Book, 'l—'l CopghtN . COPYRIGHT DEPOSIT. n Tuberculosis OF The Nose and Throat BY LORENZO B. LOCKARD, M. D. I) LARYNGOLOGIST AND RHINOLOGIST TO THE JEWISH CONSUMPTIVES RELIEF SOCIETY SANATORIUM, THE Y. M. C. A. HEALTH FARM AND THE EVAN- GELICAL LUTHERAN SANATORIUM; FORMERLY LARYNGOLOGIST TO THE NATIONAL JEWISH HOSPITAL FOR CONSUMPTIVES AND MEMBER OF THE BOARD OF DIRECTORS OF THE AGNES MEMORIAL SANATORIUM ; ONE TIME PROFESSOR OF ANATOMY, TOLEDO MED- ICAL COLLEGE; FELLOW OF THE AMERICAN ACADEMY OF OPHTHAMOLOGY AND OTOLARYNGOL- OGY, ETC. WITH EIGHTY-FIVE ILLUSTRATIONS, SIXTY-FOUR OF THEM IN COLORS. C. V. MOSBY MEDICAL BOOK & PUBLISHING CO. St. Louis, 1909 \^ 4. \ Copyrighted, 1909, by the C. V. Mosby Medical Book and Publishing Company. / Cla.A, XT-Z^IS" AUG 18 1909 Press of Stewart Scott Press Rooms. St. Louis, Mo. PREFACE The annual mortality from tuberculosis, in the United States, approximates 150,000, and from eight to ten times this number are affected, to some extent. with the disease. Statistics compiled from all parts of the world, in- cluding private as well as hospital and sanatoria records, show that complicating lesions of the throat occur in at least one-third of all persons with recog- nizable foci in the lungs. Autopsies upon individuals dead of consumption prove that nearly fifty per cent have tuberculous lesions in the larynx, but assuming only one of every four consumptives to be so affected, an ultra-conservative estimate, the fact is established that none other of the serious diseases to which the upper respiratory tract is subject approaches tuber- culosis in prevelancy nor in the unhappy consequences which it entails. : In every case the development of a focus in the larynx or pharynx increases . greatly the gravity of the constitutional malady, in many it produces pro- longed, and at times, almost intolerable pain and in a considerable proportion it proves the direct cause of death. Experience has demonstrated, however, that the larger number of such infections are preventable, that at least one-half of the already developed lesions can be brought to the stage of arrest, and that in the majority of those that do not so respond the more dis- tressing symptoms may be held in partial subjection. The chief reasons for the high mortality that has been witnessed are to be found, first, in the almost uni- versal neglect to make systematic examinations of the larynx in pulmonary patients until subjective symp- toms have developed, by which time the lesions have often passed the bounds of incipiency and the general vitality has become hopelessly impaired, and secondly, in the generally accepted but erroneous beliefs that laryngeal tuberculosis is almost invariably fatal and that treatment commonly does more harm than good. Early lesions subjected to treatment are usually curable, and the advanced not infrequently so, and when these facts are recognized the pessimism that rules to-day will be succeeded by a rational optimism with the natural results thereof; more persistent, prompt and intelligent, and therefore more effective management of all such cases. The main objects of this book are to place before the profession the modern views concerning the early re- cognition, the treatment and prognosis of the disease, in the hope that an increased faith in the efficacy of treatment and a full appreciation of the importance of earlv diagnosis and of routine examinations of the larynx in every consumptive, will be engendered. The author desires to make cordial acknowledgment of the writings of Gerber, Heymann and Wright, to which he is indebted for much of the historical and pathological material, and of all the classical works on Laryngology and Tuberculosis, from which he has at times freely translated and quoted. Of the drawings, Figures 2 and 3 are taken from the Seifert-Kahn Atlas, and Figure 4 from the well known work of Heinze. All the other illustrations are the work of Fred'k L. Cavalry, Jr., and, with a few exceptions, were made from specimens and patients under the direct super- vision of the author, who takes this opportunity of expressing his appreication of the skill and painstak- ing care given by the artist to every detail of the work. Denver, Colorado, November, 1908. - CONTENTS. CHAPTER I. Histokical Survey of Laryngeal Tuberculosis. Page Period antedating and including the recognition of the laryngeal tubercle, 400 B. C. to 1825 A. D— First attempts at the differentiation of phthisis and syphilis, 1829 to 1842. — Period of pathologic investigation, beginning in 1842. — Period of clinical observation, beginning in 1858. — Determination of the true nature of laryngeal tuberculosis, 1879. — Inaugura- tion of a rational therapy, 1886 13 CHAPTER II. Etiology — Primary and Secondary Infections. Susceptibility of the larynx to infection. — Reputed instances of primary infection. — Recent discoveries invalidating pre- viously accepted conclusions. — Latent tuberculosis of the lymphatic system. — Frequency of primary glandular infec- tion. — Infection of the larynx by way of the tonsils and cervical glands. — Other cases of so-called primary laryngeal phthisis. — Cases illustrating the possibility of infection of the larynx by the glands. — Conditions favoring primary infection. — Practical application of the question 30 CHAPTER III. Etiology — Endogenetic and Exogenetic Infection. Frequency of unilateral localization of the disease. — Primary unilateral paralysis. — Atrophy and fatty degeneration of the laryngeal muscles. — Constitutional predisposition of one side to infection. — Subepithelial distribution of the tuber- cles and bacilli. — Localization of the affected areas. — Arro- sion ulcers. — Auto-infection 47 CHAPTER IV. Etiology — Predisposing Causes. Frequency of laryngeal tuberculosis. — Influence of age. — Sex. — Occupations. — Tobacco. — Alcohol. — Previous local dis- ease. — Acute laryngitis. — Chronic catarrhal laryngitis. — Na- tionality. — Physical characteristics. — Pregnancy 58 CHAPTER V. Pathology. General phenomena due to the bacillus. — Local phenomena. — Characteristics of the infiltrate. — Tubercle. — Giant Cell. — Ulcer. — Distribution of the bacilli. — The tuberculoma. — The miliary tubercle. — The glands. — The blood-vessels. — The muscles. — The nerves. — The mucosa. — The cartilages. — Mixed infections 68 CHAPTER VI. Subjective Symptoms. Symptoms peculiar to the lungs. — Symptoms peculiar to the larynx. — Symptoms common to the lungs and larynx. — Amblyphonia. — Aphonia. — Diplophonia. — Paralysis. — Pares- thesia. — Cough. — Secretions. — Fever. — Dysphagia. — Dyspnea 80 CHAPTER VII. Objective Symptoms. Hyperemia. — Anemia. — The infiltrate. — The ulcer — The tumor. — The miliary tubercle. — Arrosion ulcers. — Perforations of the epiglottis. — Subglottic lesions. — Conditions secondary to ulceration and infiltration; Perichondritis. — Chondritis. — Anklylosis. — Edema. — Abscesses. — Adhesions 95 CHAPTER VIII, Diagnosis. General features of the tuberculous infiltrate and ulcer. — Ane- mia. — Hyperemia. — Chronic catarrhal laryngitis. — New growths. — Pachydermia. — Syphilis. — Prolapse of the ven- tricle. — Lupus. — Leprosy. — Carcinoma 130 CHAPTER IX. Prognosis. General pessimism regarding laryngeal tuberculosis. — Percent- age of present-day cures. — Influence of the pulmonary condi- tion. — The locale of the lesion in its prognostic significance. — The epiglottis. — Arytenoids. — Aryepiglottidean folds. — In- terarytenoid sulcus. — Vocal cords. — Ventricular bands. — Association of various lesions. — Infiltrative cases. — Ulcera- tive cases. — The voice. — Dysphagia. — Dyspnea. — Miliary tuberculosis. — Influence of pregnancy. — Spontaneous heal- ing. — Relapses 143 CHAPTER X. Records. Showing possibilities of treatment in some apparently hopeless cases 163 CHAPTER XI. Hygienic and Dietetic Treatment. General conditions influencing results of treatment. — Climate. — High altitudes. — Open-air treatment. — Sanatorium treat- ment. — Diet. — Methods of eating. — Enemata. — Influence of tobacco and alcohol. — Rest of the voice. — Nasal and pharyn- geal hygiene 175 CHAPTER XII. Medicinal Treatment. Constitutional Treatment. — Sodium cinnamate. — Tuberculin. — Bacterial vaccines. — Control of cough. — Local treatment. Inhalations. — Sprays. — Insufflations. — Pigments. — Intra- tracheal injections. — Submucous injections. — The X-ray. — Radium. — The arc light. — 'Sunlight 195 CHAPTER XIII. Surgical Treatment — Endolaryngeal Operations. Results to be anticipated from operative interference. — Type of cases to be operated. — Anesthesia. — Instruments. — Choice of Operation. — Incision. — Scarification. — Curettage. — Excision. ■ — Galvano-cauterization. — Electrolysis. — Complications. — After-treatment 222 CHAPTER XIV. Surgical Treatment — Extealaeyngeal Operations. Tracheotomy. — Intubation. — Thyrotomy.— Laryngectomy 246 CHAPTER XV. The Nose. Historical survey. — Etiology. — Antitoxic properties of the nasal mucus. — Other protective agencies. — Primary infections. — Secondary infection. — Channels of infection. — Frequency of nasal tuberculosis. — Relation to lupus. — Influence of age and sex. — Ozena and tuberculosis. — Subjective symptoms. ■ — Objective symptoms. — Regions affected. — Involvement of the accessory sinuses. — Diagnosis. — Prognosis. — Extension to the lacrimal duct. — The naso-pharynx. — Cervical glands. —Treatment £60 CHAPTER XVI. The Naso-Pharynx. Historical survey. — Frequency of secondary involvement. — Fre- quency of primary disease of the tonsils. — Sources of infec- tion. — Anatomical peculiarities favoring infection. — Protec- tive agencies. — Role of the tonsils in the dissemination of tuberculosis. — Characteristics of adenoid tuberculosis. — The ulcer. — The tumor. — Diagnosis. — Prognosis. — Treatment.... 304 CHAPTER XVII. The Pharynx. Historical survey. — Channels of infection. — Proportion of con- sumptives attacked. — Pharyngeal immunity. — Primary infec- tion. — Influence of age and sex.— Esophageal ulceration. — The faucial tonsils. — The tonsils as a point of entry for the bacilli. — Subjective symptoms. — Objective symptoms. — — Formation of cicatricial tissue. — Palatal perforations. — Retropharyngeal abscesses. — Diagnosis. — Prognosis. — Asso- ciated lesions. — Curative treatment. — Palliative treatment.. 327 LARYNGEAL TUBERCULOSIS CHAPTER I. THE LARYNX. HISTORY. An historical survey of laryngeal tuberculosis can be most conveniently made by a division into epochs; epochs of achievement rather than the arbitrary one of years, or in other words, by considering the notable steps through which we have arrived at our present state of knowledge. These epochs are : — 1. Period antedating and including the recognition of the laryngeal tubercle, 400 B. C. to 1825 A. D. 2. First attempts at differentiation of phthisis and syphilis, 1829 to 1842. 3. Period of pathologic investigation, beginning 1842. 4. Period of clinical observation, beginning 1858. 5. Determination of the true nature of laryngeal phthisis, 1879. 6 Inauguration of a rational therapy, 1886 First Period: — The symptoms of consumption were clearly described by Hippocrates (460-377 B. C), and as he alluded to "ulcers in the tube of the lungs," it may justly be inferred that he had some conception of the disease as it appears in the larynx. 14 LAKYXGEAL TUBERCULOSIS. From this time on no real advance, in so far as the larynx is concerned, was made nntil Matthew Baillie (The Works of Matthew Baillie, Vol. II, Page 84, 1825) described tubercles of the larynx and trachea with in- flammation and ulceration of the mucosa, associated with "scrofulous abscesses of the lungs." This description, in the posthumous edition of his "Works, 1825," shows his observations to have been made between this date and the year 1793, when in the "Morbid Anatomy of Some of the Most Important Parts of the Human Body," he referred to the frequent appearance of tubercles in the lungs, but denied their occurrence in the branches of the trachea, "where there are follicles." That tuber cules of the laryngeal mucosa were definitely recognized at this time is further evi- denced by a description of white miliary tubercles in the larynx of a man dead of pulmonary phthisis, by Broussais, in the Histoire des Phlegmasies, 1816. The pulmonary tubercle had been recognized and described during a period of almost two hundred years before Baillie and Broussais noted a corresponding condition of the larynx. Thus Sylvius (1614-1672) maintained the identity of the nodules found in the lungs and the disease known as phthisis, but erroneously considered the nodules to be enlarged lymph glands. Morton, 1689, showed that the turbercle was the necessary precursor of ulceration, and somewhat later, 1700, Magnetus described miliary tubercles. Fragmentary descriptions of various laryngeal lesions classified under the common name of phthisis, HISTORY. 15 in which this disease and syphilis were hopelessly con- fused, were given by Morgagni (Be Sedibus et Causis Morborum, 1762) and Lientand )Histoire Anatomica Medico, , 1767). Morgagni recorded two cases that have been com- monly accepted as a definite recognition of phthisis, although there is no indisputable proof that they were not syphilitic. The one, quoted from Fantoni, concerned a man who for a long time before death suffered from severe dyspnea. Post-mortem examination showed a larynx so constricted by infiltration and ulceration of the ary- tenoid cartilages that only a small aperture remained. In 1704 Valsalva performed an autopsy upon an un- married woman of forty who had been a long time sufferer from symptoms presumably due to asthma. No cause for death being found, Valsalva, at Mor- gagni 's suggestion, opened the larynx from behind. It was extensively ulcerated and filled with a crum like grayish colored pus, fully accounting for the long con- tinued dyspnea. Lieutaud's cases are somewhat similar and it is im- possible to conjecture which of these two constitutional conditions, syphilis or phthisis, was responsible. Lieutaud's carefulness of research, however, is shown by his description, after numerous post-mor- tems, of the first two cases of laryngeal polypi. At this period phthisis was not alone confused with syphilis, but with all diseases accompanied by ulcera- tion, swelling, necrosis and abscess formation; i. e., carcinoma, perichondritis, etc. Petit (Biss. de phthisie laryngea, Montpelier, 1790) ; 16 LAKYNGEAL TUBERCULOSIS. Sauvee (Rech. s. I. phthisie laryngee, Paris, 1802) ; Sigaud {Rech. s. I. phthisie laryngee, Strassb., 1819) ; and Portal (Obser. sur la Nature et sur le Traite- ment de la Phthisie pulmonaire, Paris, 1792), gave fairly comprehensive descriptions of the disease with- out, however, differentiating the tuberculous and syphilitic cases. By the end of the century the science of laryngology had only advanced to a stage permitting a division of laryngeal diseases into three groups; phthisis, croup and acute inflammations. Sachse {Beitr. z. genaueren Kenntnisz und Unter- scheidung der Kehlkopf-u. Luftrohenschivindsuchten, Hanover, 1821) and three years later Pravaz {Rech. et observ. p. serv. a Vhist. de la phthisie laryng. These de Paris), collected many cases and gave a complete resume of the literature preceding and including the era in which they wrote. The confusion of various diseases at this time, however, is shown by Pravaz 's statement that, "No one can doubt to-day that laryngeal phthisis may exist primarily." These "primary" cases were cured by the adminis- tration of mercury. Many theories were advanced as to the etiology of phthisical ulcerations of the larynx, and Columbat credited them to enlargment of the tonsils and uvula. Louis {Recherches Anatomica Pathologique sur la Phthisie, 1825) made the first real attempt at exact study and classification and although he failed to sub- stantiate Baillie and Broussais in regard to the occur- rence of laryngeal tubercles, he noted their fre- HISTORY. 17 quent appearance in the lnngs. He credited laryngeal infection to the mechanical irritation of the mucosa by the poisonous pnlmonary excretions, and main- tained that those points most subject to insult by the passing secretions were most frequently affected, and that therefore the danger of infection decreased pro- portionately to the distance of the parts from the af- fected pulmonary areas. This last observation was undoubtedly based upon the records of his post-mortems on the "tracheal ar- tery" in 102 cases of pulmonary consumption, where he found tracheal involvement 31 times, laryngeal 22, and epiglottic 18 times. Louis's conception of etiology, while containing much of error, had a germ of truth and has been ac- cepted to a certain degree by many modern observers. The theory that some tuberculous ulcers are of a catarrhal nature, long maintained by him, and to which he reverts in the 1813 edition of his works, has been generally abandoned but the majority of present day investigators credit the occurrence of some lesions — the so-called arrosion, corrosion or diphtheritic ulcers — to the mechanical irritation produced by cough, cachexia and sputum, resulting in superficial necrosis and subsequent infection by the bacillus. The existence of catarrhal ulcers in the larynges of tuberculous individuals is strongly combatted by Jona- than Wright. Borsieri in 1826 said: "There are those who think ulcers of the larynx and the aspera arteria, because they are not situated in the lungs, should be excluded from phthisis. However, from these lesions also the 18 LARYNGEAL TUBERCULOSIS. body often wastes away, and is consumed by a slow fever just as iii the parent disease.'' Second Period: — Albers (Die Pathol, it. Therap. der Kehlkopfkrankheiten, Leipzig, 1829), in a painstaking review of the literature of laryngeal phthisis, noted the occurrence of tubercles and gave a lucid descrip- tion of their clinical appearance and transformation into ulcers. To this author can be accredited the first serious at- tempt to differentiate tuberculosis and syphilis, and this may well be considered the second great step toward an intelligent understanding of the disease as localized in the larynx. A decade later, Barth (Memoir e sur les ulcerations des voies aeriennes, Archives Generates de Medicine, 1839) succeeded in furthering the differential diagnosis of the two conditions. Three years before this communication by Barth, Trousseau and Belloc won the prize offered by the Paris Academy for the best difinition and description of laryngeal phthisis, in their essay entitled: "Traite Prat, de la Phthisie Laryngee Chronique, et des Mala- dies de la Voix, 1837." They denned the disease as "tout alteration du lar- ynx, pouvant amener la consomption ou la mort. en quelque maniere que ce soit. ,J They maintained the principle of occasional primary localization of the tuberculous process in the larynx, a much discussed question at the present time, but admitted its general dependence upon preceding pul- monary involvement. HISTOKY. 