On examination of the body many ulcers were found in the ilium, one of which had ruptured and caused profuse extravasation into the peritoneal cavity. The ulcers were circular, and did not follow the course of the vessels, as in ordinary tubercular or scrofulous ulceration. The liver was fatty, but the abdominal organs seemed to be healthy. No gray granula tions were seen anywhere but in the lungs. These organs, however, were stuffed with them ; and there was some consolidation at the apices. The mucous membrane of the larynx and epiglottis was excessively swollen and red, so that the glottis formed a mere chink. No ulcerations were discov ered in this part, and my notes make no mention of gray granulations about the larynx. The trachea was healthy, and nowhere was there any sign of false Membrane.
In this interesting case the larynx was the seat of severe chronic inflam mation, and had the child lived a short time longer it is probable that ulcers would have formed in the glottis. As it was, the intestinal compli cation carried him off before any further change could take place.
Diagnosis.—In the child, on account of the extreme difficulty of using the laryngoscope, owing to the resistance of the patient, it is very rare to be able to ascertain by actual inspection the existence of ulcers or granules on the laryngeal mucous membrane. In children who have reached the age of ten or twelve years the instrument may, however, be sometimes used ; but great irritability of the fames usually attends any laryngeal catarrh, and the attempt to inspect the throat has often to be abandoned.
In coming to the conclusion that a child has tubercular ulceration of the glottis we must first exclude ulceration from other causes. Syphilis' must be set aside by inquiry into the family history, and special antece dents of the patient, and by careful examination of the body for signs of the inherited disease. We must also make sure that the child' has not suffered lately from any complaint which tends to give rise to chronic inflammation or ulceration of the larynx, such as measles, small-pox, or membranous croup. If all these diseases can be excluded, and we find hoarseness of the voice and cough, with stridulous breathing, in a child who is evidently suf fering from tuberculosis, we cannot but explain the local symptoms in the light of the general disease. A persistent, steady dyspncea, without exacerba tions or remissions, would add strength to the explanation. If, however, suffocative attacks come on, and the child is first seen when suffering from more or less paroxysmal dyspncea, an exact diagnosis may be very difficult. The history would, indeed, point to a chronic interference with the action of the glottis ; but such interference might be produced by warty growths or polypi of the vocal cords, and without a laryngoscopic examination a diagnosis is probably impossible. Such a case as the following, for example, would give rise to great perplexity.
A little boy, four years old, but short for his age, and of rickety build, who had been treated for syphilis in his infancy, is brought to the hospital for difficulty of breathing. It is said that for four months he has been noticed to breathe stertorously and to have a hoarse cough. The cough is
worse at night, and is often followed by vomiting. The child's face is rather turgid and congested, and the jugular veins are visible. On inspec, tion of the chest it is seen that at each inspiration the ribs and lower half of the breast-bone are greatly retracted. At the same time the pulse fails in fofce, and there is a stridulous sound from the throat. Examination of the chest shows no sign of disease; resonance is normal, and a loud stridor conducted from the throat is heard at all parts of the chest-wall. The heart's apex is in the normal site. An attempt to make a laryngoscopic examination has to be abandoned on account of the child's struggles. Temperature at 9 A.M., 101.8° ; pulse, 140 ; respirations, 36.
After admission into the hospital the temperature for the first eleven days is over 100°, both morning and evening. The child is found to suffer from severe fits of dyspncea, which come on usually at night. In these attacks he is excessively agitated, sitting up in bed and throwing himself about, his face gets livid and his lips are blue. He makes constant at tempts to cough, as if to remove some obstacle, but the cough is very hoarse and smothered. In one of these attacks the distress is so great, and the signs of approaching suffocation so pronounced, that tracheotomy is per formed. After the operation the breathing is easier, but signs of pneu monia manifest themselves, and the child dies. After death an examination of the larynx discovers several warty growths attached to the true vocal cords. One of these growths is long and pedunculated.
In a case such as the above, if a correct diagnosis can be arrived at in the absence of a laryngoscopic examination, it can only be by exclusion; but the elevated temperature would be an element of perplexity, and would not be in favour of warty growths. A digital examination is of little value in such a case, for the growths, being seated on the true vocal cords, are quite out of reach of the finger.
Prognosis.—The prognosis is always unfavourable, but the gravity of the case depends much upon the general disease and little upon the laryn geal complication. It is only in cases where the inflammatory swelling has almost occluded the opening of the glottis that any special danger is likely to arise from the condition of the larynx. These cases, fortunately, appear to be very rare.
Treatment.—Little can be done in the way of special medication for tu bercular laryngitis. The treatment to be adopted must consist of the measures recommended in cases of simple inflammation. The neck should be kept warm externally, and inhalations of steam, medicated with the compound tincture of benzoin, should be prescribed. If the cough is troublesome and disturbs the rest, small doses of laudanum, morphia, or paregoric may be administered. Two to three drops of liquor morphine, with the same quantity of spirits of chloroform and ten of glycerine, in a teaspoonful of water, form a useful linctus for these cases. The general treatment must be that recommended for the constitutional affection.