Tuberculosis Of The Air-Passages
By E. L. SHURLY, M. D.,OF DETROIT, MICH.
LARYNGEAL TUBERCULOSIS.
TUBERCULOSIS of the larynx consists of an ulcerative inflammatory process depending upon the presence and alterations of tubercular material in the soft tissues of the larynx. This material may appear as granular or nodular deposits, or as a more or less diffuse infiltration. There are two typical forms usually described: (a) An acute, inflammatory affection, described by Isambert and Friedlander as 11 acute tuberculous sore throat; “and by other observers as localized laryngeal tuberculosis. (b) A chronic process characterized more by infiltration and softening than by inflammation of the tissues. The former class has been by many authors considered a primary laryngeal affection, in the belief that the morbid process may originate and possibly remain in the larynx. Professional opinion, however, has been divided upon this point on account of the very frequent or almost constant implication of the lungs; although in rare instances, according to J. SolisCohen, no lesions have been found upon post mortem examination in other organs of the body. The more chronic form is often denominated “secondary," because usually occurring subsequently to tuberculous disease of the lungs or other organs of the body. Between these two types there are many gradations according to the constitutional and local physical peculiarities which also variously modify the course and character of the disease.
Etiology. According to the consensus of professional opinion at the present time, the essential cause of laryngeal tuberculosis or laryngeal phthisis in all of its phases (as, indeed, of all other forms of tuberculosis) is the invasion of the tissues by the tubercle bacillus of Koch; and to the action of this micro organism is ascribed the whole pathogenesis of the disease. Although the numerous well known and carefully accepted laboratory experiments, besides other faithful work of reliable bacteriologists on this subject, leave little doubt concerning the accuracy of this doctrine, yet it does not supply to the clinician an adequate explanation of all the etiological or clinical features of this sometimes complex disease. While various vagaries in the vitality and growth of this micro organism are sought to be demonstrated in the field of pathological histology in explanation of the diverse clinical effects ascribed to its presence, there still remains the knowledge of its notable failure to infect the larynx, except in from about 10 per cent. to 40 per cent., (according to various authors) of the cases of pulmonary phthisis, where certainly the conditions would seem exceedingly favorable.
The mode of invasion is supposed to be either from without through abrasions of the mucous membrane (exogenetic), or from within through the lymph or blood channels (endogenetic). J. Solis Cohen believes that the invasion is from without, and infers that generally "an acute laryngitis with some desquamation of epithelium affords an inlet to the germ." But if this were so, almost every case of pulmonary tuberculosis would be accompanied by laryngeal infection for obvious reasons; and, moreover, the laryngeal disease would be apt to occur anywhere about the structure, instead of (as we observe) in selected places; while the constant application of infected sputum to a continual succession of abrasions would prove an infallible method of infection. The comparative immunity of the larynx has been accounted for in two ways. One is that tubercle bacilli are slow in developing and need not only a suitable nidus but quiescence, conditions which the larynx, from its exposed situation and constant movement in respiration, phonation, and coughing, does not afford; and the other is, that the abrasions of the mucous membrane of the larynx are so quickly protected, either by exudate or granulations each of which is known to be if not quite bactericidal, at least very resistant that a proper foothold, so to speak, for the micro organism can only with difficulty be obtained. As to the first explanation we may remark that when the laryngeal membranes are in the least degree swollen, there must be numerous abrasions from friction of the parts, for according to Rice and Hodgkinson there is continual friction between the ventricular bands, the walls of the ventricles, and the vocal cords. Regarding the question of a resting place, there is probably no place more attractive to microorganisms for quiescence than the laryngeal ventricles, where even particles of dust will remain, when mixed with leukocytes or secretion, perhaps for days, and where (being rich in lymphatic tissue) the region would furnish abundant pabulum for the growth of tubercle bacilli. Yet it is immune.
Concerning the second explanation there is little to be said, except that the defensive effects of the reparative process in this situation are probably no more active and effectual than in similar tissues in other localities.