19 They included in their category of laryngeal phthisis : "1. Simple laryngeal phthisis produced by the common causes of inflammation in general, without pulmonary phthisis. "2. Syphilitic laryngeal phthisis. "3. Cancerous laryngeal phthisis. "4. Tubercular laryngeal phthisis. "Notwithstanding their recognition of tubercle in their last division, we see in their first the influence of the catarrhal theory of Louis." Cit. from Jonathan "Wright (The Nose and Throat in Medical History). In this essay they outlined the first rational therapy for laryngeal diseases : — douches, swabbing and the auto-insufflation of powders through curved cannu- lae. Third Period: — With Eokitansky we note a still further advance in the differentiation of phthisis and syphilis, and what was of infinitely greater worth in its influence upon the advancement of laryngology, a beginning of comprehensive study of the morbid lesions of tuberculous and other laryngeal diseases. While many of the ideas advanced by him were later abandoned, others were based upon truths that obtain to a considerable degree in the pathology of to-day. In the "Lehrbuch d, Path. Anat., 1842- '46," he de- scribes the tubercle as an exudate of inspissated pro- teins, and states that tubercles and scrofulous glands are identical structures, and that ulcers result from the breaking down of the exudate. He likewise deals with the question of predisposition, the tuberculous habitus, and considers it of great importance. 20 LAKYNGEAL TUBEECULOSIS. Tubercles of the air passages frequently occur — most often in the larynx, rarely in the trachea and larger bronchi, and again more frequently in the smaller tubes. In the larynx their favorite site is the posterior wall over the musculus transversus, an observation sub- stantiated to-day by clinical research. The theory that tuberculous ulcerations of the larynx are dependent upon mechanical injury through the anatomical relationship of the parts, and especially when these favored areas have been previously re- duced in resistance through injury or inflammation, was advanced by Eheiner (Ueb. d. Ulcerations proc. im Larynx, Virch. Arch., v., 1853) and fourteen years later by Colberg (Beitr. z. norm. u. path. Anat. d. Lunge, Arch. f. Klin. Med., II, 1867). The basis • of this theory was the assumption that ulcerations generally occur upon symmetrical points, points which normally come in contact during the phy- siologic movements of the larynx, i. e., the vocal pro- cesses in speaking and the free edge of the epiglottis and the tips of the arytenoids in swallowing. In refu- tation of this it is only necessary to suggest that initial ]esions are rarely seen upon these "favored" points; on the epiglottis the usual location is the laryngeal surface, the tip usually becoming affected at a later period through extension, while the vocal processes are not involved to a much greater extent than the other segments of the cords. Neither the epiglottis nor the arytenoids exhibit the same percentage of involvement as other points not subject to rubbing or pressure, i. e., the vocal cords HISTORY. 21 and inter-arytenoid sulcus, and the ventricular bands are more often affected than the epiglottis. In this period was first advanced the idea of a transference of infection in phthisis from the lungs to the larynx by way of the nerve trunks, particularly the vagus (Friedreich: Handb. d. Spec. Path. u. Ther., Bd. V., 1854). This view was supported as late as 1888 by Libermann (Be I'Etiologie de la Phthisie Put- monaire et Laryngee). While Friedreich totally misconceived the true basic facts of etiology, he attempted to differentiate between the tubercles in tuberculosis and the small gray no- dules due to simple inflammation of the mucosa. In the "Handbuch d. Spec. Path. u. Ther., Stuttgart, 1856," Wunderlich showed the influence of Louis, and of Trousseau and Belloc, in his statement that the greater number of ulcerations occurring in the laryn- ges of tuberculous individuals are of a purely catar- rhal origin. He recognized the rarity of true tuberculosis of the trachea, and its comparatively frequent appearance in the larynx, especially in those cases where the lung disease is of long standing and accompanied by colos- sal secretions. Fourth Period : — The period of clinical study began with the demonstration of the practical utility of the laryngoscope, by the Maestro, Manuel Garcia, in 1855. (Physiol. Observ. on Human Voice.) During the preceding half-century many attempts were made to see into the interior of the larynx by means of variously conceived cannulae, mirrors and prisms, i. e. : Bozzini, 1807; Senn, 1827; Babbington, 22 LARYNGEAL TUBERCULOSIS. 1828 ; Beaumes, 1838 ; Liston, 1840 ; Trousseau aud Bel- loc, 1837; Warden, 1844; Tiirck, 1857, and Czerinak, 1858. Many of these appliances were based upon the prin- ciple afterwards adopted by Garcia, but for various reasons failed of common adoption. Immediately following Garcia 's communication the science of clinical laryngology was born and advanced with giant strides, and laryngeal phthisis, so long mis- understood and obscured by a cloud of false ideas, emerged almost at once into the light, freed from most of the old misconceptions. The pioneer work was largely performed by C. Ger- hart (Gerhardt und Roth, Ueber Syphil. Krankheiten d. Kehlkopfes, Virch. Arch., 21, 1860) in detailing a large series of cases examined by the new method. In this thesis he clearly described syphilis and succeeded in finally separating it from phthisis. This work was soon supplemented by another upon the influence of catarrhal swelling of the posterior laryngeal wall in the production of aphonia. (Ueber einige Ursachen Katarrhal Heiserkeit, Wurzbiirger medic. Zeitschr., Bd. Ill, 1862.) In this essay he considered the possible influence of an apparently simple catarrh upon the development of tuberculosis, and believed that this condition might be of considerable etiologic import. In 1861, in the (l Tr. Clin. d. mal. d. enfant s, Rilliet and Barthez," we find the first reference in regard to the influence of age. They state that ulcerations in the upper respiratory tract occur usually after the seventh year of life, and very rarely before the age of three to four years, and that while usually dependent upon HISTOKY. 23 advanced pulmonary disease, they may occur as a re- sult of other organic tuberculous processes. They agree with Louis as to etiology, and maintain the general dependence of laryngeal ulcers upon pre- ceding advanced disease of the lungs or other organs. To the theory of Eheiner, the mechanical injury of symmetrical points, Tiirck (Klin. d. KehlkopfkranJch., Wien, 1866), one of the most careful observers, reverts, and concludes that this is the most frequent form, while the true tuberculous ulcers occur in but a small propor- tion of cases. As late as 1872 we again find this idea of the non- tuberculous nature of many ulcerations advanced by Waldenberg (D. loc. Behandl. d. Krankheiten d. Ath- mungsorgane), who explains his conviction on the ground that many ulcers of the larynx in phthisical individuals heal completely, and are therefore merely follicular ulcerations. The earliest descriptions of the tuberculous tumor were given by Tobold (D. chron. ■KehlkopfkranJch., 1866) ; Mandl (Tr. prat. d. mal. d. larynx et pharynx,, Paris, 1872) and Ariza (Anfiteatro, anat. Espanol, 1877). The first of these described cases in the incipient stages of laryngeal tuberculosis where the entire glot- tis was filled with tumors of the mucosa. The growths were pale in color, of cauliflower formation, and ap- peared mainly in the ventricles, on the vocal processes and the posterior wall. Kindfleisch (LeJirb. d. Path. Anat., 1873) upheld in a slightly modified way the theory of Eheiner and Tiirck, i. e., the irritation of symmetrical segments of 24 ■ LARYNGEAL TUBEKCULOSIS. the larynx by the infectious products of a scrofulous catarrh. The persistence of this idea has been shown at length, both because of its important place in history and because many more modern observers have given it a prominent place in etiology. In studying the further progress of knowledge it is necessary to revert to the role played by the tubercle. Lewin (Ueb. Krankh. einz. Theile d. Larynx, etc., Virch. Archiv. XXIV, 1862) believed some erosion of the mucosa to be an almost necessary antecedent to the deposit of tubercles, or at least that the tubercles usually develop in such damaged spots. That the tuberculous ulcer is a result of the disin- tegration of tubercles he clearly recognized, and like- wise the existence of small granulations about the edges of such ulcers, the first reference to this import- ant characteristic. Virchow (Geschwulste, 1864 and '65,) took strong exception to Louis's assertions regarding the mechanical cause of phthisical ulcers, and made it plain that laryngeal tuberculosis is due to the tubercle and nothing else, and reasserted the fact that ulcera- tion is consequent upon destruction of the tubercle. He recommended the larynx as the best locality in which to study the tubercle, which he described as fol- lows: "In the very frequent tuberculosis of the Larynx, small, flat, clear, grey or whitish swellings are found, which hardly project beyond the surface." These tubercles never caseate or form tumors. Ii. Meyer (1). gegenw. Stand, d. Fr. v. d. Kehlkopf- schwindsucht. Correspondenzbl. /. Schweizer Aerzte, Nr. 13, 1873) combatted this view of Virchow's as to HISTORY. 25 the relation of the tubercle to ulcerative laryngeal phthisis, upon the ground that he had been unable to find tubercles in laryngeal ulcerations and that there- fore they could play no part in its production. Ten years later Bosworth reverted to the old theory of the non-tuberculous nature of some laryngeal lesions in phthisis. Almost coincidently with Virchow, Forster (Lehrb. d. path. Anat., 1864) expressed the same views, and gave as the favorite site of the tubercles the inter- arytenoid sulcus and described their ultimate con- version into crater-shaped ulcers, confluent, with se- quelae of cartilage necrosis and abscess formation. He believed the tubercle might be either primary or sec- ondary. Bruns (Die Laryngoskopie n. laryng. Chirurgie, 1865) credited laryngeal ulcers to one of two sources: 1. Disease of the mucous follicles. 2. Circumscribed deposits in the submucosa (tuber- cles). The dependence of epithelial necrosis upon submucous deposits was further elaborated by Tobold (Laryngosk. u. Kehlkopfkranhh., 1867) who ascribed the necrosis to the gradually increasing pressure from beneath, with ultimate loosening of the mucosa from its attachment, or in some instances, to the degenera- tion of miliary tubercles. From this time on advance in the knowledge of pathology was rapid and unbroken, the chief work being done by E. Wagner, Waldenburg, Kindneisch, V. Ziemssen and Heinze. Wagner (D. Tuherkelahnl. Lymphadenom. Arch. f. 26 LARYNGEAL TUBERCULOSIS. Heilk., 11-12, 1870 and '71) minutely pictured the typical tuberculous infiltrate, tubercle and ulcer. Waldenburg (D. loc. Behandl. d. Krankh. d. Ath- mungsorgane, Berlin, 1872) described the occurrence, about the edges of tuberculous ulcers, of miliary tuber- cles, but was uncertain as to whether they were the cause or a product of the ulcers. With many observers he agreed in considering a large proportion of laryn- geal ulcers in consumptives to be purely catarrhal, a conclusion based upon the rapidity with which some of these ulcers healed. A new view point was assumed by Sommerbrodt (Ueb. d. Abhangigk. phthisis cher Lungenerkrankh. v. prim. Kehlkopfaffectionen, Arch. f. Exper. Path. u. Pharni., 1873) in his contention that pulmonary phthisis might be caused by purulent peribronchitis acting through a chronically inflamed larynx and tra- chea. V. Ziemssen (Handb. d. spec. Path. u. Ther., Bd. IV, 1, 1876) classified tuberculous laryngeal ulcerations as follows: 1. Ulcerations due to miliary tuberculosis and tu- berculous inflammations consequent upon pulmonary phthisis. 2. Follicular ulcerations. 3. Ulcers dependent upon specific cell infiltration. 4. Superficial aphthous, or erosion ulcers. lie likewise maintained the usual dependence of laryngeal ulcerations upon disease of the lung? and claimed that healing, while possible, was extremely rare. Fifth Period: — The credit of reconciling these many HISTORY. 27 conflicting conjectures belongs to Oscar Heinze, who in 1879, (D. KehlkopfschwindsucM, Leipzig) demon- strated that the sole cause of laryngeal and tracheal tuberculosis is tuberculous infiltration of the mu- cosa, and that ulceration in the larynx and trachea never leads to tuberculosis unless there is simultaneous or subsequent tuberculosis of the mucous membranes. This view was subscribed to by all the later investi- gators except Beverly Robinson (Ulcerative Phthisi- cal Laryngitis, Amer. Jour, of Med. Sciences, April, 1879) who claimed that "the ulcerations which have been described in the larynx under the name of miliary tubercles are none other, as a rule, than small spheri- cal swellings, which are occasioned by the filling up with transparent fluid of the closed follicles of the submucous reticulum, which have been described by Heitler and Coyne." Heinze believed in the simultaneous existence of tuberculous and catarrhal ulcers. Sixth Period: — The record of advancement in ther- apy is meager. Galen (129-200 A. D.) declared that ulcers of the i ' arteria aspera" were easily curable, but this impression was combatted by Marcellus Donatus (De Historia Medica Mirabili Lib., 1613) and his views, in so far as they concern tuberculosis, have ob- tained until the present time. During this entire period but few procedures were offered for relief through either surgical or medicinal agencies. In 1818 it was suggested that some benefit followed the use of creosote in the form of tar fumigations. 28 LARYNGEAL TUBERCULOSIS. Albers, in 1829, (Die Path. u. Ther. der. Kehlkopf- krauklieiten) advocated the performance of trache- otomy and claimed for it a wonderful influence through the complete rest given the larynx. The use of steam inhalations, swabbing, douches and the auto-insufflation of powders was advised by Trousseau and Belloc in 1837. A year later Horace Green succeeded in making ap- plications of silver nitrate to the interior of the larynx, by means of curved applicators similar to those in use at the present time. His report was pub- lished in 1846 under the caption: "Treatise on Dis- eases of the Air Passages, comprising an Inquiry into the History, Pathology, Causes and Treatment of those Affections of the Throat called Bronchitis, Chronic Laryngitis, Clergyman's Sore Throat, etc." Green's pretensions were bitterly denounced by the profession, the greater number claiming such a procedure to be absolutely impracticable. Finally, after suffering the severest of calumnies, he succeeded in proving his claims and in having the method of treatment upheld. William Marcet (Clinical Notes on Diseases of the Larynx, London, 1869) advocated puncture of the involved tissues, but the surgical treatment received no further impetus until the resurrection of Albers' suggestion of the utility of tracheotomy, by Moritz Schmidt, in 1880 (Die Kehlkopfschu-'nidsitclil und ilir<> Behandlung, Arch. f. Klin. Medicin., Bd. 25, 1880). In addition to tracheotomy he strongly recommended, in selected cases, the use of scarification and incision of the laryngopharyngeal wall. Surgery, however, owes its present recognized posi- HISTOKY. 29 lion to the work of Heryng (Beitr. z. chir. Beliandl. d. tubercul. Larynxphtliise. d. Med. Woch., 1886, and Die Heilbarkeit der Larynx phthisie und Hire Chir- urgislie Beliandlung, 1887), who advocated curettage and claimed to have effected many cures through its performance. Two years before this, Krause {Berlin Klin. Woch- enschrift, Nr. 26, 1885) introduced lactic acid and re- ported many favorable results. Consequent upon these two recommendations the pendulum swung from the ex- treme pessimism that had ruled from earliest times, to enthusiastic optimism, to recede once again to an illogi- cal point when the high promises regarding the univer- sal utility of these agents remained unfulfilled. Lactic acid, however, is still recognized as one of the most valuable agents for combatting ulceration, and the surgical treatment has steadily gained in favora- ble consideration, especially upon the Continent. In America, with a few notable exceptions, it has failed to secure the endorsement it undoubtedly deserves, although at the present time there seems to be some recrudescence in its favor. CHAPTER II. ETIOLOGY. The upper respiratory tract, owing to its anatomical position, relationships and conformation, exhibits in certain segments a marked susceptibility to infection by the tubercle bacillus. The results of this infection become manifest in any or all of the protean forms of the disease recognized as typical in other organs — in- filtrations, granulations, ulcerations, tuberculomata, miliary tubercles and lupus. THEORY OF PRIMARY AND SECONDARY INFECTION. The chief contention from an etiologic standpoint concerns the route by which the tubercle bacillus, the invariable causative agent, gains entrance into the tissues. Two theories are advanced, the one of primary in- fection depending upon the assumption of an initial lesion of the nose, pharynx, or larynx as the case may be, the infecting material being deposited by the in- vested food or inspired air; the other assuming- a pri- mary involvement of some distant organ, usually the Lungs, with an infection of the upper tract through the PEIMAEY AND SECONDARY INFECTION. 