read to you a 
synopsis of the observation. I refer to the one published by 
his assistant, Dr. George Juffinger, in which hoarseness, with- 
out known cause, had existed two years and a half in a man 
25 years of age. This was followed by dyspnoea, eventually 
requiring tracheotomy. Six weeks after the operation all 
communication was shut off between air passage and pharynx— 
attempts at dilatation failed—division of the larynx and removal 
of the obstructing tissues were only temporarily serviceable. 
Schrotter found complete occlusion of the larynx. The 
arytenoid cartilages were closely adherent, and the ventricular 
bands were thickened and in contact. After repeated failures 
to find a passage by way of the mouth or by way of the 
trachea, Schrotter passed a harpoon lance between the ven- 
tricular bands and through the cicatrical tissue into the 
trachea. A thin thread was then thrown around this instru- 
ment in the tracheal wound and drawn up through the mouth, 
when its two extremities were tied together. The next day a 6 
thicker thread was tied to the tracheal end of the first one and 
drawn through in its turn. Subsequently larger threads, then 
catgut, and eventually a leaden wire of considerable size were 
drawn through. This was followed by the graduated dilating 
prisms, until on the fortieth day Schrotter’s No. 20 could be 
introduced. At this time a small granulation tumor was 
detected in the glottis, and was removed with the electro- 
caustic snare. Dilatation was continued as before, and 
eventually confided to the patient, who became enabled to 
work and to sleep with his canula closed. It was hoped that 
eventually the canula could be removed. 
Leaving this very interesting question of etiology, I will 
proceed, gentlemen, to sayafew words in regard to the practical 
point of treatment in cases of chronic stenosis of the larynx, 
my remarks now applying to the chronic forms of this trouble. 
I must tell you that this question of treatment of chronic 
laryngeal stenosis has been in the past few years the subject of 
numerous publications, and has led to the invention of numerous 
instruments. In time not far removed a medical interference 
amounted to little less than the apperance of the physician as 
a Deus ex machina, when he arrived in time to perform the 
operation of tracheotomy. Asphyxia was for the time being 
remedied, but the physician, as well as the patient, had to 
face the awful prospect of a canula which had to be worn 
generally for a life time. 
To-day, thanks to the treatment advocated in 1876 by Dr. 
Schrotter, and also to the procedure of intubation, as perfected 
by O’Dwyer, this painful necessity is becoming rarer and 
rarer. 
Not that these gentlemen have an exclusive right to the 
honor of this great progress, for it is proper to remember in 
this connection the pioneers, like Desault, Chaussier, Currey, 
Bouchut, Trendelenburg, Weinlechner, and others. 
In looking over the literature of this subject, I find in the 
Index Catalogue of the Surgeon General’s Library the title of 
an observation published in 1828 by Liston, which reads as fol- 
lows: ‘‘Notes of a case in which the canal of the larynx after 
being nearly obliterated, was re-established.” 
Now when we tome to synthetize the very numerous op- 7 
erative procedures instituted to remedy laryngeal obstruc- 
tion, they can all be ranged under the head of three general 
methods : 
1. The endolaryngeal method, by itself. 
2. Dilatation, with preliminary tracheotomy. 
3. Laryngotomy. 
A complete study of these three methods and their nu- 
merous modifications would tire your patience, as they have 
taxed the minds of specialists, and more than justify what an 
expert like O’Dwyer has expressed in the following lines: 
“ To insure success in management of chronic stenosis of the 
larynx, some ingenuity and a great deal of patience and perse- 
verance are necessary in order to overcome the many difficul- 
ties encountered.” 
1. The first method is the one which naturally absorbs 
from the start the attention of the surgeon. It consists, as 
you can very well understand, in dilatation of the parts by 
means of bougies, with or without the adjunct of liberative 
incisions, or even of excisions. We can divide the instru- 
ments used for this purpose in two general classes : 
(«) Those which are calculated.to remain in place only a 
limited time, a few hours at most, such as ordinary bougies; 
Mackenzie’s three-bladed parallel dilator, Whistler’s cutting 
conical dilator, Navratil’s ingenious but complicated four- 
bladed dilator, and Moure’s instrument, which has the advan- 
tage of allowing one to work it with one hand, whilst with 
mirror in the other hand, the operator can direct his manipula- 
tion. We have next, in this same class, Schrotter’s hard- 
rubber hollow tubes, which are prismatic, and, therefore, 
better adapted to the shape of the larynx. 
