A CASE OF SYPHILITIC STENOSIS OF THE LARYNX, WITH FIBROUS ADHESIVE BANDS OF THE TRUE VOCAL CORDS: TRACHEOTOMY, RUPTURE OF BANDS, AND CURE OF STENOSIS BY GENERAL AND LOCAL TREATMENT. BY W. H. DALY, M.D., Senior Physician to the Western Pennsylvania Hospital, Physician for Diseases of My advice was sought on October 8, 1879, for asthma by Mr. L. V., æt. 26, married, a livery stable proprietor. The following history, given with semi-aphonic raucity of voice, with some of the points expressed more fully by his wife, was substantially as follows: He had suffered for the past five weeks with what was pronounced asthma by his physician, and so regarded by himself. He had been under medical treatment during this time without benefit-indeed, quite the contrary. His dyspnoea had grown steadily worse, without intermission. He had suffered from a similar attack nine months before, which, though not so severe, lasted from three to four months, recovery following. He was able to lie down, and sleep, during the former attack, but a sense of suffocation has prevented him altogether from lying down during the past five weeks. Both attacks followed taking cold. He is much distressed for want of rest and sleep, a sense of suffocation coming upon him if for a moment he relaxes his efforts to get breath by means of aid rendered by the voluntary muscles. Dismissing his wife for a few minutes' privaté conversation with the patient, I learned that seven years ago he had a venereal sore on the penis. This he described as being a "little larger than a pin's head," and healing rapidly. It was followed by non-suppurating buboes in each groin, within a period of four to five weeks. Under the professional care of his physician these were cured, and his health continuing good, he had long since ceased to think of his experience with venereal disease, or even to suspect that any trouble could befall him from that cause. His wife gave birth to a stillborn child, after eight months' pregnancy, in an easy labor about three and a half years ago. Her health, though not robust, is fair. General examination. This being the history elicited from the patient, I proceeded to an examination of his case. His efforts at breathing are now most urgent, and distressing to look upon; skin cold and clammy, and of a dusky hue, from non-aërated blood in the dermic capillaries. The pomum Adami rises and falls at each respiratory act fully one and three-fourths of an inch. Externally, upon the right alæ of the thyroid cartilage, and over its full extent is a diffused and elevated pinkish-red patch, which is tender to pressure. The duration of the inspiration as compared with the expiration is as one to three, the latter being difficult, and aided by the voluntary muscles. There is syphilodermata upon the abdomen of a tinea versicolor type, but of a brownish-copper color, and a gummatous node-like growth two and a half inches in diameter in the aponeurotic tissue of the linea alba just below the umbilicus. There is an irregular cribriform ulcer about two and a half inches in diameter upon the left scapular region, which is half an inch in depth in some of its parts, and with ragged and undermined edges. The patient is a mere skeleton and much broken down, though he has a fine shapely frame, and must have been of good physique. His countenance is anxious and beseeching; large beads of sweat are upon his brow and temples; the angles of his mouth are retracted and depressed. The respiration is entirely through the mouth. His tongue is dry and denuded of its epithelium from the full width at the tip down to a point just in front of the circumvallate papillæ. The chest is full and round, characteristic of emphysema. Apparently the difficulty in expelling the quantity of residual air from the lungs is as though the obstruction is acting like a valve, permitting ingress of air, but obstructing its egress. This causes the patient to voluntarily compress the chest by stooping forward at each expiration, while the inspirations are quick, short, and jerking. Upon the clavicle of either side there is a slight irregularity of surface, but no tenderness. Upon the tibia of right side, at upper third, I find a node three inches in length, and fully one-fourth of an inch high, which is quite hard. This node has grown within three months and has not been attended with much nocturnal pain. Upon the left tibia at upper third there is also a node two inches long and one-third of an inch high, which has grown within the same period as the one on the other tibia. A laryngoscopical examination reveals an epiglottis which is abruptly arched laterally, and much thickened. It is immovable by the respiratory act, and rather overhanging. An image of the subjacent parts within the larynx is obtained, and recorded as follows: There is serious encroachment upon the calibre of the glottis, and the rima glottidis is a mere chink, about onethird of the extent of the vocal cords in length, and in expiration of a breadth equal to the thickness of writing paper. During inspiration the separation of the vocal cords is slightly greater by a laxity, and sagging downward of their middle portion, there