31 agency of bacilli-laden sputum, or by way of the blood or lymph vessels. In so far as the larynx is concerned, the possibility of an occasional primary infection has apparently been proven by the post-mortem investigations of Orth, Po- grebinski and Demme, in cases where, with undoubted laryngeal tuberculosis, the lungs were found to be en- tirely normal. These cases, in connection with a few others of a less definite nature, would be absolutely conclusive were it not for one factor which may invalidate previ- ously accepted conclusions — the possibility of infection of the larynx by way of the lymphatic glands. Latent tuberculosis of any of the constituent parts of the lymphatic system, particularly of the tonsils and bronchial glands, may exist for years without symptoms or alterations in their macroscopic images, and yet from such foci, through lymphatic or blood transmission or perhaps by direct transmission through the tissue spaces, a secondary laryngeal focus might become established, particularly if the involved gland has been subject to traumatism or to the action of such inflammatory processes a scarlet fever and mea- sles. That such a nidus, even when situated within the the interior of the gland, may become the point of de- parture for other widely disseminated processes has been repeatedly demonstrated. Cornet has seen general miliary tuberculosis follow an experimentally induced focus of small size in such a lymph gland, and various observers, notably Volland, have witnessed the invasion of the lung by bacilli from the cervical glands. 32 LAKYNGEAL TUBEKCULOSIS. Tuberculous peritonitis lias been known to have its origin in a tonsillar lesion, and Shurley, in considering this source of infection says : "Much enlarged adenoid glands at the vault of the pharynx, especially with dis- eased conditions of the follicles or lymph spaces, are often conducive to the accession of pulmonary dis- eases.'' The relations of the lymphatics of the larynx to neighboring structures need not be considered for in- fection does not invariably follow in the direction of the lymph current; it may take a course vertical or directly opposed to it. Upon this point Cornet writes : "Dissemination from the primary gland takes not only a centripetal, but also a radial direction, in such wise that the main movement sets in toward the heart, along with the lymph current; that minor movements take a course vertical to that of the lymph current ; finally, that there is a slight tendency, often imperceptible or even en- tirely lacking, to spread in a direction opposed to that of the lymph current." Invasion may also occur through the tissue spaces without leaving trace of its passage. The frequency of this latent lymphatic condition is shown by a study of recent statistics. In forty cadavers, thirty of which during life had shown no signs of tuberculosis, Pizzini found latent disease of the bronchial glands in 42 per cent. Cornet found the same conditions in four, and Spong- ier in six children who had died of diphtheria, sepsis and peritonitis. PEIMAKY AND SECONDAKY INFECTION. 33 Jackson (Boston Med. and Surg. Journal, May 12, '04) reported the following: 18 cases — Tuberculous meningitis. 1 case — No history obtainable. 2 cases — Tuberculosis found on general examination. 14 cases — No history of tuberculosis. AUTOPSIES. 16 cases — Evidence of chronic tuberculosis. 9 cases — Pulmonary tuberculosis. 7 cases — Tuberculous bronchial glands. Demme claims that these glands, i. e., the bronchial, are diseased in 80 per cent of all cadavers, and Neu- mann found them involved eight times in 105 autop- sies upon children supposedly non-tuberculous. Examinations of the tonsils show equally surprising results. In studies made of apparently healthy or hy- pertrophied tonsils, from subjects not known to have had tuberculosis, the following results were tabulated: AUTHOR. Cases. Lermoyez 32 Gottstein 33 Brindel 64 Lartigan and Nlcoll 75 Wright 63 Pluder & Fischer 32 Pilliet 10 Broca 100 Dieulafoy 61 Dieulafoy 35 Ruge 18 McBride & Turner 100 Cornil 70 Dempel 15 Piffl 100 Lewin 200 Schreiber 29 Hynitsche 180 Friedmann 145 Tarchetti & Zanconi 17 Baup 45 Ito 10 Rethi 100 Maccayden & MacConkey 78 Wex 210 Theissen 45 Lathan 45 Lockard 74 1,986 Tonsillar Involvement: Pharyngeal and Faucial. 2 4 8 12 5 3 8 7 6 3 4 1 3 10 2 7 6 1 6 7 2 7 5 119=5.9% 34 LAKYNGEAL TITBEKCULOSIS. In tuberculosis of the cervical glands it is estimated that 90 per cent of the infections originate in the ton- sils. Friedmann makes the following tabulation of 91 tonsils examined post-mortem, taken (with one excep- tion) from subjects under five years of age: 1 tonsil - - - Riddled with tubercles. Bacilli present in large numbers. No other lesions in body. 4, and probably Tonsillar tuberculosis probably pri- 5 other cases - mary. Partly complicated by sec- ondary involvement of glands, in- testines and bones. 7 other cases - Giant cells but no bacilli. 2 other cases - Tuberculosis present, but not primary. 3 other cases - Giant cells, but condition not tuber- culous. 8 cases - - - General tuberculosis without tonsil- lar. Old scars in tonsils, the result of early tuberculosis. 2 other cases - Similar but less distinctive results. 4 cases - - - Internal without tonsillar tuberculosis. 3 cases - - - Bacilli found in smears from surface of tonsils, but no tuberculous changes found. Baup, in 841 cases, including 48 of his own, found 53, or 6 per cent, tuberculous. Eethi found bacilli present in six of 100 hypertro- phied tonsils removed from persons showing no signs of tuberculosis. Walsham, in 34 autopsies on patients dead of tuber- culosis, found the tonsils tuberculous in 20. Babes, in the Children's Hospital at Budapest, dis- covered tuberculosis of the lymph glands, particularly of the mediastinum and bronchi, in more than one- half of the autopsies. PKIMAKY AND SECONDARY INFECTION. 35 Strassmann, in 21 autopsies upon phthisical sub- jects, demonstrated tonsillar involvement in 13. The author, in 74 tonsils from subjects showing no signs of tuberculosis, found five tuberculous. The removal of one of these was followed by the accession of the disease in the cervical lymphatics and larynx. From an examination of the tonsils of 200 subjects, L. Lewin makes the following deductions : 1. Hyperplastic pharyngeal tonsils conceal tuber- culous lesions in about 5% of the cases. 2. The tuberculosis is present in the so-called tumor form, and is characterized by the absence of surface indications of its presence. 3. This latent tuberculosis may apparently be the first and, indeed, the only localization of the disease in the individual. 4. It is generally, however, associated with other tuberculous processes, generally of the lungs, which may, however, not have developed at the time the ton- sil was operated upon. 5. It is a comparatively frequent condition among those suffering from tuberculosis of the lungs. 6. It is found in the normal-sized tonsil as well as the hyperplastic. These few cases previously cited (Orth, Demme, Po- grebinski), culled from the entire voluminous literature and quoted by all authors as the most typical upon which to base the claim of occasional primary localiza- tion of the tuberculous process in the larynx, cannot therefore be accepted as definitely establishing the sup- position without further confirmatory evidence, for not only must lesions of the lungs be excluded but of the lymphatic system as well. In the above cited cases no cognizance was taken of this condition. Neither is o 6 LARYNGEAL TUBERCULOSIS. this evidence, i. e., absence of lymphatic as well as of pulmonary involvement, afforded by other reported instances. M. Schmidt says : " I have myself seen a number of such cases of primary involvement, especially in the form of tumors of the ventricular bands and cords, but also as ulcerations. ' ' Yet none of these cases were sub- stantiated by post-mortem examination. Numerous other observers, among whom may be mentioned Dehio, Neidert, Fischer, Cadier and Gleits- mann, have maintained the principle of primary inoc- ulation, based upon the observation of patients where no pulmonary lesion was manifest or in whom it devel- oped only late in the course of the laryngeal disease. This last author, after citing two cases of cured laryn- geal tuberculosis where involvement of the lungs was never clinically demonstrated, makes the admission that : "Obviously, if the postulate is brought forth that nowhere in the lungs the smallest tuberculous area exists, then the occurrence of primary laryngeal tuber- culosis cannot be any longer maintained, neither in the dead nor much less in the living. But, for my part, I do not see the rationale of the argument to demand the abstract absence of the disease, in this instance of the lung, to be able to believe in the existence of another, viz., primary laryngeal tuberculosis. " It is here we have the crux of the question. Is pri- mary infection capable of proof when other foci exist? Central lesions of the lung, old partially cicatrized areas and new cheesy deposits in the lymph glands, bones, kidneys or retroperitoneal tissues, frequently escape the most careful search and cannot be demon- PRIMARY AND SECONDARY INFECTION. 37 strated except upon the cadaver, yet such lesions may develop, remain unrecognized, give rise to other infec- tions and cicatrize, or later, under fortuitous circum- stances, recur. The frequency of such lesions of the lungs has been shown by Birch-Hirschf eld : Autopsies, 3,0G7; Pulmonary Tuberculosis, 41.86%; Tuberculosis cause of death, 23.3%; Old Cicatrized Pulmonary lesions, 11.97%; very early lesions, 2.8%. When cicatrization has occurred the age of the lesion cannot be definitely ascertained, and upon this ground we must refuse to accept the evidence of such cases as those quoted by Trifiletti and Josephsohn. The former reported the case of a girl of twenty-one years with tuberculous infiltration of the laryngeal mucosa and apparently healthy lungs, who eight months later showed the first signs of pulmonary involvement. In Josephsohn 's case the evidence of lung involve- ment arose two years after laryngeal phthisis was diagnosed. Similar and equally indefinite cases are reported by Ziemssen, Barth, Haslund, Garre and Moritz. Bernheim refers to twenty-nine cases of primary laryngeal disease seen by him, without post-mortem confirmation. That such a large number of apparently primary cases should be seen by one observer is re- markable when we consider the paucity of cases from all other sources. J. Home has not once in ten years met with an exaim. pie in the necropsies of nine large hospitals. In 904 consecutive cases for which exact records are 38 LARYNGEAL TUBERCULOSIS. available, the author has met but three in which the lung examination proved negative and in one of these the necropsy revealed a healed lesion. In a second case, one of slight laryngeal involvement in which death could not be attributed to the tuberculous pro- cess, the lungs were normal but the faucial tonsils were affected, showing the possible dependence of some laryngeal cases upon old lymphatic lesions. The third case could not be subjected to autopsy. An oft-quoted case is that of Champeaux's, where a tumor was present on the ventricular band, with apical dullness, but no bacilli in the sputum. That such a case is absolutely without value in this connection goes without saying. Sheedy (Post Graduate, XVIII, p. 164) reports a case in which the larynx was involved for nine months, with bacilli in the sputum, before the lungs became affected. Kelson (Laryngoscope, April, 1903) presented be- fore the Laryngological Society of London a man with swelling of the epiglottis, ary-epiglottic folds, ventricu- lar bands and vocal cords, but no bacilli in the spu- tum. To establish proof of this supposition, i. e., the possi- bility of involvement of the larynx by way of the lym- phatics or blood vessels from the lymph glands, or by direct transmission through the tissue spaces, the fol- lowing facts and somewhat parallel cases are adduced : ' ' Caries of the processus mastoideus and of the pet- rous bone are mostly referable to tuberculous disease of the middle ear through the lymphatic channels. A PEIMAKY AND SECONDARY INFECTION". 39 bony focus originated through infection by way of the pharyngeal tonsils. ' ' — Euge. "In an infection proceeding by way of the vascular system, it is of course immaterial where the primary focus is situated:'' — Cornet. In 67 autopsies (Konig-Orth) lesions of the bones or joints were found to be dependent upon other lesions in 53 cases — 79 per cent. Of these the lungs were re- sponsible in 37 cases, the glands in 21. Ph. Schech reports the case of a man who in his sixty-third year had the right testicle removed because of tuberculous involvement. He remained free from the disease for two years, when the posterior pharyn- geal wall became affected ; then the larynx, and finally the lungs succumbed. Another example given by the same author concerns a man who in his twenty-eighth year developed tuber- culosis in the left apex with hemoptysis. After fifteen years of seemingly perfect recovery he suddenly devel- oped tuberculosis of the ear, velum and lips. "Laryngeal tuberculosis may be caused by lymphatic transmission from a neighboring focus, i. e., in the palate, fauces or tonsils." — Cornet. Chiari and Eiehl examined 68 persons who suffered from lupus either of the face or of the mucous mem- branes, but gave no subjective symptoms of laryngeal disease, and discovered lupus of the larynx in six cases. It has been proven that a tuberculous process of the larynx itself becomes a source of further infection, either by contact, as of symmetrical portions of the larynx, or by lymphatic extension to neighboring organs, either of the mouth or pharynx. If mouth in- 40 LARYNGEAL TUBERCULOSIS. fection can result by lymphatic transmission from the larynx the converse mnst likeswise be true, as infec- tion occurs not only in the direction of the lymph cur- rent but in a direction directly opposed or vertical to it. In a number of instances a retrograde infection — of the tonsils from diseased cervical glands — has been demonstrated to have taken place. Grunwald (Diseases of the Larynx, 1900) remarks : " There is no doubt that diseased cervical glands are capable of infecting the larynx; many a so-called i pri- mary' case is no doubt due to this cause.' ' Two cases proving connection between disease of the larynx, cervical glands and tonsils, occurring in the author's practice, may be adduced: Girl, aet. 11. Hypertrophied tonsils and small mass of adenoids. Bilateral enlargement of the cervical glands. Lungs normal and general condition good. Three months following the removal of the adenoids and tonsils, the cervical glands having in the meantime partially disappeared, hoarseness developed and examination revealed incipient tuberculosis of the left side of the larynx. The left cord was infiltrated throughout its entire extent and there was moderate infiltration of the inter-arytenoid sulcus. The fur- ther history substantiated the diagnosis, but pulmon- ary tuberculosis was never demonstrated. In this case we had an undoubted infection of the cervical glands from the tonsils, and of the larynx by way of the cervi- cal glands. Examination of the tonsils had proved them tuberculous. The second case concerns a girl of seven years, who PRIMARY AND SECONDARY INFECTION. 41 had a large mass of suppurating cervical glands on the right extending from the angle of the jaw to the clavi- cle. The immediate cause of the consultation, how- ever, was a retro-pharyngeal abscess of three days' duration. The tonsils were not large, but ragged, with numerous deep crypts filled with cheesy concretions. The lungs and other organs were apparently normal. The retro-pharyngeal abscess was opened, draining almost completely the mass of suppurating cervical glands. Ten days later these glands were removed and two weeks later the tonsils were completely extir- pated, and on microscopic examination showed un- doubted tuberculosis. At this time the first complete laryngeal examination was made, the child having previously rebelled. There was rugous infiltration of the interarytenoid sulcus, with a small ulcer at the point of union of the arytenoid cartilage, vocal cord and right ventricular band. Seven months later the child died and examination showed the lungs to be normal and the larynx tuberculous. This case is of special interest from another stand- point; the cervical suppuration antedated the pus for- mation in the retro-pharynx, burrowed its way into that space, and was partially emptied through the phar- yngeal incision. McKinney (Journal of Tuberculosis, January, 1903) reports a case of laryngeal tuberculosis secondary to tuberculous cervical glands, and it is the generally ac- cepted belief that in the great majority of the cases of pulmonary tuberculosis occurring in children, infection takes place from the lymph nodes ; the latter may be infected in many ways. There is no certain relation 42 LARYNGEAL TUBERCULOSIS. between the points of entrance of the infection and the points of development of the disease. Lartigan and Nicholl (American Journal Medical Sciences, June, 1902) after long research, concluded that primary tuberculosis of the pharyngeal tonsils is probably more common than is generally supposed in the production of either localized or general infection. Upon this subject Cornet says: " Since the as- sumption of a primary disease, i. e., of the larynx, de- pends very largely upon the absence of demonstrable signs of disease in the other organs, especially the lungs, intra vitam, we should be very guarded, in view of the imperfections of our methods of clinical re- search, in inferring the primary nature of the disease. ' ' As proving the uncertainty of the source of infec- tion he refers to a case, classified as primary pharyn- geal, reported by Isambert, of a boy of four and a half years who had tuberculous ulceration of the velum without signs of pulmonary involvement. He had, how- ever, in early infancy shown signs of scrofula and "scrofulous (?) coryza." Pulmonary phthisis frequently develops from dis- ease of the cervical glands; the glands, in the majority of instances, owe their infection to previous disease of the tonsils and doubt no longer exists as to the occa- sional spread of the process from the cervical glands, and probably from the bronchial glands as well, to the larynx. In view of the above proven facts, these frequently cited cases of Orth, Pogrebinski, Demme and others, can no longer be held to indisputably prove the occur- rence of primary tuberculous infections of the larynx. PEIMAEY AND SECONDARY INFECTION. 