THE DETROIT LANCET. VOL. III. OCTOBER, 1879. No. 4. Original Communications. with grey, ragged membrane, already separ A Study of Inflammation of the Throat. Professor of Principles and Practice of Medicine in Detroit THE Medical College. ating in some places. Tracheotomy was desired by the parents even as a means of relief alone. I made the usual operation without any accident, and the dyspnoea at once disappeared, not to return; the membrane (Read before the N. E. Dist. Med. Association of Michigan.) extended below the opening and continued HE following cases are instructive as to progress downwards. The patient quietly illustrating the marked distinctions succumbed to the general disease twelve which occur in inflammatory affections of hours later. the larynx and fauces, but, at the same CASE II.-M., a servant girl, 17 years of time, have a general pathological similarity. age, of good physique and healthy. Her em As far as they go, it seems to me that they ployer called upon me for prescription for are a "drop in the bucket" on the side of sore throat, saying that the girl was not variety in the nature of exudative diseases of much ill and that if she became worse he the throat. As the discussion stands at pres- would call me. Three days later, Sept. 15, ent it reminds one of the days before the in- 1878, an urgent message came in the eventroduction of physical exploration, when ing. I found the girl very apprehensive, pleuritis, pneumonia in its various forms, with considerable dyspnoea, rather rapid res and even bronchitis, were included together piration and pulse; temperature about 102°; under the head of "inflammation of the surface cool, with trifling cyanosis; voice, a lungs." Perhaps, finally, it will be made whisper; had had several very severe suffo clear that exudations similar chemically and cative attacks, evidently largely spasmodic. morphologically may appear upon mucous On examination the whole pharyngeal region, surfaces as the result of different morbid including the soft palate and uvula, were states. All but two of the cases reported occurred during the last fall and winter in this city. seen to be covered with a thick, leathery, ashen-grey membrane, closely adherent to the mucous surface, and extending as far CASE I.-S. B., male, æt. 15, of spare habit, down towards the larynx as could be seen. but fairly healthy. Was called to see him by There was little or no fœtor to the breath. the attending physician after his illness had The general condition of the patient was continued several days, presenting the ordin- such that a fatal prognosis was given and ary symptoms of a severe attack of diph- operation not advised. Stimulants, concentheria. A few hours before my visit the trated nourishment and a mixture of chlorate larynx became involved, and when I reached of potassa and tinct. chloride of iron were the house the patient was apparently mori- ordered. Death occurred the next day, as bund. Temperature high, pulse small and much from blood deterioration as from the very rapid; respirations rapid, labored and implication of the trachea. Dyspnoea was loudly stridulous, with strong depression of not extreme during the last few hours. A the supra-clavicular and infra-sternal spaces moment before death she sat up, and exclaimduring inspiration; surface cool, moist and ing that it was growing dark, fell back dead. livid, especially the prolabia; glands at the No post-mortem obtained. angles of the lower jaw tumefied; breath Inquiry revealed a bad condition of the fœtid; fauces, as far as could be seen, covered house. The soil pipe from a pan closet in the next house passed down from the second oedema glottidis and the natural tone of the story within the brick partition wall dividing voice. the houses. A stoppage had occurred re- Treatment: Maintenance of high temperapeatedly, and the overflow of the contents ture in the room and constant vaporization had saturated the wall and flowed out upon of water; the local application of spray of the floor of one of the rooms in the house. bicarbonate of soda solution; externally, an This condition of things had existed for ointment of equal parts of mercurial and sometime. A number of the family had re- iodine ointments to be applied to the throat; cently suffered from sore throat, some hav- internally, a mixture of bicarbonate of aming had "white spots" in the fauces. The monia, senega and digitalis every two hours, case was unmistakably one of pharyngo- with stimulants and nourishment. tracheal diphtheria. ing became more difficult, an emetic of syr. ipecac and powdered alum to be given. CASE III.-M. B., girl, 7 years old, healthy and well nourished, not subject to throat or lung troubles. Father syphilitic before marriage, and since has manifested tertiary symp. toms, often suffers from bronchitic attacks and spasmodic dyspnea. Mother has also shown specific symptoms, and soon after mar. riage aborted once or twice. Both were put upon an anti-syphilitic course,since which four healthy children have been born; one or two show crescentic notches in the front teeth, and one, a boy, is delicate looking. CASE III.-W. M., two and one-half years 6th, 9 A. M.