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Suppuration About the Larynx

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formation of an abscess in connection with the larynx is not a com mon complaint at any period of life. But the disease, when present in the child, causes so much_ interference with respiration, and produces symptoms which bear so close a resemblance to those of membranous croup, that it must not be passed over without a word of notice.

Three cases of suppuration about the larynx were published some years ago by Dr. W. Stephenson, of Aberdeen. Two others have been placed upon record by Dr. John S. Parry, of Philadelphia,. A few cases are also scattered about in the various journals.

Causation.—A state of feeble health appears to favour the occurrence of the disease, for the patient is generally weakly and cachectic-looking. In two of Dr. Stephenson's cases the child was just convalescent from an acute specific disease (scarlatina and small-pox). In a case narrated by MM. Rilliet and Barthez, under the name of submucous laryngitis, the boy (aged four years and a half) was still in a weakly condition after an attack of measles. A preliminary period of ill-health is not, however, indispen sable, for in one of Dr. Parry's cases (a little negro baby of four and a half months old) the infant seemed to be in perfect health just before the first symptoms appeared.

Morbid Anatomy.—The abscess is usually situated at some point in the immediate neighbourhood of the larynx. In one of Dr. Stephenson's cases its seat was at the outer side of the right thyroid cartilage, laying bare the upper margin, and extending to the superior cornu. It had opened inter nally. In another a sac containing pus was seated in front of the thyroid cartilage, and extended upwards on each side as far as the upper margin of the alw of the cartilage, the pouch on the right side being somewhat larger than that on the left. In one of Dr. Parry's cases an exactly similar condition was met with. The thyroid cartilage itself may be eroded and roughened and denuded of perichondrium.

Symptoms.—The symptoms produced by suppuration around the lar ynx are very similar to those which arise as a consequence of retro-pha ryngeal abscess, for in both cases there is pressure upon the air and food passages. There is dyspncea and laboured breathing ; hoarse, noisy inspi ration, and increase of distress in the recumbent position. Swallowing is greatly impeded ; the child, if an infant, refuses the breast; if older, he cries when an attempt is made to force him to take nourishment. An effort to swallow is often followed by cough, and an increase in the dysp ncea, with return of the fluid through the mouth and nose.

The most prominent symptom is the dyspncea. The child's eyes are prominent and his face dusky. His breathing is hurried (40-50) and his

nares act with respiration. If an infant, he lies back, with head retracted and the muscles of the nucha rigid. If able to sit up, he sits huddled together in his cot instead of lying clown, and whimpers if disturbed. Each inspiration is accompanied by a loud rattling stridor, and at the same time the soft parts of the chest are retracted and the epigastrium is depressed. The expirations are short and comparatively noiseless. The difficulty of breathing varies in degree. It is subject to exacerbations, dur ing which the child is in the greatest agitation, and seems on the point of suffocation. In the intervals, although quieter, he is still greatly distressed. Anything which irritates or disturbs the patient, such as attempts to give food or medicine, encourages the attacks ; and if he try to swallow, the dyspncea comes on at once. The voice is almost suppressed, and the cry is hoarse or whispering. Cough is either absent or is merely hoarse with out clangor. In one case it was paroxysmal.

The physical signs of the chest are normal, with the exception of the loud stridor which is transmitted to all parts of the chest-wall and quite obscures the normal vesicular murmur. On examination of the throat the fauces appear to be perfectly healthy, and the finger pushed to the back of the pharynx finds no tumour such as is present in cases of retropharyngeal abscess. At first, too, the most careful examination of the neck may detect no deviation from the normal state ; but after a few days a little swelling may perhaps be discovered on careful inspection. In some cases the larynx has been usually prominent or pressed out of the mesial The swelling in most of the cases appeared at some part of the posterior border of the thyroid cartilage, just in front of the sternomastoid muscle, and in two cases it spread to the front. In one instance it was noticed to become more prominent in expiration, and to recede again in inspiration. The swelling is not hard, and rarely fluctuates ; indeed, as Dr. Stephenson remarks, " it may feel more like air than fluid." If the swelling is punctured and the accumulated pus let out, instant relief is obtained. The dyspncea subsides and rapidly disappears ; the child takes food without hesitation or difficulty, and the cough im proves. voice may, however, remain feeble for some weeks after wards. The duration of the disease is. short. In all published cases the suppuration ran an acute course, and ended fatally in many instances. As in the case of abscess behind the pharynx, death may be the conse quence of exhaustion, or the child may die suffocated in an access of dyspncea.

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