43 The probability of a direct infection of the larynx from without is extremely doubtful, although upon purely theoretical grounds the possibility must be admitted. While the bacilli-laden air in its passage through the nose and naso-pharynx is freed from the greater num- ber of contained organisms and dust, a small propor- tion penetrates into the larynx and bronchial tubes. The larger part of those introduced in this man- ner, and not passing onward into the lungs, is imme- diately expelled by the upward motion of the cilia that exist everywhere in the larynx except upon the vocal cords and posterior wall. At these points the dust particles to which the bacilli are generally at- tached cause an increase in the normal secretions which aid in the expulsion. When, however, owing to previous inflammations of the mucosa, erosions exist, the reflex irritability is abnormally low and many of the organisms may be retained and gain entrance through these breaks in continuity. The abraded con- dition of the mucosa is not always essential as it has been demonstrated that the bacilli may penetrate intact membranes, or even pass through the ducts of glands, as will be shown in discussing the etiologic role of the sputum. If infection by inhalation plays an important role in etiology as many observers would have us believe, would it not be natural to conclude that laryngitis would occur in a larger proportion of those people who live under unhygienic surroundings and follow un- healthful occupations, than of those not subject to these disadvantages'? A statistical study of these patients, 44 LARYNGEAL TUBERCULOSIS. however, shows that the relative proportion of laryn- geal to pulmonary cases is no larger in the so-called unheal thful than in the favorable avocations, and that the same proportion maintains between individuals liv- ing in the rural communities and in the congested areas of the large cities. If laryngeal tuberculosis occurred as a primary in- fection there would undoubtedly be more positive evi- dence in its support. When but a few cases can be adduced from such voluminous reports as are now ac- cessible, and these take into account the condition of the lungs only, it practically removes the question be- yond the pale of serious consideration. It is the almost universally accepted dictum that an absence of pul- monary foci establishes the primary nature of any ex- isting laryngeal infection, whether or not there are foci present in other organs, but such a conclusion is abso- lutely unwarranted. Thus, in referring to primary laryngeal tuberculosis, Richard Lake says : "As already mentioned, the author has seen two cases in which the larynx became affected secondarily to an apparently primary tuberculous otitis media, and in which the signs of the disease in the lungs did not show themselves until considerably later.' ' — Laryngeal Phthisis, p. 93. These cases he classified as "primary laryngeal." A somewhat parallel case, classed as primary laryn- geal tuberculosis, in which a child of four and a half years, dead of tuberculous meningitis, was found to have a laryngeal ulcer containing bacilli, is recorded by Demme. From a purely practical standpoint, thai is from a PEIMAKY AND SECONDARY INFECTION. 45 prognostic and therapeutic point of view, a tuberculous lesion of the larynx may be considered primary when there is no demonstrable evidence of pulmonary or other organic involvement, but while theoretical con- siderations point to the possibility, and even the proba- bility of such an occurrence (for there is no special peculiarity of the laryngeal mucosa or secretions to prevent it from becoming infected) we have as yet no indisputable evidence to establish it as an abstract fact. EESUME. 1. The absence of pulmonary disease alone does not establish the primary nature of tuberculous laryngeal disease. 2. Lymphatic involvement, especially of the tonsils and cervical glands, must likewise be excluded. 3. The tonsils are tuberculous in perhaps five per cent of the cases in which hypertrophy exists. 4. It is found in the normal-sized tonsils as well as in the hyperplastic. 5. The dependence of some laryngeal cases upon disease of the tonsils and cervical glands has been clinically demonstrated. 6. Infection of the lymphatics usually follows in the direction of the lymph current, but may spread in a direction opposite, or vertical to it. 7. It may also travel through the tissue spaces. 8. But a few cases are recorded, substantiated by post-mortem investigations, in which, with lesions of the larynx the lungs have been found normal, and in these instances no reference is made to the condition of the lymphatic system. 46 LARYNGEAL TUBERCULOSIS. 9. There is no inherent peculiarity of the laryngeal mucosa or its secretions to prevent it from becoming primarily infected. 10. This occurrence, however, has not been demon- strated, despite the fact that phthisis is the most com- mon and widespread of all serious laryngeal diseases. 11. From a practical standpoint, a case may be considered primary if there is no demonstrable disease of the lungs. 12. Until a case of laryngeal phthisis, unaccom- panied by either pulmonary or lymphatic disease, has been proven, the assumption of primary infection can- not be maintained. CHAPTEE III. ENDOGENETIC AND EXOGENETIC INFECTION. While the usual and probably sole form of laryngeal phthisis has been shown to be the secondary one, opin- ions as to whether infection can be attributed to the direct effect of bacilli-laden sputa or to hematoge- nous and lymphatic deposit, diverge as widely as upon the primary question. The majority of morbid anato- mists look upon sputal infection as the predominant cause, while the clinicians, with few exceptions, con- sider the blood and lymphatic vessels to be largely re- sponsible. Neither school claims that the cause advo- cated by it is the exclusive one and thus it becomes a question of determining which factor is active in the greater number of instances. The entire domain of laryngology presents no problem of greater complex- ity, for almost every fact adduced in favor of one or the other theory is subject to various interpretations. In support of the theory of infection by hematogen- ous or lymphatic deposit we have the fact that the laryngeal process is usually most marked upon the side where the pulmonary disease is farthest advanced, or in unilateral pulmonary involvement, the laryngeal 48 LARYNGEAL TUBERCULOSIS. infection is in the majority of instances npon the cor- responding side. Many observers, however, have de- nied this localization, thus Jurasz (Krankheiten der oberen Luftwege) found only 7.9 per cent of 378 cases which were unilateral and corresponding. Walsham (Channels of Infection in Tuberculosis) denies the frequent occurrence of lateralization, and Magenau (Archiv. fur Laryngologie, Bd. IX, 1899) in 400 cases, found but 85 that were unilateral, and of these only 26, or 40 per cent, corresponded to the in- volved lung. On the other side there is the authority of such ob- servers as Schrotter, Schech, Friedreich, Shaffer and Krieg. Krieg (Archiv. fur Laryngologie, Bd. VIII, 1898) in 700 cases, found that in 275 the disease was unilat- eral, and in 252 of these, or 91.6 per cent, the pulmon- ary and laryngeal lesions were upon corresponding sides. In 114 cases at the Agnes Memorial Sanatorium, there were 31 of unilateral laryngeal involvement, and of these 22, or 70 per cent, corresponded to the side of greater pulmonary involvement. The author, in 904 cases, met with the following: Laryngeal lesions unilateral in 203 cases, of which 139, or 68.4 per cent, corresponded to the pulmonary disease. In 207 additional cases the greater involvement was upon that side where the pulmonary process was most advanced. To offset this strong evidence of endogenetic infec- ENDOGENETIC AND EXOGENETIC INFECTION. 49 lion, two explanations have been offered as to its probable cause: (1) As the primary symptom of a developing tuber- culous laryngitis, before other demonstrable laryngeal or pulmonary symptoms have developed, there has oc- casionally been observed a unilateral paresis of the cords with intermittent hoarseness. This has been followed by other signs of local infection and finally by the appearance of pulmonary symptoms. SchafTer reports having fond this paresis, after long observation and careful search, in 74 of 110 cases, a percentage of 67. The phenomenon has been ex- plained by the assumption of incipient tubercles of the apex, not clinically demonstrable, pressing upon the recurrent nerve or to like action upon the part of en- larged bronchial and tracheal glands. E. Frankel (Virch. Arch., LXXI, p. 261) attributes it in some cases to atrophy of the muscular fibres, with waxy or fatty degeneration. In some instances it may be due to an inflammatory process in the nerves them- selves, the so-called "tubercular pseudo-neuroma." The paretic condition results in loss of tone in the corresponding half of the larynx, resultant stagnation of the secretions and increased susceptibility on the part of the mucosa to infection by the sputum. While this cause may be active in a small proportion of the cases it does not occur with sufficient frequency to invalidate the claim of an endogenetic source in the majority of instances, for apart from SchafTer, few laryngologists have witnessed it save as a rare phe- nomenon. The author has seen it in less than five per 50 LARYNGEAL TUBEECULOSIS. cent of his cases in which unilateral involvement of corresponding sides developed. (2) It has been assumed that the entire side of the body upon which the lung infection originates is con- stitutionally predisposed and weakened, and that there- fore the corresponding side of the larynx is first invaded. The histologic findings have generally been inter- preted as proving infection from within, i. e., by way of the blood or lymph vessels. The first macroscopic alterations in cases of laryn- geal tuberculosis are points of more or less circum- scribed swelling covered by healthy mucous membrane. Histologically these swellings are found to be subepi- thelial tubercles, the epithelium itself and an interven- ing zone of varying thickness remaining entirely normal. The distribution of the bacilli corresponds closely to the arrangement of the infiltrated tissues, decreasing in number from within out and entirely disappearing as the epithelial layer is reached. The subepithelial distribution of the tubercles and bacilli, while strong corroborative evidence of endo- genetic infection cannot be accepted as conclusive proof, for it has been experimentally proven that the bacilli can penetrate normal mucous membranes and even lymph glands without leaving trace of their en- trance or passage. The bacilli, having reached the subepithelial layers, would naturally multiply with great rapidity and thus lead to the conclusion that they had been deposited from within, as was done by Korkunoff (D. Arch. f. ENDOGENETIC AND EXOGENETIC INFECTION". 51 Klin. Med., Bd. XLV) Heinze (KehlkopfscliivindsucM, Leipzig) and others. Various feeding experiments in animals have shown that the bacilli may penetrate the walls of the gut, and even the skin does not offer an impenetrable barrier for its inunction with infected sputum has been fol- lowed by various tuberculous changes. Jonathan Wright, of Brooklyn, in a drawing of a section, has shown in clearest manner the passage of bacilli through the intact epithelium. The subepithelial distribution of the tubercle bacilli, according to E. Frankel, is not typical. In an exami- nation of sixteen tuberculous larynges he found as many bacilli upon the epithelial surface as within the center of the ulcer, and from this argued invasion by way of the epithelium. The majority of his observations were made upon ulcerative cases and therefore have little weight, for they concern those cases either admittedly due to con- tact infection — the so-called "arrosion" ulcers — or subepithelial tubercles that through growth and degen- eration have destroyed the epithelial layers with su- perficial spreading of the bacilli. Moreover, of eighteen cases examined, fourteen show- ed streptococci and staphylococci, and he states that he invariably " found tubercle bacilli in deeper layers of the tissue than the pyogenic germs," showing con- clusively, despite his former negation, that the tubercle bacilli are found chiefly below the epithelial surface. The strongest proofs concerning the infective role of the sputum are afforded by two well-known phe- nomena ; the localization of the infected areas and the 52 LARYNGEAL TUBERCULOSIS. occurrence of the so-called "arrosion," corrosion, or diphtheritic ulcers. (1) The fact is easily demonstrable that the seg- ments of the larynx most commonly affected are those most subject to irritation by the passing secretions. The following table shows the comparative frequency with which the various areas are involved, although some slight discrepancies will be noted in the reports of the different observers : Gaul Mackenzie Lake Lockard Phipps Inst. Total Vocal Cords 53 230 221 450 43 997 Posterior Wall 36 196 174 640 35 1,081 Arytenoid Cartilages 17 449 168 270 36 940 Ventricular Bands.. 5 113 176 169 22 485 Epiglottis 27 186 82 127 14 436 Subglottic Space... 2 ... 38 15 .. 55 Total 140 1,174 859 1,671 150 3,994 From this large series of cases it is seen that the regions most frequently involved are the vocal cords, the posterior wall and the arytenoid cartilages. The vocal cords, owing to their exposed position and to the absence of ciliated epithelium, are almost con- stantly bathed with the tenacious pulmonary secre- tions, while the points at which the sputum meets the most resistance during expulsion are the arytenoid commissure, the posterior insertion of the cords and the inner surfaces of the arytenoid cartilages. As a general rule it may be said that infection occurs proportionately to the exposed position of the parts, but we meet with a striking exception in the case of the epiglottis. In a total of 3,994 lesions, but 436 occurred upon the epiglottis and yet no segment of the larynx is more ENDOGENETIC AND EXOGENETIC INFECTION. 53 exposed to insult by the passing secretions, or more prone to destrnction when invaded. Several strong objections to accepting this localiza- tion as a proof of spntal infection may be advanced : Cases of laryngeal tuberculosis are frequently seen in which the lung lesion is either quiescent or incipient, with little or no sputum and therefore practically no chance of contact infection; and conversely, many cases of advanced phthisis run their lethal course at- tended by colossal secretions rich in bacilli without the slightest sign of laryngeal involvement, even when local predisposition, points of locus minoris resist en- tiae, exist. A third objection is noted in the fact that those por- tions of the larynx that are covered by squamous epi- thelium are especially subject to attack, and yet corre- sponding parts of the pharynx, the deep posterior and lateral walls, are rarely involved. These immune sec- tions are natural reservoirs in which the sputum is collected and retained for much longer periods than is the case with the larynx, where reflex cough is soon called into play to aid in its expulsion.. The pharyngeal immunity may possibly be due to the fact that it is kept in a state of almost constant ex- citation through the passage of food and mucus, and that therefore the bacilli find little chance of lodge- ment, although at night these disadvantages are re- moved and the pharynx is as much at rest as the lower segments. (2) Arrosion Ulcers. The chief support afforded the followers of the exo- genetic hypothesis is furnished by the occurrence of 54 LARYNGEAL. TUBEBCULOSIS. the so-called "arrosion" ulcers, due undoubtedly to the action of the secretions upon a normal or abraded mucosa, resulting in local necrosis and, as a general thing, subsequent infection by the tubercle bacillus. The clearest exposition of this view has been given by Orth (Lehrbuch der spec. path. Anat.) who writes: "When we have to deal with a typical case, where, perhaps, there is only a large ulcerated cavity in one apex; where all the bronchi through which the secre- tions from this cavity must pass during expectoration are full of tubercular ulcers; where we find smaller ulcers only on that side of the main bronchus and lower portion of the trachea, which, from the position of the body, must come into contact with the secretion, and the ulcers are found to increase in size and frequency as we ascend; where, omitting a part of the trachea, the tubercular affection is seen to be more extensive wherever the walls of the air passages are approxi- mated and the sputum is therefore forced against the sides, — the conclusion seems inevitable that the spu- tum constitutes the vehicle by which the tubercular toxin is conveyed from the cavity and deposited during its transit through the air passages on favorable re- gions of the mucous membranes." That infection does occur in this manner must be admitted, but as the ulcers resulting from this form of infection are relatively rare and essentially different both anatomically and clinically from the true tuberculous ulcer, which is due to the sloughing of the superficial membranes through the pressure of the con- stantly increasing subepithelial tubercles, their occur- rence cannot militate against the theory of usual in fee- ENDOGENETIC AND EXOGENETIC INFECTION. 