-Increased cyanosis, respiraold, a healthy boy, the youngest of six children; had never been seriously ill; no here- tion more labored, mind lethargic, surface ditary tendency to croup known; residence pale and cool; a delicate pearly white dein a high, well-sewered part of the city; posit here and there over the pharynx and at house a comfortable one-story cottage, so far the laryngeal opening, as I think, though it as known in good sanitary condition; privy was difficult to gain a fair view; pulse feeble; separate from the house; no other cases of vomiting had given some temporary relief; disease in the house. Scarlatina prevailing no membrane distinguished in the matters in a mild form at the time, but not in the im- vomited. Child died at 2 P. M., more from mediate neighborhood. Mother had lost two asthenia than apnœa. children with the disease three years before, and is morbidly apprehensive in regard to it. Was called to see the child on the evening of Feb. 5, 1879. Up to 7 P. M. it had been as well as usual, with the exception of a slight cold. At that hour it began to have a metallic croupy cough, with stridulous, labored respiration. On close questioning, the mother, a very intelligent woman, said there had been a slight wheezing for several days, not interfering with the child's comfort at all. The symptoms increased rapidly in severity, so that at ten o'clock, when I reached the house, the condition was that of the second M. had had a tight cough and wheezy resstage of croup well advanced, i. e., slight piration for several days, when her throat cyanosis, stridulous, gasping respiration, became sore and white. Patches appeared with strong depression of the infra-sternal upon the tonsils, attended by suffocative atspace on inspiration. Voice not hoarse and tacks, worse at night, for which especially I nourishment fairly taken, spasmodic exacerwas consulted. Visited her Jan. 25, 1879. bations occasionally. Careful examination She was dressed, but not inclined to play; of the fauces revealed no sign of exudation, temperature a few tenths above 100° F.; no either on the tonsils or about the laryngeal external swelling of glands of throat; cough orifice. There was some redness, especially metallic; respiration markedly stridulous; about the latter locality. The respiratory no cyanosis, except after occasional attacks sounds were normal, though feeble There of spasmodie dyspnea; respiratory sounds. was no glandular enlargement at the angles of normal, but rather feeble. Examination of the jaw and the temperature was not above throat revealed extensive deposits of yellow101° F. I gave a fatal prognosis, and sug- ish white exudation upon either tonsil, thin gested tracheotomy, which was declined. and easily broken down; could not trace it The operation was not urged as I apprehend- to the laryngeal orifice, which, however, was ed exudation low down in the trachea, from tumid and red. There was slight hoarseness, the intensity of the dyspnoea, the absence of no fœtor. From the long continuance of the symptoms the prognosis was cautiously favor cold for a few days; becoming feverish, I able. was called. The child was restless, irritable, Treatment: Cinchonia, gr. iii, twice a day; skin dry and hot, temperature 102° F, a dry every two hours a mixture containing chlor- cough and injected fauces, but no indication. ate of potassa, tr. muriate of iron and tr. of exudation; respiration quickened and lobelia; locally to the throat, a powder of slightly roughened; no stridor. Ordered red iodide of mercury, gr. j, to powdered cinchonia, gr. iii, night and morning, a mixwhite sugar, ss, a pinch dusted upon the ture of bicarb. ammonia, tr. aconite root tonsils three times a day; externally, to the and syr. ipecac every two hours. throat, comp. iodine ointment. Evening, stridor aggravated, no infrasternal depression on inspiration; exudate breaking down. Second day, symptoms more pronounced, cough metallic, inspiration stridulous, no infra-sternal depression, no increase of bronchial irritation; through the night had sev26th, morning, slight improvement; exuda- eral suffocative attacks. Tissues about tion clearing away; strident cough and op- laryngeal opening tumid and red, no exudapressed breathing continue. Treatment tion visible. Directed hot applications to varied by alternating with the mixture of the day before one containing bi-carbonate of ammonia, fir balsam and syr. ipecac. 27th, morning, symptoms much improved, exudation nearly gone, cough less croupy, stridor softer. From this time onwards the case progressed favorably to convalescence, although the respiration continued somewhat stridulous for some weeks. throat for relief of dypsnoa; a ten per cent. solution of oleate of mercury to be applied to throat externally, two or three times a day, as a counter-irritant; spray of solution of bicarb. soda to be thrown into pharynx every hour or two; internally a solution of chlorate of potassa and tr. mur. iron to be alternated with the ammonia mixture; that the air of the room should be kept at or about 75° F, and moist. By evening symptoms somewhat relieved, stridor about the same, temperature lower and no spasmodic dyspnea. CASE V.