being evidently but little hyperplasia beneath them. But in expiration they are pressed upwards against the overhanging growths upon the ventricular bands, forming an almost completely closed valve. The hyperplastic encroachment upon the calibre of the larynx is greatest upon the right side of the thyroid cartilage, and extends downward. It obliterates the ventricles and ventricular bands, and pushes out the vocal cords which are adherent by a web of organized plasma to a little more than one-fourth of their extent from the anterior commissure. The posterior commissure is obliterated by the vocal cords overlapping one another rather loosely, in a line to the left of the middle, and are there adherent also by a band of fibrous tissue in one-third of their length. The shortening and thickening of the aryepiglottic folds have occasioned the extreme bilateral arching of the epiglottis; they have also given the entire opening into the larynx more the appearance of a thickened rim of a truncated tube. The anatomical landmarks are obliterated, leaving a rather oval opening, which shades off into a mere fissure, with the bottom formed by the vocal cords, where there is a small slit, through which all the respiration the patient is capable of is carried on. The color of the epiglottis arytenoids and aryepiglottic folds is of a grayish or leaden hue. The parts within the larynx, including the vocal cords, are all of a continuous dark India red color, and it is only with phonation in which the vibratory action of the cords is coarse and uncertain, that they could at all be distinguished from the irregular surface above them. VOL. XXXI.-12 The patient was admonished that tracheotomy would in all probability have to be performed, and he was at once placed upon active antisyphilitic treatment, consisting of ten drops of the compound liquor of iodine every three hours, and six grains of Dover's powder upon a full stomach three times a day, cold, damp napkins applied to the throat, and inhalations of iodine vapor three times a day. Three days later the occlusion had become so distressing as to impel the patient to send for me to "come and perform tracheotomy right away; that he would rather die than suffer another hour in such agony." I made the operation within the next two hours, being kindly assisted by Dr. Jas. McCann, T. J. Gallagher, Wm. Wallace, and J. C. Rea, of Pittsburgh. Less than a half ounce of blood was lost. No anæsthetic was administered, owing to the extreme cyanosis of the patient. (See Plates I. and II., taken two months after the tracheotomy, but previous to removal of adhesive bands of the vital cords.) In three days after the operation the stenosis was perfectly air-tight, and the chondritis and perichondritis of the right ala of the thyroid cartilage were increasing. A tumor presented externally over the right ale of the thyroid cartilage the size of a hen's egg with a coppery red apex. This subsided gradually, and the patient, being able to lie down, sleep comfortably, and take nourishment freely, in twelve days was able to come to my office for treatment. The hyperplasia gradually subsided during the six following weeks. Then, from exposure to cold, the patient having been driving a carriage during the coldest weather either day or night, his neck merely muffled with a comforter, the parts again. became nearly as much occluded as before. Again subsidence of the growths set in under the administration of iodide of potassium, thirty grains, three times a day, with the one-twentieth of a grain of the bichloride of mercury, the patient gaining thirty-nine pounds in three months; the cribriform ulcer healing upon the scapular region, and the nodes upon the tibiæ being visibly reduced. The fibrous bands were ruptured by means of a laryngeal bougie at several sittings, and the vocal cords, though still of the same hue as the other tissue of the larynx, can be more plainly distinguished by their sharp edges. The mercury is withdrawn after two months' administration, and the compound solution of iodine again resorted to, both locally and internally. At the date of this writing (April, 1880), six months afterwards, the patient works hard at manual labor all day with the tracheal tube tightly corked up, and by placing his finger upon the tube he can speak in a good clear voice. The vocal cords are lighter in color and free throughout their extent. There is still some thickening and nodular growths in the larynx about the seat of the operation, which are being treated through the fenestrum of the trachea tube, which is now worn to insure a safe confirmation of the cure. A cork is worn in the tube preparatory to its permanent removal, so that the patient is practically breathing per vias naturales; and the only inconvenience he experiences from it is the conveyance of an unpleasant odor and taste to his nostrils and palate from the muco-pus which accumulates within the trachea tube. NOTE. Oct. 18, 1880.-The tube was removed six months ago; the patient is quite well, and has remained so ever since the removal of the tube; his voice is good, and breathing perfect; he is forty pounds heavier than at date of operation. |