55 tiontion from within. The arrosion ulcers are not the result of infiltration but are due to the degeneration of superficial miliary tubercles. They are always su- perficial, have a decided tendency to spread and fail to show, upon the floor and about the edges, the characteristic granulations of the typical ulcers. The base is commonly covered by a thick, yellowish exudate that frequently forms a true fibrinous mem- brane elevated above the surrounding parts, hence the older name of diphtheritic, or aphthous ulcers. They are to be looked upon as a specific manifesta- tion of the tuberculous process, due to contact infec- tion, and while practically always tuberculous, they may in occasional instances be purely catarrhal. That is, in the larynges of tuberculous patients we sometimes meet with small points of necrosis due to irritation by the sputum and cough, — the same as we sometimes have small corrosion ulcers in the vagina or in pure catarrhal laryngitis, — but infection almost immediately follows, hence there is small opportunity for their observation. Against the theory of endogenetic infection it has been advanced that if invasion occurred through these channels, the entire region supplied by the vessel or vessels in fault would be equally exposed to danger, instead of isolated parts thereof. Such a conclusion is unwarranted; the spots where the sputum impinges and those most irritated by cough or physiologic move- ments, are necessarily points of lowered resistance, and as some previous weakening of the tissue resist- ance is essential to the development of tuberculous changes, no matter in what way the toxin is conveyed, 56 LARYNGEAL TUBERCULOSIS. it is at these points that infection would follow even from a widely distributed lymphatic or hematogenous deposit. According to Cornet the assumption of a predisposi- tion does not help the case, for he claims the more favored areas lose their apparent immunity as soon as a focus develops in their immediate neighbor- hood, so that they then become as liable to invasion and as little resistant to destruction when involved, as the more predisposed areas. Although he denies that local predisposition of the larynx exists, he explains the infrequency of pharyn- geal infection, in those parts unduly exposed to sputal irritation, by the assumption of some inherent property of self-defense. Auto-infection is occasionally observable, particu- larly in the case of ulcers upon the edges of the cords, and supports, in very small measure, the theory of spu- tal infection. As a final argument in favor of lymphatic transmis- sion we may advance the infrequency of primary laryngeal infection. It has been shown that in no case of tuberculous laryngitis so far studied has there been proven an ab- sence of foci in the glands, even when the lungs were entirely free of disease. If infection occurred generally by contact, through the bacilli entering the tissues by way of gland ducts and intact epithelium, is it not reasonable to suppose, in view of the ubiquity of the bacillus, that primary laryngeal infection worild be more frequently observed? Moreover, the larynx offers an exceptionally favorable point of attack. ENDOGENETIC AND EXOGENETIC INFECTION. 57 because in a large percentage of people some catarrhal inflammation, leading to points of locus minoris resis- tentiae, exists. The connection between laryngeal and lymphatic dis- ease in some cases has been established, and not alone of the cervical glands and tonsils but of the bronchial glands as well. Careful consideration of all these conflicting theories which cannot be fully reconciled, permits of no other deduction than that both agencies are at fault, but that the more common route of infection is that of the blood and lymph vessels, while the role of the sputum is a not infrequent but somewhat subsidiary one. CHAPTEE IV. PREDISPOSING CAUSES. FREQUENCY. Statistics bearing upon the frequency with which laryngeal phthisis occurs in consumptives vary to a striking degree : Pulmonary Laryngeal Cases Kruse 742 Gaul 424 Eichorst (autopsies) 462 Heinze (autopsies) 1,226 De Lamallerie 502 Willigk Not given Buhl Krieg Frey Frommel Mackenzie Lublinski Schaffer Lake, Mackenzie & Magenau . . . 1,189 volvement Percentage 123 16.6 113 25.7 130 28.1 376 30.6 222 44.2 Not given 13.8 15.5 26.0 26.1 40.0 33.7 60.0 97.0 373 30.18 34.54% Thus the average of fourteen reports from various sections of the world is 34.5 per cent, which may be accepted as a fair estimate, although the inclusion of incipient cases through the medium of systematic ex- PBEDISrOSING CAUSES. 59 animations of all phthisical subjects, without awaiting the development of symptoms referable to the throat, would without question materially increase this per- centage. A lamentable tendency to neglect routine laryngoscopic examinations exists even in many of the most up-to-date sanatoria, thus accounting in large measure for the popular misconception which regards laryngitis as a relatively uncommon complication. The lowest percentage recorded is by Maurice Per- rin (Rev. foebd. de Laryngologie, d'Otologie, 1902) who in 325 cases of pulmonary tuberculosis found but 1.2 per cent with laryngeal involvement. The majority of the sanatoria refuse to admit patients with advanced laryngeal lesions and in consequence the percentage of these cases, based upon such records, is often artificially low. Kidd (Albutt's. ''System of Medicine") finds that 50 per cent of all cases dying of phthisis show, upon post-mortem, some tuberculous changes in the larynx. AGE. The age of the individual exercises a strong determi- ning influence, and a study of the statistics shows that it is most common between the twentieth and fortieth years. Moritz Schmidt finds that two-thirds of all the cases occur between the ages of twenty and forty. Schrotter places the average age at thirty; Kruse from twenty to thirty; Jurasz, thirty to forty, and Heinze and Mackenzie from twenty to thirty. In the author's cases the average has tended toward the lower limit of the above period, but some allow- 60 LAEYNGEAL TUBERCULOSIS. ance must be made in considering this series, owing to the fact that it includes many cases from the Y. M. C. A. Health Farm, where most of the patients are young men in the early twenties. The tendency of the disease to attack people between their twentieth and fortieth years is shown in the following analysis of 2,469 cases : AUTHORITY • Agnes Memorial Mae- Age Sanatorium kenzie Magenau Lake Author Total 1-10 * 1 3 2 6 11-20 6 35 24 100 131 296 21-30 82 194 139 252 465 1,132 31-40 33 162 141 165 203 704 41-50 11 82 67 64 71 295 51 and upwards.. 1 27 28 21 32 109 Totals 133 500 400 605 904 2,542 *Not admitted under 16 years. A table by Lake shows how the proportion of con- sumptives attacked by tuberculous laryngitis increases up to this age period and then steadily declines : Pulmonary Laryngeal Percentage of Age Phthisis Ulceration Laryngeal Cases Under 1 year 13 1 7.7 1-10 39 4 10.25 11-20 92 23 25.0 21-30 406 130 32.0 31-40 303 112 36.96 41-50 179 67 37.43 51-60 104 27 25.96 61-70 53 9 17.17 Wide extremes are occasionally met: Santvoord saw undoubted tuberculosis in the larynx of a child of 31 months, Schmidt in one of twelve months, and Rhein- dorfT (Ueb. Kehlkopftiibcrcul. i. Kindesalter, i. Anschl. a. e. Fall v. Pseudo paralyse u. Tub erculose,, Diss., Wurzburg, 1891) a case of combined tuberculosis and syphilis in a child of 13 months. PREDISPOSING CAUSES. 61 I have seen one fatal case in a child of sixteen months. J. Solis Cohen (American Journal of the Medical Sciences, January, 1883) reports a case of miliary tu- bercles in a child of seven years. Heinze places the percentage of laryngeal involve- ments occurring in infants at from two to three, and Frobelius at from two to four per cent. Schech has seen but one case under ten years of age. Tuberculous laryngitis in children under ten years is clinically rare although it is undoubtedly more com- mon than statistics indicate. This is due in large mea- sure to the general impracticability of conducting thorough laryngoscopic examinations in the very young and hence the overlooking of many incipient cases. The comparative immunity enjoyed by children may be credited in part to the fact that pulmonary consump- tion runs a rapid course in the young, and that a fatal termination ensues before there is time for, or a likeli- hood of general infection, and to the additional safe- guard of an absence of preceding laryngeal disease. The condition is rarely met with in those of advanced age but few cases having been seen after the seven- tieth year. The oldest of whom I have record origi- nated in the seventy-fourth year. This case recovered. Hardie (Laryngoscope, July, 1905) reports a case in a man of 76, with ulceration of the epiglottis and poste- rior wall. SEX. The following table shows the relative frequency with which the two sexes are affected : 62 LAKYNGEAL TUBERCULOSIS. PROPORTION Author No. of Cases Males Females Mackenzie 500 2.7 1 Schmidt 2,156 2.45 1 Heinze 376 1.5 1 Kruse 3.7 1 Jurasz 3.0 1 Rosenberg 2.4 1 Lublinski ... 2.3 1 Magenau 400 2.17 1 Lake 667 2.44 1 Bezold 2.62 1 Phipps Institute 67 2.0 1 Agnes Memorial Sanatorium 133 1.29 1 Author 904 1.6 1 Average 2 . 09 1 The disparity in the proportion of the two sexes has been much less in my series than in the others reported, excepting that of the Agnes Memorial Sanatorium, and this despite the fact that cases have been inclnded from one institution limited to male patients. OCCUPATION. A direct connection between this greater suscepti- bility on the part of the male and the greater aver- age unhealthfulness of his surroundings and habits can be seen in considering the role of occupations as a causative factor. The avocations of 1,280 patients with laryngeal tu- berculosis are shown in the following table : 1. Voice users (actors, singers, elocutionists, huck- sters, fakirs, etc.) 71 2. Open air occupations (cabmen, carmen, solicit- ors, collectors, etc.) 101 3. Laborers and porters 64 4. Clerks, accountants, shop assistants, stenograph- ers, etc 196 5. Painters 32 6. Students 81 7. Traveling salesmen 40 8. Saloon-keepers, etc 21 9. Artists (painters, photographers, etc.) 14 PREDISPOSING CAUSES. 63 10. Housewives (laundresses, servants, etc ) 203 11. Physicians, dentists and nurses " 58 12. Dusty occupations (bakers, farriers stone-cut- ters, etc.) ' 86 13. Sedentary occupations (tailors, ' ' shoemakers dressmakers, etc.) 72 14. Machinists, engineers [][[ §% 15. Merchants, lawyers, bankers, etc . '. . . .... ] [ . .' ... 81 16. Farmers 49 17. Musicians — wind instruments ' ' .' 12 19. No occupations \\' m 37 1,280 Lake's table, showing the occupations of 200 patients with laryngeal tuberculosis, compared with 200 con- secutive cases of phthisis admitted in each of the years 1898 and 1899 to the Mount Vernon Hospital for Con- sumption, follows: FIRST 200 CASES Laryngeal — In Years — Occupation Cases (200) 1898 1S99 1. Dusty occupations (bakers, far- riers, etc 50 55 59 2. Sedentary occupations (tailors, shoemakers, etc 17 21 15 3. Clerks , 15 6 9 4. Shop-assistants 12 9 9 5. W|aiters 8 5 9 6. Housewives, servants and laun- dresses 31 43 51 7. Voice users (actors, singers, etc.) 7 2 6 8. Painters 11 12 7 9. Laborers and porters 26 25 6 10. Open air occupations (cabmen, carmen, etc.) 11 9 18 11. Healthy occupations 12 13 11 While those occupations which are particularly un- healthful show a large percentage of cases with laryn- geal involvement, maintaining a relative correspond- ence to the cases of pulmonary phthisis in the same occupations, it cannot be shown, despite common belief to the contrary, that avocations demanding great vocal strain under unhygienic surroundings, i. e., vaudeville 64 LARYNGEAL TUBERCULOSIS. artists, singers, fakirs, etc., show an unusual percent- age, at least in excess of that shown by others living under the same conditions but not forced to undergo particular vocal effort. As practically all singers and fakirs of this class suffer from chronic laryngitis it would tend to the belief that this condition, so com- monly considered a precursor of tuberculosis, can have but slight determining effect. Living under the unhygienic conditions of the tene- ments, etc., does not seem to exert the same deleterious influence that it does upon lung infection, for throat in- volvements are found as frequently in people from the farms and rural communities as from the tenements and congested areas of the cities. If tuberculous laryngitis occurred as a primary man- ifestation of the disease, we would expect to find a large proportion of the cases from those avocations en- tailing undue exposure to contagion, independent of the number of pulmonary cases. TOBACCO AND ALCOHOL. Tobacco and alcohol can be at fault in favoring in- fection only in so far as they are responsible for con- stitutional and local lessening of tissue resistance. In moderation they exert no appreciable influence, and statistics do not show an increased percentage even in excessive indulgers. PREVIOUS LOCAL DISEASE. Some sort of previous disease or abnormal condition of the laryngeal tissues affected is common, if not in* variably essential. PKEDISPOSIN G CAUSES. 65 Woodhead, in his lecture before the Henry Phipps Institute in 1905, said: "The bacillus must make it way not merely onto a free surface, but into the tissues of the body, before it can do any harm ; nay, more, it seems that, in the hu- man body at any rate, the tissues must be damaged or weakened and a special mode of entrance into these damaged tissues must be prepared for the tubercle bacillus before it can work its dire effects. "From my experiments on animals I am satisfied, as are all experimenters, that tuberculosis is never pro- duced without the presence of the tubercle bacillus, but unless the tissues are weakened or dam- aged, i. e., the soil is prepared, there can be no reaction between the bacillus and the tissues which can end in the production of a tuberculous lesion." One of the most frequent of these causes of impaired resistance is syphillis. An active lesion is not essen- tial although the secondary infection of such by the tubercle bacillus is frequently observed, but old lesions presumably cured may be as pernicious as the more recent, in that the parts are so weakened as to be sus- ceptible to insults normally impotent. ACUTE LARYNGITIS. Acute laryngitis in the phthisical rarely induces the accession of local tuberculosis if the attack be promptly combatted, but neglected attacks or frequent seizures may, under fortuitous conditions, lead to infection or, in healed lesions, to a recurrence. CHRONIC LARYNGITIS. In a considerable percentage of cases of laryngeal 66 LAEYNGEAL TUBEKCULOSIS. phthisis chronic laryngitis exists to a certain degree, independent of, or in connection with pharyngitis and obstrnctive lesions of the nose. How much influence this chronic inflammation has npon the subsequent development of laryngeal tuberculosis it is impossible to say. Personally, I have been unable to establish any direct etiologic relationship and, as considered in the dis- cussion of occupations, it is impossible to show that those avocations leading to chronic catarrh show an unduly large proportion of cases of laryngeal phthisis. NATIONALITY. All races show an almost equal susceptibility. It has been claimed by some observers, i. e., Norman Bridge (Tuberculosis, p. 75, 1903) that: "Nationality has some influence on susceptibility in tuberculosis. The Jewish people have very little of it." The fallacy of this is readily shown. Of the last 100 cases occurring in the author's practice, 24 were Jews, practically 25 per cent, and these did not include cases resident in the National Jewish Hospital for Consump- tives, or the Jewish Consumptives ' Eelief Society, where there are at all times from fifteen to forty laryn- geal cases in a total of some one hundred and fifty patients. PHYSICAL CHARACTERISTICS. Certain peculiarities of physique and temperament have been advanced as likely causes of predisposition, but as yet they are little more than theoretical conjec- tures. PKEDISPOSING CAUSES. 67 Thost claims to have observed a greater suscepti- bility on the part of individuals of a tall, slender habit, with long throats and deep voices. I have been unable to find any verification of this. PREGNANCY. Child-bearing in consumptives may be the cause of a tuberculous invasion of the larynx through a lighting up of the general process with disseminated infections, or it may lead to the rapid progression of an already existent focus. The strong influence of the parturient state will be seen in the discussion of prognosis. In conclusion it may be stated as axiomatic that any condition either local or constitutional, leading to im- paired vitality of the larynx, renders it more suscept- ible to invasion by the tubercle bacillus and less resist- ant to attack when invaded. CHAPTER V. PATHOLOGY. Two groups of phenomena, general and local, follow the advent of tubercle bacilli into the tissues. The general manifestations, fever, tissue waste, etc., due to the absorption of soluble proteins, belong to the domain of general tuberculosis rather than to a study of the disease as manifest in the larynx. The local effects are likewise of a dual nature; those consequent upon the action of the bacillus as a simple corpus alienum, and those dependent upon its metabolic products and its proteins. As a corpus alienum, the bacillus produces changes of a purely inflammatory na- ture, in large measure of a productive type. The pro- teins and metabolic products, on the other hand, are responsible for the exudative processes, but in practice it is impossible to differentiate these actions or agen- cies in considering the tissue changes, for their action is concurrent. The primary deposit of the bacilli in the larynx, no matter through what channel they may have passed (intact epithelium, erosions, gland ducts, blood or lym- phatic vessels) occurs in the sub-epithelial layers of the mucosa and in the sub-nmcosa and here their first PATHOLOGY. 