-W. B., a younger brother of the above, nine weeks later went through almost the same experience in all particulars, except that the croupal respiration came on almost Third day, about the same as to respiratory immediately with the throat symptoms. Could symptoms, temperature 100° F., cough less not determine the presence of exudation in metallic, takes nourishment better, and can the larynx, the child being unmanageable. be amused with playthings; remedies conThere was more exudation and it yielded tinued. less promptly in this case, but there was no fœtor or glandular swelling. fourteenth day. Fourth day, better, and from this time forTreatment ward Treatment ward convalescence progressed steadily, similar to the former case. On the second although stridor was noticeable as late as the day applied solution of equal parts of tr. mur. iron and glycerine to the throat twice daily, and directed the frequent use, with the atomizer of a solution of lactic acid, gtt. xx, to water 3j. Externally, a 10 per cent. solution of oleate of mercury twice a day until the skin was irritated. From the third day all the symptoms moderated and the patient convalesced well. Stridor continued many days after other symptoms had disappeared. No other members of the family suffered with throat symp toms, and I did not hear of any similar cases in the neighborhood. The hygienic surroundings were good except that a sewer odor was occasionally observed about the kitchen sink waste pipe. CASE VI.-R. D., 11 months old, a vigorous, healthy boy, had symptoms of a slight 1 CASE VII.-M., boy, 14 months old, well nourished, but has suffered repeated illnesses; for several months had frequent convulsions, attendant upon teething; during several weeks the general convulsions were coincident with laryngismus stridulous, attended by strong carpo-pedal contractions. During the last winter was very well, but in February had a severe bronchitic attack, with laryngeal symptoms, closely allied to those observed in case VI, although the spasmodic element was more marked, and the stridor not so persistent. The faucial mucous membrane was injected and swollen, but no exudation. appeared. The patient was convalescent within a week. Treatment similar to the last. This brief series of cases suggests distinc ! tions which may be drawn between laryngeal own judgment is that thus far the weight of diphtheria, membranous croup, and simple testimony, though not of numbers, lies with laryngitis. In no cases is it more necessary the dualists. It can hardly be assumed that to bear in mind the liability to fallacy in all fibrinous exudations upon mucous surfaces diagnosis from too great dependance upon are diphtheritic, since they appear as the similarity of symptoms; a two-fold danger in- result of swallowing corrosive liquids, also deed, leading on the one hand to the inclu- notably in fibrinous bronchitis. The fact sion of different pathological states under the that the fibrillar network is similar in all exusame cause, and on the other to the confusion dations does not necessarily prove identity of different degrees of severity in the same of cause, any more than the appearance of morbid condition, with distinct diseases. pus in sputum always indicates tubercular phthisis, or albumen in the urine the existence of inflammatory change in the kidneys. Neither does it affect the result whether we regard the fibrinous material as derived from a peculiar functional activity of the epithelial layer as held by Wagner, or as directly transuded from the blood vessels, according transuded from the blood vessels, according to the more common opinion. The question If there is a grave blood poison underlying is mainly important as affecting prognosis. the symptoms, with the common sequela of Cases I and II were unmistakably true diphtheria, the exudation was thick and leathery, involving a large portion of the pharynx, and probably the posterior nares; it was with difficulty separated from the tissues beneath, and was finally separated by supbeneath, and was finally separated by suppurative action. The sub-maxillary lymphatics were swollen, there was persistent eleva tion of temperature, and rapid prostration. These symptoms all preceded by some days the development of the laryngeal complica tion. In only the first case were portions of membrane from the trachea obtained, but in numbers IV and V it could be seen as far down as it was possible to push the examina tion. In numbers VI and VII no exudation could be seen, and I regard them as cases of acute laryngitis where there was no tendency to a fibrinous transudation. In case III there was probably exudation below the glottis, since there was little or no interference with vocalization until near the close. In the Detroit Medical and Library Association Transactions for April, 1879, a case is reported where a considerable portion of membrane was expelled with temporary relief, though the child afterwards died, where no exudation at any time appeared above the epiglottis. A number of cases of so-called croup have been reported lately in Detroit, in which a fatal result was reached without any appearance of exudation. Of course the determination of the existence of the diphtheritic element is an important one in determining the necessity for isolation and disinfection, but I think that in the present state of the pathology of the subject, the means for an absolute differential diagnosis do not exist, in many cases; therefore it is better to err upon the side of safety. The diphtheria, threatening long continued morbid conditions, such as albuminuria, paralysis, anæmia, etc., the result will be much less promising than if there is only a simple mucous inflammation, violent though it may be, and attended by faucial, or even tracheal exudation. In the latter case, while death may be imminent from mechanical obstruction, yet if we can tide the sufferer over the obstructive danger, there is little likelihood of an unfortunate termination from constitutional disturbance, while in the former, though the exudation may be remedied, yet a fatal end often supervenes from exhaustion. While, therefore, in some cases there may be doubt as to the presence or absence of a zymotic element, yet in so far as the practical necessities of treatment are concerned, there is enough settled to enable every physician to institute intelligent and reasonably successful treatment. No. 50 Lafayette avenue. Clinical Reports of Surgical Cases. CASE I.