A few years ago Dr. Gibbes and myself scarified the pharynx and epiglottis of several healthy monkeys and applied thereto sputum from tuberculous patients, without producing in any instance local tuberculosis. We also scarified in like manner the pharynx and epiglottis (and possibly the membrane covering the arytenoids) of two monkeys suffering from pulmonary tuberculosis, without the production of local infection. In this connection I might relate that a patient of mine suffering from pulmonary tuberculosis accidentally suffered from the lodgement of a piece of chickenbone in the pyriform sinus of the larynx. In his effort and that of others to dislodge the foreign body the pharynx was considerably wounded, as was also the aryepiglottic fold and the covering of the arytenoid and supraarytenoid cartilages. It was with some difficulty that I was able to remove the bone, Owing to the impaction of some of its spiculae beneath the surface of the mucous membrane. As be came from a distance, considerable time bad elapsed (about ten hours) between the period of the accident and the period at which I saw him, and in consequence there was considerable tumefaction of the region. I fully expected a development of secondary laryngeal tuberculosis on account of this accident, but no such phenomenon occurred. The man lived about eighteen months after this accident and was under my observation more or less of the time, but never presented any tubercular lesion of the larynx or pharynx that could be detected by the laryngoscope or by the observation of subjective symptoms. I regret to say that no postmortem examination of the case could be obtained in order to verify microscopically this assumption. Therefore, it would seem that the moderate degree of invulnerability of the larynx to tuberculosis, or the invasion and ravages of the tubercle bacilli, if you please, must depend for explanation upon some other hypothesis or facts than can be ascribed to either the latent or oblique behavior of the tubercle bacillus, or to the mere abrasion of the laryngeal mucous membrane under the circumstances usually set forth. While I would not unjustly underestimate the property of latency so generally recognized as belonging to tubercle bacilli (Bollinger has shown that tubercle bacilli may remain latent in bronchial glands for twenty years without losing their vitality'), nor the modifying efects upon their growth of " tissue reactions," yet I believe with Unterberger not only that the role of the tubercle bacilli in spreading disease is overstated, but that the independent powers ascribed to them have also been overestimated.
Neither will the addition of the "tubercular tendency" ("congenital tendency ") serve to supply completely the missing etiological link, because there are so many cases of chronic laryngeal catarrh observed in persons who possess the tubercular tendency who go through life without becoming subjects of laryngeal tuberculosis; while on the other hand, in a considerable number of cases of tubercular disease, no tubercular or " scrofulous " family history, nor event of exposure to other cases, nor history of previous severe disease can be elicited. The accession of this disease, therefore, must await some definite bio chemical or nutritional alteration of the part, of a more or less local character, before its particular pathogenesis can be established. Undoubtedly, as Cohen says, 11 it is not improbable that certain bacillary elements exist normally in the tissues of the healthy individual, which under certain conditions undergo conversion into tubercle bacilli."
Gibbes, Mittendorf, and others describe forms of tubercular tissue differing in histological character, , from one another. The second author indeed asserts, upon the basis of numerous bacteriological and histological examinations, that tubercular tissue, called technically " crude " or 11 healthy," is very frequently devoid of tubercle bacilli.
Regarding the so called secondary variety there can be no doubt that the toxic agent arrives at the larynx through the lymph channels, and depends for its local development upon the continuous and enduring alteration of the cellular elements either created or maintained by the lympho cellular metabolism which belongs to the general disease, whether the tubercle bacilli or some specifically depraved cellular or protoplasmic elements be regarded as the initial ferment or not. In the light of recent investigation upon the nature and powers of the various proteids of the animal body in health, as well as in disease, it is, of course, very difficult to understand the early steps in the development of any general disease of an infectious or septic character; especially as the exact relation of the microphytic ferments to the various proteids upon which they are supposed to operate has not yet been definitely settled.
" The effect on the body cells of the presence and growth of tuberclebacilli varies considerably and depends upon the number and virulence of the germs present, the character of the tissue in which they lodge, and the vulnerability of the individual" (Prudden and Delafield).
Ever since Virchow pointed out the wonderfully independent and specialized functions of the cellular elements of the body, both physiology and pathology have made important progress; but as yet the real mutations, both in health and disease, of these incessantly working components have escaped positive or complete detection. Their exact source and manner of regeneration are as yet unknown, as well as the definite chemical composition of all their various protoplasmic contents; while their relation to, and influence upon, the body fluids, such as blood and lymph, are still to a great extent subjects of speculation. Hence, until further progress is made in this direction, we shall be unable to say whether chemical changes in them precede or follow 'the presence and operation of bacteria; in other words, whether toxins or bacteria constitute the initiation of morbid processes, and whether the defensive or immunizing agency resides altogether in the mobile or fluid tissue (blood and lymph), or partially or essentially in the formed tissues and secretions of an apparatus or organ.