69 effects are produced, usually about the blood vessels and glandular acini. One of four forms of the disease may be provoked : infiltration, ulceration, tuberculoma, or miliary tubercle. Of these the infiltration and tuberculoma may exist as isolated processes, but the ulcer and miliary tubercle are always preceded and accompanied by other tuber- culous conditions. The Infiltrate : — Pathological and anatomical inves- tigations, as well as clinical observation, establish the fact that every typical tuberculous infection of the larynx begins as an infiltration. Clinically the picture varies with the anatomic peculiarities of the parts in- volved as well as with the extent of the process, the degree of swelling depending upon the thickness of the submucosa and its relations to the deeper laryngeal structures. In the aryepiglottidean folds, the interary- tenoid sulcus and upon the arytenoid cartilages the infiltrate may attain large proportions; on the vocal cords, the lingual surface of the epiglottis and the inner surface of the arytenoids, where there is a scantier supply of submucous tissue, the swelling is usually of moderate extent. The ventricular bands occupy a medium position; the enlargement as a rule is slight, although it may occasionally be sufficient to produce perfect approximation. Perichondritis is especially liable to occur in those localities where the mucosa is closely adherent to the cartilage, i. e., the epiglottis and arytenoids. Microscopically an infiltrated area shows the follow- ing structure : A normal epithelium, unless the process 70 LARYNGEAL TUBERCULOSIS. has advanced to the stage of ulceration or at those points beneath which there is a large aggregation of tubercles, and a subepithelial stratum thickened from two to four times the normal diameter by a de- posit of small mononuclear cells, each with a deeply staining nucleus and small protoplasmic body. The primary deposit of these cells usually takes place im- mediately above the glands, and they are embedded in Fig. 1. a fine or coarse network of connective tissue. Enclosed in this mass there are usually found numerous small and large nodules, or tubercles, the units of which this infiltrated mass is composed. (Fig. 1.) The Tubercle: As visible macroscopically, the tuber- cle is a translucent, pearl or grayish colored, spherical body, composed of a cluster of microscopic nodules, the PATHOLOGY. 71 whole forming a body that ranges in size from a mus- tard seed to a pea. Caseation destroys the translu- cent appearance and it then becomes opaque and yellow, or a dirty white in color. The first step in the formation of a tubercle is a proliferation of the endothelial cells of a blood vessel or lymphatic, from which there results a mass of epi- thelioid cells, so-called because of their resemblance to epithelial cells. Interspersed among these epithelioid cells are a num- ber of lymphoid cells, separated and enclosed by a sparse fibrillae. The formation within this mass of one or more giant cells completes the typical tubercle, — a rounded nodule, circumscribed and bloodless. The tubercle formation is most marked in the super- ficial layers of the mucous membranes, immediately be- neath and parallel with the epithelial layer; rarely it extends with even distribution throughout the entire thickness of the mucosa. In many instances there exists between the epithelial border and the superficial deposit of tubercles a zone of uninvaded tissue, rich in capillaries and containing a few round cells. It was this appearance that led Heinze and Korkunotf to the assumption that the ba- cilli must be deposited from within by way of the lym- phatic and blood vessels. The Giant Cell : — The giant cell is situated within the tubercle, and is often separated from the small round cells by a collection of large, nucleated, epithelioid cells. These small cells, in gradually decreasing numbers, in- filtrate both toward the interior and exterior. The giant cell itself, a globular body, is composed of 72 LARYNGEAL TUBERCULOSIS. a central mass of granular protoplasm showing some degeneration, and a number of nuclei arranged in a semi-lunar, circular or irregular form around the peri- phery but probably never in the center. The cell or cells — there may be one or several — occupy either the center or periphery of the tubercle. (Fig. 2.) Fig. 2 The giant cell is frequently found in conditions not tuberculous, i. e., many of the other infectious granu- lomata, in sarcomata, and in areas chronically irritated by foreign bodies. In the tubercle they may be very numerous or en- tirely absent. The number of tubercles likewise varies, depending PATHOLOGY. 7 o in large measure upon the tissue involved, and hence their absence, together with that of the giant cells, can- not entirely disprove the diagnosis of tuberculosis. For the same reason the presence of the giant cells alone cannot be taken as an absolute sign of tubercu- losis. Within the tubercle no blood vessels are seen; for a brief period they persist in the tissues between the individual tubercles but even here they soon disappear. At this stage of development the tubercle commonly undergoes one of two changes — degeneration or organi- zation. The center of the tubercle begins to show the same condition that has been noted as occurring in the center of the giant cell : the increase in size of the indi- vidual tubercle and the conglomeration of the various neighboring tubercles result in shutting off nutrition from the center of the mass, with its consequent de- struction, or caseous degeneration. To this effect the toxic properties of the bacilli con- tribute. In the course of time this cheesy material liquifies, extends to the surface, breaks through the superficial layers and forms an ulcer. In the lungs this fluid material, after undergoing certain chemical changes, may unite with the lime salts that are dis- solved in the blood and are present in the liquid mass, and form calcareous deposits. In the larynx, however, this calcareous degeneration has never been observed. Organization, or fibrous transformation, however, is not rare, and is the method by which the process be- comes circumscribed. The areas involved are slowly converted into scar tissue, i. e., fibrous transformation, 74 LARYNGEAL TUBERCULOSIS. with encapsulation of the bacilli. If the bacilli are de- stroyed the disease is cured, otherwise the word arrest is to be employed. So long as these encapsulated areas, enclosing living bacilli, remain intact, the condition continues quiescent, but subsequent traumatism, through whatever media, may lead to destruction of the protecting wall with breaking down of the old foci or invasion of new areas. Ee-attacks are, therefore, as a rule more severe and harder to combat than the primary. The Bacilli : — The bacilli in their distribution usually correspond closely to the arrangement of the infiltrated tissues ; they are numerous in the deeper layers, more sparsely distributed as the superficial layers are reached and usually entirely absent in the epithelial layer. In the early stage of tubercle evolution the bacilli lie between the epithelioid cells and in the tis- sues, but later they are situated to a large extent within the cells and especially within the giant cells. In sections of involved tissue removed endolaryn- geally, the bacilli are difficult to demonstrate and rarely more than one or two are to be found even upon pro- longed research. The Ulcer: — The transformation of an infiltrate into an ulcer is due to the caseation of one or more subepi- thelial tubercles. The tubercles from their primary localization in the submucous tissues extend gradually toward the surface until the epithelial layer is com- pletely detached and destroyed, and the ulcer thus formed enlarges through a continuation of the degener- PATHOLOGY. iO ative process in the individual tubercles, and the coa- lescense of neighboring ones. (Fig. 3.) The nature and extent of the individual ulcer de- pend upon the character and location of the preceeding infiltration. In the beginning it is always superficial unless it has its origin in an infiltrate that involves the glands or glandular layer, in which case it forms a crater-shaped depression with prominent edges, and "■**, • -•■ oStJ f • Fig. 3. may extend to and involve the perichondrium and carti- lage. The variety not situated immediately above the gland- ular layer is superficial and extends very slowly toward the deeper structures; it has an indefinite border line, irregular, flat or but slightly elevated, and its base is covered by a yellowish exudate through which appear numerous small granulations. If the infiltrate has been 76 LARYNGEAL TUBERCULOSIS. extensive the resultant nicer is generally large and shal- low, but if the original deposit was circumscribed and minute, the ulcer is a mere pinhead spot of necrosis. In all forms of the tuberculous ulcer resulting from infiltration there is present as a typical feature the granulations which cover the base and surround the edges. Occasionally these become exuberant to a de- gree sufficient to closely resemble papillomata, and almost completely hide the ulcer and fill the glottis. The "arrosion" or contact ulcers have different char- acteristics. They are always flat and superficial; they spread rapidly along the surface of the mucosa and have little if any granulation tissue, a marked charac- teristic of the true ulcer. The exudate which covers the base is thick, tenacious, yellow in color, and some- times slightly elevated above the level of the surround- ing parts. Taberculomata: — The tuberculous tumor is one of the rarest manifestations of the disease, but it is impos- sible to estimate its comparative frequency owing to the fact that there is as yet no strict understanding as to the type of cases to which the term tumor should be applied. The most satisfactory interpretation of the term is that of Schech (Handbuch der Laryngologie und Rh'ui- ologie, p. 1144), who understands it to include all tuber- culous growths resembling true tumors where the pre- vious existence of an ulcer upon the affected spot can be definitely excluded. Such growth are most commonly situated upon the posterior wall, in the ventriculns Morgagni and at the anterior commissure. In rarer instances they occur PATHOLOGY. 7 / upon the vocal cords the epiglottis and the ventricular bands. In size they vary from a pin's head to a hickory nut, and may appear singly or in clusters. Microscopically the tumor is composed of a number of nodules covered by a thickened pavement epithelium. The individual tubercles consist of numerous small round cells, giant cells and bacilli, and usually show some evidence of caseous degeneration. The Miliary Tubercle : — The miliary tubercle is rarely seen macro scopically in the larynx, but that the condition does occasionally occur and is clinically rec- ognizable can no longer be denied. Many cases so classed, however, are nothing more than minute granu- lations, obstructed gland ducts or epithelial abscesses. The miliary tubercle soon breaks down and ulcerates, but in its early stages it may be seen as an exceedingly minute, gray, yellow or whitish spot gathered in clus- ters over an infiltrated area or upon the base and around the edges of an ulcer. The Glands : — Two forms of glandular tuberculosis are recognized: the inter and intra-acinous. In the former there is a multiplication of cells in the connec- tive tissue occupying the spaces between the individual acini, causing their separation and compression, where- by the normal contour is completely destroyed. The intra-acinous involvement is characterized by a deposit of cells in the acini themselves, ending in complete obliteration. The Blood Vessels : — Cross section of the blood-ves- sels shows a pronounced zone of small round cells about the vessels, mostly outside the adventitia but also, to a 78 LARYNGEAL TUBERCULOSIS. small extent, invading it, causing an increase of the connective tissue. Unless the vessel is fully enclosed by a tubercle the muscular layer remains intact even when the adven- titia has been destroyed. Muscles : — Tubercles seldom invade the muscles but that this invasion does exceptionally occur has been demonstrated by Heinze, and Schech has shown their presence in the crico-arytenoideus posticus muscle in a case of tuberculous perichondritis of the cricoid carti- lage. Atrophy of the muscles with fatty and waxy degen- eration, due to systemic infection, may occur and pro- duce paralysis. As will be shown later this condition is sometimes accountable for aphonia in cases of pulmonary phthisis when the larynx is apparently free of disease. Nerves : — Neuritis and proliferation of the nerve filaments have been described by Dansac (Annales des Maladies de VOreille, December, 1893). To this condi- tion Gouguenheim gave the name "tubercular pseudoneuroma. ' ' A paralysis is not infrequently seen that may be traced to pressure upon the recurrent laryngeal nerve by enlarged bronchial glands, or in some instances, to the nerve being embedded in an adherent pleura at the apex. The Mucosa : — Congestion or anemia of the mucous membrane unaccompanied by other evidences of local disease, and frequently classed as tuberculous or pre- tuberculous catarrh or anemia, cannot with any his- tologic warrant, be so considered. They are to be PATHOLOGY. 79 classed as "catarrh" or "anemia" accompanying tu- berculosis. With the advance of infiltration the epithelium be- comes detached and finally ulcerates, but it remains un- affected in the initial stages, except in the case of ar- rosion ulcers where superficial necrosis is the primary change. Chondritis and Perichondritis : — Chondritis, neces- sarily associated with perichondritis, is a late mani- festation developing only when the tuberculous disease has extended to or in the immediate vicinity of the peri- chondrium. The cartilages of the larynx are not involved with equal frequency : those most often affected are the ary- tenoids; then in the order of frequency come the epi- glottis, the cricoid and the thyroid. The thyroid, howev- er, according to many observers, is most frequently in- volved "primarily," — that is, without demonstrable disease elsewhere. Mixed Infection: — In the ulcerations other bacteria are usually found, notably the Streptococci and Staphy- lococci, consequently most ulcers can be considered as depending upon mixed infection. The tubercle bacillus is the first cause, however, and is found in the deeper structures, while the Strepto- and Staphylococci are near or upon the surface. CHAPTER VI. SUBJECTIVE SYMPTOMS. Laryngeal phthisis is accompanied by symptoms so complex that a thoroughly comprehensive view can be obtained only by some such arbitrary classification as the following : (A.) Subjective symptoms. (B.) Objective symptoms. The subjective phenomena are subdivided into two groups : (C.) Symptoms peculiar to the lungs. (D.) Symptoms peculiar to the larynx, and those common to the lungs and larynx. The manifestations falling in the latter group (D.) are best considered under two heads : (1.) Symptoms due to systemic poisoning unas- sociated with local structural changes of a tuberculous nature. (2.) Symptoms dependent upon tuberculous cell proliferation in the laryngeal tissues. (C.) Symptoms peculiar to the lungs: Except in rare instances the laryngeal symptoms are antedated for variable periods by those dependent upon the lungs, and these do not immediately follow SUBJECTIVE SYMPTOMS. 81 infection; — a sufficient time must elapse in which the bacilli can produce the changes recognized as typical, and this original focus must either produce others or disintegrate with diffusion and absorption of the solu- ble proteins before constitutional symptoms can ap- pear. Unfortunately the nature of the process thus pre- cludes the appearance of any distinctive signs until the disease has become fairly well established. The primary symptoms are usually those of lowered vitality, evidenced by anemia, dyspepsia, loss of weight, appetite, strength, &c. Following — or in some cases primarily — there is cough, with or without ex- pectoration; fever, usually in the afternoon or even- ing with normal morning remissions ; huskiness of the voice or simple voice fatigue; night sweats; hemor- rhage ; pleuritic pains, &c. (D.) Symptoms peculiar to the larynx and those common to the lungs and larynx. (1.) Phenomena not dependent upon structural changes in the larynx: Certain alterations in the voice, ranging from simple fatigue after prolonged use to complete and lasting aphonia, are occasional symptoms of pulmonary tuber- culosis unaccompanied by recognizable laryngeal le- sions. Amblyphonia, or voice weaknesses the most frequent of these phenomena and is usually evidenced by a sense of laryngeal discomfort or fatigue after pro- longed reading or speaking. It is an expression of muscular weakness due to anemia or of a lessened 82 LARYNGEAL TUBERCULOSIS. expiratory power consequent upon the gradual elimina- tion of certain pulmonary segments. This last factor naturally becomes more pronounced in the late stages of the disease. The first and more important factor — muscular weakness — is active in any disease accompanied by rapid or pronounced exhaus- tion and is therefore not typical of tuberculosis. Voice fatigue may give way to hoarseness and this in turn be succeeded by aphonia, although there is no regular sequence such as that which usually obtains in true tuberculous laryngitis, for either the aphonia or hoarseness may be primary without any preceding changes. On the other hand the voice may retain its original strength and purity throughout the entire course of the disease, or in case of preceding altera- tions, may return to its normal state shortly before death. Either aphonia or amblyphonia may precede all other symptoms of the disease and thus direct atten- tion to the constitutional condition, although they usu- ally develop after the pulmonary process has become well established. In addition to the etiologic factors already men- tioned, muscular weakness and expiratory insufficiency, two other conditions must be taken into consideration : intralaryngeal changes of a non-tuberculous character and tuberculosis of contiguous or extralaryngeal structures. First among these causes is paralysis of the recur- rent laryngeal nerve, which by reason of its long course and varied relationships is especially subject to insult. SUBJECTIVE SYMPTOMS. 