-Extensive laceration from the horn of a vicious ox, in the gluteo-femoral region, penetrating the rectum. CASE II.-Gunshot injury of the shoulder, necessitating the removal of head of humerus with five inches of shaft, resulting in a successful arm. BY F. GUNDRUM, IONIA, MICH. very fact that a large number of distin- MICHAEL K, aged 40, German, a very stout and muscular man, while in the act of chopping a pine log in two, and while guished pathologists are arrayed upon each side of the question, proves that a fair basis for decision is yet to be enunciated. My stooping, was gored by a vicious ox which ap proached him from behind, and inflicted the able force, I succeeded in bringing them toinjury which will be described below. The gether. I could just reach the rent in the man was picked up, carried to the nearest rectum. house, and from there he was carried on a On the 12th, fæces began to pass through sleigh 16 miles to a country hotel, six miles the wound, and continued to do so entirely from Ionia, where I first saw him, Dec. 10, until after the operation. There was con1870. The injury had been inflicted at 2 siderable sloughing in the wound until the P. M., and I saw him at 10 P. M. of the same beginning of the third week, when we had a day. I found him lying on some blankets clean granulating surface. The urine had to which had been spread on the floor. He had be drawn for the first week, but there was not re-acted from the shock, being yet cold, no evidence of any serious bladder injury. hands and feet icy, pulse small and very com- On beginning of fourth day symptoms of pressible, and he was taking on fearfully from peritoneal inflammation developed themthe pain in the wound. I administered one- selves. He had quite high fever, distension half grain of morphine in an ounce of brandy of abdomen, tenderness, especially below at once, wrapped him in warm blankets, and level of umbilicus, and the characteristic in about an hour he began to get warmer pulse peculiar to inflammatory trouble of and easier. I now made an examination to the peritoneum. This was controlled with see where and how badly he was hurt. I opium, verat. virid, quinia, fomentations, found, on the inner and upper aspect of the counter-irritants, etc., etc., until in the midright thigh, involving slightly the gluteo- dle of third week he had normal temperfemoral fold, a large, irregular laceration in ature, ate and slept well. Now came the the integument, with venous blood oozing question of closing the artificial anus and from it. The wound was slightly behind having the fæces come the natural way. the median line (i. e., if the thigh were di- Consultation was desired and consented to, vided laterally), and the skin torn chiefly who advised closing up external orifice by horizontally. While washing some of the compression or stitches, but he was soon reablood off the thigh, air escaped through ex- soned out of this, and he consented to my ternal opening of wound, which was recog- proposal, namely, to operate as is customary nized by its characteristic odor as coming for fistula in ano. Although this would make from the intestinal canal. The patient a large wound to heal, I thought it would pleaded to be left alone, which I did for the present. Next day, Dec. 11th, he was taken to his brother's house (as love or money could not induce the proprietor of the hotel to keep the man, the excuse being he didn't want him to die in his house), where, after giving him rest and nourishment, he soon recovered from the fatigue of moving. Late in the afternoon of the 11th I administered chloroform and made an exploration of the wound, and found it as follows: From the orifice in the skin I passed my finger upwards and inwards and a little backwards, quite deep into the tissues, but was unable to reach the end of the artificial open. ing. My finger could only penetrate about even with anal sphincter. I now brought to my aid a large rubber (English) bougie, which, after being well oiled, was introduced, and with my left index finger in the rectum I succeeded in bringing the two exploring instruments nearly together, and after passing the bougie some higher, and crowding my finger up as far as possible, using consider succeed in time in restoring a good and natural condition of the parts. Accordingly the counsel gave ether, and I proceeded to operate. I introduced index finger of left hand into rectum, then took a long probe. pointed bistoury, introduced it into artifical canal until the probe point reached the tip of my finger. I then withdrew them, cutting all tissues between them until the two canals were made into one. I think the divided tissues would measure 7 inches in length and from 1 to 2 inches in the thickest part. Considerable hemorrhage followed, which was soon checked by packing rectum. The wound was treated on general principles. It was found that a soluble condition of the bowels, when the wound was bathed in fæces all the time, retarded the healing process very much, and the wound progressed most favorable when it was kept scrupulously clean. This object was obtained by the administration of opium in small doses and confining bowels as long as patient was comfortable, then by aid of laxatives and large |