Of predisposing causes of the so called inflammatory varieties, the most striking are undoubtedly frequent attacks of acute and chronic laryngitis. Consequently such cases show much variation in their course, according to the circumstances of the previous disease and the amount and extent of local inflammation of the larynx. The local disturbance, of course, is very much aggravated if accompanied by miliary tuberculosis (in wbich event it is apt to be very rapid and extensive); also if connected early with pulmonary lesions of even limited area, such as localized broncho pneumonitis (Cohen) or broncho pulmonitis. But with the latter class of cases the march of the local disease is usually slower and milder.
Tuberculosis of the pharynx or tongue may in rare cases extend to the larynx. The larynx may also become infected from tuberculosis of the tonsils, which it is said (Hans Ruge) occurs much more frequently than is supposed, and is difficult to demonstrate clinically because ulceration is so often absent. An extension to the larynx from the cervical lymphatic glands may occur although, perhaps, not frequently also from tuberculous caries of the teeth. Schatz has reported cases of tuberculous caries of the teeth with involvement of the cervical glands where tubercle bacilli ,I ere found in the cavities of the teeth, while their floors showed microscopically granular tissue containing giant cells.
Constitutional syphilis and the excessive use of alcohol are common determining factors in the origin of laryngeal tuberculosis. Indeed, the former disease may occur concurrently with it.
Inordinate and improper use of the voice is also a common predisposing factor.
Age. Laryngeal phthisis is generally observed in persons between the ages of eighteen and thirty five years. It may occur, however, in infancy or childhood (Cohen, Beverly Robinson, Bosworth), or rarely in old age (Bosworth) as a primary affection.
Sex. Males are more liable than females to suffer from the disease; a fact so striking in relation to the occupation and domestic or social history of the two sexes in general, that one is led to place even additional emphasis upon the exogenetic over the hemogenetic or endogenetic sources of the morbid process.
Occupation. Vocations requiring the use of the voice in the open air (peddlers, etc.), exposure to noxious or dust laden air, or frequently alternating variations of temperature, or confinement in close rooms, offices, or shops are predisposing causes.
Pathological Anatomy. The earliest appearances in the so called inflammatory varieties are those of hyperemia. The capillaries are enlarged and more or less stuffed with blood corpuscles (Gibbes). Into the surrounding tissue there is soon effused an abundance of leukocytes and small round cells, while the mucous glands are swollen with serum and the same cellular products, so that their acini become either obliterated or distorted by pressure. Here and there, after the disease has progressed, may be seen tubercular granula in the strorna without necrosis (Delafield and Prudden), either coalescent or more or less discrete ; and distinct nodular formations of granula, perhaps with reticulated surroundings, may supervene as a result of productive inflammation or tissue reaction. There become manifest in places, attempts at organization instead of necrosis, or vice versa; the latter process, however, finally occurs from the subsequent obliteration of vascular supply through turgescence of lymph channels and capillaries. According to Wright, productive inflammation and the formation of depraved granulation tissue are apt to precede the necrosis in most instances. The mucous glands, which at first are excited to yield extra secretion, are soon compressed from without or invaded by infiltration products. The productive inflammation may lead to the formation of a granulation tissue, which in spots will endure for quite a time; but the majority of such patches ultimately break down ulcerate. Giant cells may not be found in the granulation tissue in some cases; and, excepting in the undoubted “miliary “forms, where extensive ulceration or caseation rapidly supervenes, tubercle bacilli may also be absent.