83 In considering the etiology it was shown that involve- ment of the bronchial glands occurs in nearly all cases of pulmonary phthisis and that in a considerable per- centage of all cases they are primarily affected. Paralysis is frequently due to the pressure of these nodules, or to like action upon the part of the tracheal glands which are situated along the course of the nerve between the trachea and esophagus. Pleuritic exudates and adhesions may likewise embed the nerves on either side. Landgraf, Dansac (Annates des Maladies de I 'Oreille, Dec, 1893) and others have described inflam- matory processes in the nerves with proliferation of the nerve filaments which result in paralysis. — the so- called "tubercular pseudo neuroma" of Gouguenheim. Dansac has found the condition in arytenoid swell- ings, and Landgraf noted a left recurrent paralysis in which post-mortem examination showed fatty degen- eration of both posterior crico-arytenoids, with de- struction of the medullary sheath and axis-cylinders of the left nerve. Although there was a small enlarged gland pressing upon the nerve under the arch of the aorta, he believed the degeneration to be the result of primary inflamma- tion of the neurilemma rather than of pressure. Atrophy of the laryngeal muscles with fatty or waxy degeneration, either isolated or in common with like changes in the muscles of other organs, has been de- scribed by E. Frankel (Lehrbuch d. path, gewebelehre,' 4th edit.) and may be accountable for certain cases of hoarseness. As previously shown, this de- 84 LARYNGEAL TUBERCULOSIS. generation is due to the systemic condition and not to local tuberculous infection. In nearly all cases of pulmonary phthisis there is more or less inflammation of the vocal cords caused by coughing and the constant passage of irritant sputum, with the formation of mucus threads stretching across the glottis from cord to cord, forming a mechanical hindrance to pure tone production and leading to slight, and usually intermittent, attacks of coughing and hoarseness. A rarer cause is the former occurence of bleeding or pleuritic attacks, leading to voluntary suppression through fear of pain or recurring hemorrhage. In addition to these manifestations certain other symptoms classed as paresthesias, may develop either concurrent with, or independent of the vocal phe- nomena. These sensations, notably those of retained foreign bodies, scratching, tickling and excessive dryness, are referred to either the larynx or pharynx and are prac- tically always provocative of spasmodic attacks of an explosive, or shallow, hacking cough, usually dry but occasionally accompanied by a small amount of frothy mucus. They are an expression of nerve perversion and lowered vitality. These symptoms, unaccompanied by local tubercu- lous disease, may disappear spontaneously or by rea- son of treatment, but usually persist and merge in- sensibly into the more obstinate symptoms originating in specific cell proliferation. The change is so gradual that it is usually impossible to determine the exact time of transition. SUBJECTIVE SYMPTOMS. 85 ' (2.) Symptoms due to specific cell proliferation in the laryngeal tissues : The advent of a true tuberculous infection is usually soon followed by one or more of a group of symptoms regarded as more or less characteristic, although cases are occasionally seen which progress to death without any momentous subjective manifestations. The character of the individual symptoms depends more upon the locale of the lesion than upon its type and extent. For example, in many cases of advanced and wide- spread extrinsic involvement the purity of tone re- mains almost unimpaired throughout the entire course of the disease, while on the other hand, moderate in- filtration of the inter arytenoid sulcus or arytenoid cartilages may lead to complete aphonia. Likewise with dysphagia : a small, shallow ulcer of the epiglottis or aryteno-epiglottidean folds sometimes produces se- vere and lasting pain, and yet widespread ulceration and infiltration of the vocal cords, interarytenoid sul- cus or ventricular bands rarely causes any dysphagia whatsoever. As a general rule it may be said that ex- trinsic lesions produce pain and that intrinsic involve- ment causes disturbances of phonation. VOICE ALTEBATIONS : The hoarseness of tuberculosis is produced by condi- tions as manifold as the variations in the voice itself. The typical tuberculous voice is weak, dull, muffled and inflexible, progressing gradually to complete aphonia. Usuallv it is less harsh and forcible than the raucous 86 LARYNGEAL TUBERCULOSIS. voice of syphilis, although at times it is impossible to distinguish between the two, for either may depart from the typical and assume the characteristics of the other. It is invariably produced by gross lesions of the cords, infiltrations and ulcerations producing an un- even edge; by inter-arytenoidal swellings, enlarged arytenoids, ankylosis of the crico-arytenoidal joints and extensive infiltrations of the ventricular bands. Small nodal thickenings on the cords frequently lead to the condition known as diplophonia : a voice gen- erally normal but occasionally broken by sudden changes in pitch. The same condition is met in syphil- itic laryngitis and in certain small tumor-like growths, i. e., singers' nodules, polypi, &c. Moderate infiltration of the cords unaccompanied by ulceration, and lesions leading to imperfect adduction, produce as a rule nothing more serious than slight muf- fling and premature fatigue. Large infiltrations of the ventricular bands interfere with tone production to as great an extent as involve- ment of the true cords. It is needless to explain why absolutely no inference can be drawn as to the extent or nature of the local lesions from the condition of the voice, although this is a common error of the medical profession as well as of the laity. In like manner we cannot conclude during the course of treatment, that because of progressive voice destruc- tion, the process is advancing, nor, per contra, because of a gradual improvement in phonation that the condi- tion is nearing arrest or undergoing gradual better- ment. SUBJECTIVE SYMPTOMS. 87 Complete cure may result with permanent hoarse- ness due to a distorted cord, or with a lasting aphonia consequent upon ankylosis or recurrent paralysis; on the other hand, the voice may be regained while lesions of other segments of the larynx, i. e., extrinsic, prog- ress and disintegrate. Occasionally an atypical case is met, in which there is aphonia with lesions presumably exerting no direct influence upon tone production, and in which the modus operandi cannot be satisfactorily explained. Cough : — Cough practically always accompanies tu- berculous laryngeal disease but some few cases escape any except that essential to the removal of sputum. In the early stages it is usually dry, hacking and of a paroxysmal and explosive type; with the advance of the infection it becomes looser and easier though more frequent. If ulcers are present, particularly of the epiglottis, either isolated or in combination with disease of the aryteno-epigiottidean folds, or if the posterior wall is widely infiltrated, each seizure is attended by severe pain causing efforts at suppression with consequent muffling. In any given case, no matter what the type of the lesion, it is impossible to form a just estimate as to the exact role played by the larynx for many elements con- tribute to the production of the phthisical cough. Naturally it is in large measure due to the lungs — and in so far as the expulsion of secretions is con- cerned, necessary. Consideration must likewise be given to such causes as the dropping of saliva or particles of food into the 88 LARYNGEAL TUBERCULOSIS. larynx, naso-pharyngeal or pharyngeal catarrh, simple laryngitis and pressure of the vagus. The "nasal," "stomach," and "nervous" coughs must also be taken into account. The nervous type of cough in particular plays a very important role in these cases. Granting the importance of these agencies we must still recognize the larynx itself as a not inconsiderable contributory factor. Certain segments, especially the inter-arytenoid sulcus, are highly sensitive and when diseased respond by outbursts of coughing to the slightest irritation. In phthisis this stimulation is given by previous attacks of coughing and the frequent passage of irritant secre- tions. Hypertrophy of the lingual glands, causing contact with the epiglottis, is a not uncommon cause of uncon- trollable coughing in many cases. These glands are enlarged to some extent in almost all old cases of pul- monary tuberculosis and in a considerable percentage they are themselves the seat of tuberculous changes. In this hypersensitive condition of the mucosa many things normally impotent become active irritants, i. e., inhalation of smoke and dust; immoderate use of the voice in speaking, singing or crying; sudden variations in temperature; cold air; strong winds; alcohol; to- bacco, &c. When granulations, irregular growths, rugous infil- trations or ulcers exist, the secretions cling tenaciously to their uneven surfaces and lead frequently to pro- longed attacks of coughing, so severe as to leave the patient completely exhausted and fighting for breath. SUBJECTIVE SYMPTOMS. 89 SECRETIONS. In the late stages of the disease the lungs pour into the already diseased larynx such colossal quantities of irritant secretions that the cough becomes almost inces- sant and adds much to the already intolerable condi- tions. The inflamed laryngeal mucosa itself excretes considerable mucus, but not sufficient to occasion any particular distress in its expulsion unless there is si- multaneous discharge from the lungs. With widespread ulceration there is produced a thin, dirty white, and occasionally bloody pus, mixed with mucus and dead epithelial cells, which has a peculiarly sour, penetrative odor. In cases of perichondrial abscesses the breath is foul and small fragments of cartilage may be found in the secretions. Small hemorrhages from ulcerated areas or exuber- ant granulations are sometimes noted but true bleed- ing almost never occurs from the larynx. I have seen but one such case, a young man with deep ulceration of the right ventricular band from which bleeding oc- curred on two separate occasions, the quantity each time amounting to between two and three drams. After thorough cleansing the blood could be seen exud- ing from the ulcerated area. '» FEVER. Laryngeal tuberculosis may cause considerable fever at times, as is shown by an increase of the daily range coincident with the breaking down of new areas or ex- tension of old lesions. A temperature of 100 to 101 degrees occasionally ac- 90 LAHYNGEAL TUBEKCULOSIS. companies acute cases where the pulmonary process has been for some time quiescent, but as a rule, unless the local process is associated with considerable acute inflammation, a comparatively rare condition, the tem- perature is not much affected by the laryngeal in- vasion. After endolaryngeal operations the tempera- ture rises from one to three degrees, then gradually re- cedes until it is again normal by the end of two or three, or occasionally four days. DYSPHAGIA. True dysphagia occurs, as a rule, only when the laryngeal condition is well advanced. In 904 personally observed cases of laryngeal phthi- sis, dysphagia occurred at some period of the disease in 247, or 27.32 per cent. The term dysphagia, as here used, includes all varie- ties — odynophagia or painful deglutition; dysphagia or obstructed swallowing, and the entrance of food and liquids into the larynx. The conditions practically always coexist and in large measure depend upon like pathologic conditions, hence the propriety of considering them under the com- mon appellation of dysphagia. The appearance of this symptom must always be considered ominous, both because it marks an extension of the process with probable involvement of the deeper, or more vulnerable structures, and because, unless promptly controlled, the consequent enforced reduction or withdrawal of food leads to rapid collapse. Dysphagia is an invariable consequence of all wide- spread involvements of the upper aperture of the SUBJECTIVE SYMPTOMS. 91 larynx, i. e., epiglottis and aryteno-epigiottidean folds. Moderate infiltrations, or small-sized ulcerations of the epiglottis and aryteno-epigiottidean folds may be unaccompanied by pain, but when either process is moderately advanced each act of swallowing is accom- plished at the expense of such excruciating and unbear- able suffering that starvation seems the lesser evil. Extensive infiltrations of the posterior wall or aryte- noid cartilages, and perichondritis or perichondrial abscesses, are almost as potent in the production of pain. In all such cases the passage of liquids is usually more difficult than the swallowing of solid and semi- liquid food. Involvements of the middle larynx, whether ulcera- tive or infiltrative, cause pain only in exceptional cases. Chordal lesions do not produce dysphagia and the ven- tricular bands are responsible only when the lesion is acute or widespread. Acute, lancinating pain nearly always characterizes the outbreak of miliary tubercles. In addition to the painful and difficult deglutition, there is frequently added a sharp, neuralgic-like pain in the ear of the corresponding side or in both ears in bilateral lesions, by transference through the auricular branch of the vagus. This aural pain occurs, at some period, in practically all dysphagic cases. In rarer instances the pain is referred to the sal- pingopharyngeal fold and palate. Eigidity of the muscles, particularly of the posterior wall and epiglottis, leading to imperfect closure during deglutition, permits both solids and liquids to enter the larynx with violent cough and laryngeal spasm. Actual destruction of tissue plays no role in this for 92 LARYNGEAL TUBERCULOSIS. deglutition can occur normally after complete removal or destruction of the epiglottis. The pain depends upon various causes : — when ul- cers exist it is due to the mechanical, thermic and chemical action of the passing food and secretions upon the exposed nerve endings, but in the absence of ulcera- tion it may be ascribed to rigidity, to pressure of the inflamed tissues and muscles, to neuritis and to peri- chondritis. Pain may likewise be caused by speaking or coughing through the movement produced in the af- fected tissues. Many patients also complain of a con- stant ache or soreness in the throat independent of any muscular action. Intimately associated with the various types of dys- phagia is a symptom almost totally overlooked in works on laryngeal phthisis, yet it is one that is responsible for extreme discomfort and annoyance : the regurgi- tation of fluid and solid food through the nose. In 247 cases of dysphagia, regurgitation occurred at some period of the disease in 198, over 80 per cent. Even when the pain is not severe, this factor if pro- nounced may necessitate, for the time being, the almost complete withdrawal of food. DYSPNEA. Shortness of breath is the rule in advanced cases of phthisis, but true dyspnea of a degree sufficient to occasion alarm, dependent upon intralaryngeal swell- ing, is the most uncommon of the special symptoms, and usually occurs only in those cases where treatment has been neglected or where an acute inflammation lias been superadded to the chronic process. SUBJECTIVE SYMPTOMS. 