(b) The second class of instruments comprise those 
which are destined to remain in situ a longer period than a few 
hours. They can be placed and retained by the patients, for 
days, weeks and months. The intubation tubes of O’Dwyer 
represent the most perfect type of these instruments. 
In regard to these tubes, as used in connection with chronic 
cases of stenosis, I can not express my view of their utility 
better than by quoting the author himself, who said at the In- 
ternational Congress in 1887: “ Had intubation of the larynx 8 
proved a complete failure in the treatment of croup, I should 
still feel amply repaid for the time and expense consumed in 
developing it, for I believe it offers the most practical and 
rational method yet devised for the dilatation of chronic stric- 
ture of the glottis.” He supports this view by the record of 
five cases treated by intubation. 
Since these cases were published, many other contribu- 
tions to this subject have appeared. Among them I will call 
your attenlion to the article of Dr. Lefferts, of New York, 
on the treatment of syphilitic stenosis by intubation, which 
proved to be one of the most interesting papers read before 
the Laryngological Section of the International Congress of 
Berlin. To bear out the correctness of his views, he cites 
ten observations, in which intubation proved to be the simplest 
and speediest method of remedying alarming dyspnoea, and 
thereby avoided the inconvenience and danger of tracheotomy, 
one of which certainly lays in the temporary or permanent use 
of tracheal canulae. 
In these chronic cases, the tube is often worn for very 
prolonged periods without harm or inconvenience. In one of 
O’Dwyer’s cases, owing to the patient being lost sight of for a 
length of time, the tube was worn continuously for ten months. 
Experience has shown, as might have been anticipated, that 
when the larynx is affected with chronic inflammatory thicken- 
ing and cicatrical narrowing, considerable pressure can be 
tolerated from tightly fitting tubes without injurious conse- 
quences. In introducing the tube, also, in these cases, more 
or less force may have to be employed, and can be employed 
without injury. 
In cases requiring the retention of a tube for several months, 
it is important, says O’Dwyer, to change the points of pressure 
in the vestibule of the larynx about once in two weeks, in order 
to prevent erosion of the mucous membrane, with consequent 
sprouting of fungous granulation, which is liable to occur from 
the compression exerted by the constrictor muscles during 
every act of swallowing. 
A hard rubber tube may be allowed to remain in the larynx 
for a much longer time than one constructed of metal, because, 
owing to its lightness, it does not occupy a fixed position, but 9 
moves upward by coughing, and is again pressed downward 
by the act of swallowing. Another objection to the long reten- 
tion of a metallic tube, is the fact that the gold plating soon dis- 
appears in places, followed by erosion of the metal and the 
deposit of calcareous matter, which produces a good deal of 
irritation. 
The difficulty of deglutition, which sometimes is present, 
after the introduction of an intubation tube is not a source of 
trouble in chronic cases, for deglutition has invariably been 
found to be carried on quite easily after the first few days, 
both in children and adults. In the stenosis which sometimes 
follows tracheotomy, and which renders it impossible to dis- 
pense with the tube, intubation has been found a valuable 
method of treatment. Ranke, in discussing this subject, gives 
as the principal cause of difficulty in dispensing with the 
tracheotomy tube: 
a. Granulations growing up in the region of the trache- 
otomy wound, especially at its upper end. 
b. Cicatricial stenosis, either at the site of the incision or at 
some point in the trachea where the canula presses. 
c. Swelling and thickening of mucous membrane of the 
larynx, between the under surface of the cords and the lower 
margin of the cricoid (chorditis inferior hypertrophica;. 
d. Bilateral paralysis of the abductors. 
e. Paresis of the cords from disease. 
f. Dread of having the canula removed, producing laryn- 
geal spasms. 