93 In any case sndden dyspnea may result, due to edema, abscess formation, perichondritis or paraly- sis of the abductors. The last cause is well exemplified by the following case: Miss S., aet 29, nurse, was first seen in April, 1904, when the larynx presented the following picture : both cords extensively ulcerated and infiltrated; ventricu- lar bands partially overlap the cords and are deeply ulcerated; right arytenoid edematous with a small ulcer on its inner surface. During the following nine months the condition rapidly improved and by January, 1905, there re- mained only moderate infiltration of the cords with fixation of the right cord in the median line. At this time she had an attack of pleurisy with a large effusion on the left side and it was not until several weeks later that she again appeared for examination. The larynx was unaltered and the breathing fairly easy, considering the medium fixation of the right cord and the labored heart action due to the large pleural effusion. The following day, while resting quietly, she was attacked by sudden dyspnea and examination re- vealed total bilateral abductor paralysis. Tracheot- omy was immediately performed but death ensued eleven hours later. No autopsy was held. Dyspnea of slow development, the essentially chronic type, may depend upon any one or more of a variety of conditions; a distorted or greatly infil- trated epiglottis; swelling of the aryteno-epiglotti- dean folds with simultaneous enlargement of the ary- 94 LARYNGEAL TUBERCULOSIS. tenoid cartilages ; bilateral infiltration of the ventricu- lar bands; ankylosis of the cricoarytenoids; abductor paralysis; subchordal swellings; excessive granula- tions and tuberculomata. The formation of cicatricial bands between the cords is a rare factor and in all likelihood depends upon the existence of a mixed lesion, syphilis and tuberculosis, for the latter disease alone rarely leads to the forma- tion of scar tissue to any considerable extent. Ordinarily the process does not advance to the point of complete closure; by the time the breathing has become labored the general disease has advanced so far that the patient succumbs, if not, endolaryngeal surgical and medicinal treatment will usually cause some retrogression. The cases in which tracheotomy is necessitated are exceedingly rare, and will become ever rarer as the infections are more universally recognized in the early stages and therefore are more rationally and persist- ently treated. CHAPTER VII. OBJECTIVE SYMPTOMS. Infiltration is the first objective sign of laryngeal phthisis. Nearly all observers speak of a tuberculous or pre-tuberculons catarrh as the first and therefore the mildest form of laryngitis, but the assumption of such a condition is entirely without warrant. CATARRH. Many cases of pulmonary phthisis show a more or less catarrhal condition of the laryngeal mucosa. This chronic congestion depends upon one or more of sev- eral factors; lowered vitality; cough; passage of spu- tum; disturbed digestion; naso-pharyngeal catarrh, etc.. Neither must it be forgotten that the unhygienic conditions which predispose the individual to pulmon- ary tuberculosis likewise predispose to chronic ca- tarrhal laryngitis. While the frequency of this early catarrh must be admitted, there is in fact no reason for assuming it to be tuberculous and even less for considering it " pre- tuberculous." Unless it can be shown that it later evolves into true tuberculosis the use of this latter term cannot be defended, and this transforma- tion, it can be most emphatically stated, does not occur. Bacillary infection may take place in catarrhal 96 LARYNGEAL TUBERCULOSIS. membranes the same as in normal membranes, but a conversion of a simple catarrh into tuberculosis never occurs. Many of the cases of so-ealled tuberculous catarrh are in reality incipient tuberculous infiltrates, as can be demonstrated by the injection of tuberculin, which produces a visible increase of hyperemia and swell- ing with the occasional eruption of miliary tubercles. The clinical history in such a case is different from that of a simple inflammation; the congested areas are more resistant to treatment, commonly affect only one side of the larynx and if neglected advance to localized tumefaction and possibly ulceration. The most common site of the early infiltrate is the interarytenoid sulcus and here the differential diag- nosis between early tuberculous infiltration and sim- ple catarrhal thickening is exceedingly difficult, for it is also one of the points of election for the latter condition. The most characteristic feature of the tuberculous hyperemia is its tendency to affect only one-half of the larynx while the catarrhal congestion is always bilateral. Eedness of one cord, arytenoid, ventricular band, etc., is generally indicative of one of four conditions : tuberculosis, syphilis, malignancy or traumatism, and the differential diagnosis depends upon the accom- panying conditions and personal history. ANEMIA. Perhaps the most widespread of all the fallacies concerning laryngeal phthisis is that respecting the OBJECTIVE SYMPTOMS. 97 diagnostic significance of palatal, pharyngeal and laryngeal pallor. The commonly accepted view is thus expressed by J. Solis Cohen: "Congestion of the mucous membrane almost always marks the earliest recognizable stage of the acuter form, while pallor of the mucous membrane almost always characterizes the earliest recognizable stage of the chronic and more frequent form." This early laryngeal pallor, it is claimed, is inde- pendent of general pallor and is frequently associated with anemia of the pharynx, palate and mouth. While the diagnostic worth of this sign has been almost universally acclaimed, it merits, according to the author's experience, but slight consideration. Its frequency in the early stages of the chronic variety of phthisis has been greatly exaggerated as is shown by the following table based upon six hundred cases of comparatively early lesions: Total number of cases, 600. Hyper- Normal. Anemic. emic. Palatal Mucosa 264 129 207 600 Laryngeal Mucosa 38 95 467 600 Total 302 224 674 1200 In this table, in so far as possible, every unusually acute case has been eliminated. These statistics show that pallor of the mucosa is far less frequent than congestion even in the essen- tially chronic cases. The proportion is about 1 to 3. In the far advanced cases the percentage showing anemia is necessarily much larger. Moreover, in nearly all cases in which this anemia 98 LAEYNGEAL TTTBEKCULOSIS. was present, its value in diagnosis was almost nil, as other signs existed which made clear the condition without considering the pallor, and in the majority of instances the pallor was not localized in the larynx or mouth hut was simply an expression of general anemia, the conjunctiva, etc., showing like changes. Even the first stage of pulmonary tuberculosis, the so-called "apical catarrh," is almost always associa- ted with signs of general anemia. In these cases, according to Grawitz and Strauer, the red cells are reduced and the clinical picture is that of pseudo- chlorosis. A like condition of the laryngeal mucosa is found in many normal individuals in whom tuberculosis does not later develop; it is almost invariably present in general anemia and may be general or of local- ized areas. It is an expression of the various wasting diseases, diarrhea, etc., and a grayish white color of the interarytenoidal mucosa is found in many cases of simple chronic catarrh, due to necrosis of the epithelial layer. Certain tuberculous lesions of an advanced type, flabby granulations, warty growths, old infiltrations and edematous swellings may be pale and anemic, but the areas surrounding and separating the indi- vidual lesions are usually somewhat congested. It may be said then, that the pallor of laryngeal phthisis is nothing more than an expression of general tissue waste, and that as such it should lead to further investigation as to its probable origin,— «irat that it is not pathognomonic of phthisis, is not distinctive and not even suggestive, except as any expression of gen- era] anemia may be so considered. OBJECTIVE SYMPTOMS. 99 Both the initial catarrh and anemia, unless the former can be shown to depend on infiltration, should be classed as catarrh or anemia accompanying tuber- culosis and not as a tuberculous or pre-tuberculous catarrh or anemia. Excluding these two conditions four forms of laryn- geal phthisis are clinically demonstrable. 1. The infiltrate. 2. The ulcer. I. The tumor. 4. The miliary tubercle. Certain subdivisions have been attempted, such as the " sclereuse et vegetante" of Gouguenheim and Glower, the "forme dysphagique" of Ferrand and Bo- vet, the hypertrophic form, etc., but such a multiplica- tion of terms is inadvisable as they are not distinc- tive types but merely variations of the primary groups. Granulations, likewise, are a result of ulceration and are not to be looked upon as a distinct variety. Except in rare instances the individual case does not conform exactly to any one of the four types; two or more coexist. In the incipient stages infiltration alone is generally present but with advance of the process some point gives way and ulceration complicates the picture. The true tumor, alone of the other forms, exists as an uncomplicated entity. The miliary type is gener- ally found in connection with ulceration and infiltra- tion. 1. The INFILTBATION. Infiltration is the earliest and most characteristic of the objective symptoms, and may persist indefinitely 100 LAKYNGEAL TUBEKCULOSIS. without degeneration or the development of other signs of local infection. Commonly, after a shorter or longer interval, the superficial layers of the mucosa succumb to the con- Fig. 4. stantly increasing pressure of the subepithelial exu- date and to the gradual obliteration of the blood ves- sels, and the characteristic ulcer appears. OBJECTIVE SYMPTOMS. 101 In the beginning the infiltrate, especially if it is limited to the posterior ends of the trne cords or to the interarytenoid sulcus, may strongly resemble simple catarrhal laryngitis, but in the majority of the cases, however, we do not have to deal with such an isolated simple process, for there is usually an early extension to neighboring structures and contiguous tissues, until finally the entire larynx, or a large por- tion thereof, is involved, either with or without con- comitant ulceration. (Fig. 4.) Interarytenoid Sulcus : Infiltration of the inter- arytenoidal mucosa is the most frequent and pathog- nomonic localization of the earlier manifestations of the disease, and often persists unaltered and uncom- plicated for many months or years. The comparative frequency of this type is shown in the following table : Inter- Isolated arytenoid Interarytenoid Author. Cases. Infiltration. Lesions. Keller 48 34 8 Carmody 81 71 7 Author 904 640 79 Total 1033 745 94 In the early stages of the disease the sulcus is par- tially filled by a circumscribed swelling which forms a convex projection during deep inspiration. The growth may occupy any part of the incisure; it is usually in the middle, more seldom upon one side infringing upon the corresponding cord, and occasionally upon each side giving to the middle portion a sunken, punched out appearance. The size and character of the infiltrate also varies within wide extremes ; in the simplest type it forms a 102 LARYNGEAL TUBERCULOSIS. broad-based, more or less elevated, red or grayish white projection covered by a smooth or slightly un- even epithelium. (Plate I, Fig. 5.) The grayish white color depends upon necrosis of the superficial epithelium and is not distinctive of tu- berculosis for it also, obtains in other conditions. The pallor, therefore, cannot be considered as diag- nostic unless it covers a convex infiltrate — and then it is the peculiar character of the swelling and not the pallor that is distinctive. In some cases the growth is an angry red in color. The infiltrate frequently departs from this early type and takes on the characteristics of a tumor ; it is sharply circumscribed, with wide base and pointed ex- tremity, and projects slightly into or almost com- pletely fills the space between the vocal cords. (Plate 1, Fig. 6.) The free edge of this tumor-like body may be com- paratively smooth or distinctly rugous, i. e., covered by numerous sharp, ragged, tooth-like projections. In rare instances the infiltrate may somewhat resem- ble papillomata, the so-called "vegetierende" or "pap- illaere" forms. (Plate I, Fig. 7.) Vocal Cords: Infiltration of the vocal cords, in the early stages, is marked by a diffuse or circumscribed redness and moderate swelling strongly suggestive of simple chronic laryngitis. The tuberculous hyperemia, however, lias a decided tendency to involve only one cord or isolated portions thereof, or if bilateral, both sides are rarely involved to an equal extent, in contrast with the symmetrical PLATE I. Fig. 5. Broad-based infiltrate of the posterior wall. Fig. 6. Tumor-like infiltrate of the posterior wall. Fig. 7. Papillomatous infiltrate of the posterior wall. PLATE I. Fig. 5. Tuberculous infiltrate of the posterior wall. Fig. 6. Tumor-like infiltrate of the posterior wall. Fig. 7 . Papillomatous-like infiltrate of the posterior wall. Fig. 5. Fig. 6. Fig. 7. PLATE I. OBJECTIVE SYMPTOMS. 103 and bilateral distribution of the non-specific inflamma- tions. The circnmscribed infiltrations are most common on the vocal processes, and are generally fonnd in con- nection with hyperplasia of the interarytenoidal mu- cosa. In such cases the posterior ends of the cords are of a pink or deep red color, somewhat uneven or notched along the free edge and rounded in form with an apparent increase both in width and thickness. If the ligamentous portion remains free the condi- tion has some resemblance to pachydermia and a microscopic examination, if other symptoms are lack- ing, may be the only means of determining the nature 01 the process. Before the infiltrate has attained sufficient volume to produce evident increase in size the only alteration is in color, either as a redness or a loss of the normal pearly lustre. Even this slight change, particularly when limited to one cord, is highly suggestive. In rare instances the anterior commissure is the site of a circumscribed infiltrate which affects either the angle of the cords or the region immediately above or below it. Even when moderate such a thickening in- terferes with perfect adduction and vocalization. The circumscribed infiltrations rarely persist for any considerable time without involving the mid-sec- tion of the cord and when this occurs the appearance is almost pathognomonic; the cord becomes cylindrical in form, convex from free edge to inner margin and from end to end, whereby the mid- section appears con- siderably wider than the extremities. (Plate 2, Fig. 8.) 104 LARYNGEAL TUBERCULOSIS. The surface may show a number of oblique dilated vessels and the color is either a dull or beefy red. The cord is sometimes thickened to many times its normal diameter, completely closing the ventricle and obliter- ating the line between the cord and ventricular band ; in such cases the border between the two is indicated by a thin dark line. Frequently the free edge of the cord is furrowed by a longitudinal groove through the pressure exerted by the opposite cord. The same condition is simulated by marked swell- ing of both the inferior and superior surface of the cords, due to the close connection between the free edge and the muscular layer whereby it is prevented from swelling to a degree equal to that of the other segments. Arytenoid Cartilages : Isolated infiltration of the arytenoid cartilages is comparatively common, but frequently there is simultaneous involvement of the ary-epiglottic folds. In the early stages the process is mostly unilateral, in the advanced bilateral, and shows as a single or double pear-shaped mass of deep red or purplish color, the extremities of which extend upward and outward until lost in the ary-epiglottic fold. (Plate 2, Fig. 9.) If the infiltrate is of long standing and large propor- tions the mucosa becomes pale and translucent, the i nterary tenoid sulcus partially obliterated and Wrisberg's cartilage hidden. Movement of the cords is mechanically hindered by the enlarged cartilage as well as by ankylosis of the crico-arytenoidal joint. Acute inflammatory swelling of one or both arytenoids PLATE II. Fig. 8. Infiltration of the vocal cords and interarytenoid sulcus. The cords have assumed the typical cylindrical form. Fig. 9. Infiltration and congestion of the right arytenoid cartilage and ventricular band. The correspond- ing cord is ulcerated along the free edge and somewhat thickened. Fig. 10. Edema and colossal swelling of both arytenoid cartilages. PLATE II. Fig. 8. Cylindrical vocal cords. Fig. 9. Ulceration of the right vocal cord and infiltration of the corresponding arytenoid and ventricular band. Fig. 10. Edema of the arytenoid cartilages. Fig. 8. Fig. 9. / (El Fig. 10. PLATE II. OBJECTIVE SYMPTOMS. 105 during the course of chronic tuberculous inflammation frequently occurs. Aryteno-epiglottidean Folds: In these folds in- filtration reaches a high degree owing to the abundant loose, submucous tissue. It is usually bilateral but may be limited to one side, and is always found in combination with either arytenoidal or epiglottic dis- ease, and frequently both. Fig. 11. In connection with bilateral arytenoidal swelling the appearance is absolutely pathognomonic. On either side the pyriform or flask-shaped tumors encroach upon the lumen of the upper aperture, which is still further closed by the enormous globular masses repre- senting the arytenoids proper which meet in the mid- dle line posteriorally and extend back into the pharynx. 106 LARYNGEAL TUBERCULOSIS. There is usually some edema present giving to the otherwise red body a pale and translucent appearance. Such cases generally have a fatal termination and their course is attended by severe dysphagia and some dysp- nea. (Plate 2, Fig. 10.) Epiglottis : Widespread infiltration of the epiglot- tis, in the great majority of instances, is a late manifes- tation although now and then it is met as an early or even the primary laryngeal focus. In the milder forms the edge is swollen to several times the normal thickness and has the appearance of being rolled upon itself ; the color may be either bright red or pale. (Fig. 11.) The swelling is often almost as great as that of the ary-epiglottic folds, giving it the so-called "turban" or "omega" shape. (Plate III, Fig 12.) The infiltration is sometimes limited to one half the organ (Plate III, Fig. 13.) and I have had occasion to observe several unusual cases in which there has been no swelling except in the space between the epiglottis and base of the tongue, extending, with gradually decreasing distinctness, toward the free edge. Severe pain almost always marks epiglottic involve- ment and even slight infiltration destroys its mobility. Ventricular Bands: A considerable percentage of all cases of tuberculous laryngitis show some infil- tration of the ventricular bands, which may be the first localization of the process in the larynx. As a rule it is of moderate extent but occasionally reaches large proportions. I n the latter case ilie vocal cord of the corresponding PLATE III. Fig. 12. "Turban" or "Omega" shaped epiglottis. Both cords show slight ulceration and the arytenoid cartilages are uneven and nodular. Fig. 13. Warty infiltration of the left side of the epiglot- tis. The corresponding arytenoid is slightly thickened, the interarytenoid sulcus infiltrated, and both cords congested. Fig. 14. Bilateral infiltration of the ventricular bands. The left vocal cord and interarytenoidal mucosa are slightly ulcerated. PLATE III. i Fig. 12. Turban-shaped epiglottis. « Fig. 13. Warty infiltration of the epiglottis. Fig. 14. Bilateral infiltration of the ventricular bands. Fig. 12. Fig. 13. (f^N>V>v I— 1— V - CD