In all these forms of difficult decanulement Ranke advo- 
cates intubation, although his own experience is confined 
to its employment in the first two forms. 
If time permitted, I could prolong this dissertation by en- 
tering into the minute details of intubation in children, as 
compared to the same procedure in adults, by speaking of the 
use that can be made of cocaine in facilitating the manipula- 
tion, also of the use of laryngeal mirrors in adults. I will limit 
myself, before discarding the subject, to call your attention to 
the fact, as demonstrated in, the case I present to you, that in 
the treatment of chronic stenosis in the adult the set of croup 
tubes (as this one) used for children will do to begin with, 10 
but the calibre, shape, length and material of the tube, as also 
the strength of the handles, have to be modified in order to 
complete the treatment. No set of instruments, however com- 
plete, will be sufficient for all cases, no two of which are alike, 
says O’Dwyer, and the construction of tubes adapted to 
special peculiarities will sometimes be required. 
2. I now come to the second general method of treat- 
ment in these troublesome cases—I mean to dilatation with pre- 
liminary tracheotomy—a method which is not to be resorted to 
until all the possibilities of the endolaryngeal method have been 
thoroughly exhausted. It is true that it is the one that I have 
pursued in this case; but let me tell you candidly, had the *sum 
of evidence produced to-day in favor of intubation been dis- 
played two years ago, and especiallly had the dyspnoea been 
less alarming, I sincerely think I could have managed my case 
better and avoided a great deal of trouble and anno3Tance. To 
this method belongs the improved Schrotter’s plan of treat- 
ment. I soon found that the Trendelenburg hollow tube, as 
perfected by him, could only be used for very temporary 
dilatation, occasioning at times serious irritation and very great 
loss of saliva (as evidenced in my patient’s case, who was cer- 
tainly weakened by a daily loss of over one pint of saliva). 
He subsequently advdsed preliminary tracheotomy, and devised 
his method of dilatation of chronic stenosis by introducing 
through the mouth small prismatic bougies. Through each 
prism a rod, having an eye at the top for affixing a thread, and 
a knob below, or a perforation, by which the bougie can be 
secured by a pincette or by a bolt passed through the fenstrated 
canula in the artificial opening. The bougie is inserted by 
means of a canulated directorfitted to a perforation surround- 
ing the eyed rod at top, thethread attached to which has 
previously been drawn through the director by a special wire 
hook and is then united at the distal end. 
As soon as the bougie has been secured at the lower end 
the thread is loosened from the director and that instrument is 
withdrawn, leaving the bougie in position and the thread hang- 
ing from the mouth. The thread being secured, the bougie 
remains in position day and night until it becomes necessary to 
clean it or desirable to replace it with a larger one, when it is 11 
released below and withdrawn by traction on the thread. This 
method has produced remarkable results in the hands of 
Schrotter and was universally acknowledged to be the most 
effective until intubation, as shown you in the present case, was 
proved to be more than a serious competitor. In connec- 
tion with this general method I will simply mention the numer- 
ous attempts made by Stoerk, McHenry, Czermack, Renich, 
Burow, Bruns, and many others to dilate the stenosis from 
below upwards. Whilst some' of them have proved effective 
in isolated cases, as in Liston’s observation, still these pro- 
cedures have generally been abandoned in favor of the above 
mentioned one. 
3. The third general method of treatment of chronic 
stenosis of the larynx, and to which I will simply make a 
rapid allusion, is laryngotomy, orlaryngo fissure. This method, 
formerly recommended by French surgeons, is, and especially 
has been, enjoying quite a reputation in Germany. The 
larynx is open on the median line, and the causes of obstruc- 
tion are either incised, or excised, by means of the bistouri, 
scissors, or thermo-cautery, and to avoid ulterior cicatrical 
retraction the larynx is subsequently cauterized. Whilst I 
admit that there are cases in which this method is perfectly 
justifiable, and, indeed, has given good results, still they are 
so few lhat I think it can be discarded. It should be limited 
to those cases of chronic stenosis, the result of obstructive 
neoplasm, or for extraction of foreign bodies, and intended 
as much for their permanent removal as for the relief of the 
stenosis.