When the morbid process is localized, the surrounding tissue shows an active formation of connective and fibrous tissue with increasing vascularization Nature's attempt undoubtedly to throw out a barrier. The zone of tissue nearest the seat of disease is well filled with small round cells and leukocytes in rather compact order. The pathological process is, as a rule, at first confined to the subepithelial layers, but soon involves the submucosa or even the deeper tissues. When softening occurs it is usually from below toward the surface, resulting in ulceration. The confinement of the caseation products, so as to produce what may be termed abscess, but rarely occurs; although after solution has taken place more or less pus, together with mucus, may be seen in the tissues as well as upon the surface. The epithelial layers of the mucous membrane suffer greatly and are entirely changed in their histological characters both as to shape and dimensions. In the infiltration form (see Fig. 613) there is a state of anemia, the capillaries are not increased either in number or caliber, but the lymph channels are enlarged and filled; the mucous glands are also filled with serum and lymphoid cells, which form the basis of the so called tubercle granula, as well as round cells, which also fill the interacinous spaces. The epithelial layers are thinned and uneven from distention perhaps more marked in the arytenoid region and epiglottis, where distention may be greater. At or near the sites of ulceration the epithelial layers, are either lost or merged into one heterogeneous layer. Softening may quickly occur and the tissue breaks down rapidly to the surface of the perichondrium, even involving that structure; although it is apt to be checked by attempts at repair through the formation of granulation tissue. The detritus from the ulcers usually shows an abundance of tubercle bacilli, pus, mucus, altered epithelial cells, and epithelioid bodies.
The regions usually first affected are the arytenoids, posterior wall, aryepiglottic folds, and the epiglottis, although the ventricular and vocal bands may be simultaneously involved. The ulterior ravages of the disease, if the patient lives long enough, may include any of the cartilages of the larynx (see Fig. 615).
Symptoms. The early local symptoms are usually such as belong to persistent chronic laryngeal catarrh and are of slow accession, unless, of course, the type of the disease be acute or it be a concomitant of general miliary tuberculosis. These symptoms consist of more or less hoarseness, sense of uneasiness or dryness referred to the larynx, varying degrees of tenderness, and short, hacking, laryngeal cough. As the disease progresses there is soon added more or less pain in deglutition (odynophagia), and still later difficulty of destitution (dysphagia) and painful and difficult phonation (dysphonia), or extinction of the voice (aphonia).
The severity of these clinical signs varies greatly, of course, according to the extent, progress, and seat of the morbid process; since, for instance, limited and unabraded infiltration or nodules, as a rule, give rise to less pain than more extensive and ulcerated lesions. Lesions of the epiglottis and arytenoids produce pain and embarrassment of deglutition much earlier than those situated at the aryepiglottic folds, vocal bands, or posterior wall of the larynx. Considerable infiltration of the interarytenoid region may exist without giving rise to much discomfort. The degree of suffering experienced will be according to the amount of ulceration and swelling of the larynx and the involvement of the neighboring lymphatic tissue, and may reach such a condition that the patient will dread to swallow, cough, or speak. We sometimes meet with odd cases, however, which show a comparatively anomalous degree of insensibility of the parts throughout the whole course of the process. These cases are usually secondary to pulmonary tuberculosis.
In the type of cases characterized by extensive infiltration and anemia of the tissues, the local subjective symptoms are less marked excepting, perhaps, dysphonia or aphonia owing undoubtedly to the lesser degree of inflammation present. The sensibility of the laryngeal tissues may be somewhat obtunded in many of these cases. There is, however, a marked degree of embarrassment of the vocal function and often 'mechanical obstruction to respiration. In any case, when the vocal bands escape implication, the change in the voice is of a less decided and progressive character.
If the pharynx be involved the distress and pain in deglutition is aggravated the pain extending to the ears and perhaps to the face and teeth Patients often complain of a sharp pain over the pectoral region of the chest, on the side corresponding to the most affected side of the larynx. This is probably due to the connection of the short thoracic nerve with the laryngeal through the central sensory centers.
The cough is often of a peculiar stridulous or rattling character, and when causing much pain is repressed as much as possible by the patient. The amount of expectoration varies greatly, according to whether there is Much softening or ulceration of the tissues going on; but after the first stages there is usually considerable expectoration of mucus and saliva often mixed with more or less pus and streaked with blood. A certain degree of immobility of the larynx, as a whole, is usually observed, which may be due to infiltration of the lymphatic glands in the neighborhood of the muscles or through the unconscious effort of the patient to escape the pain attending its movement. The suffering of a patient with extensive ulceration of the laryngeal structures is excruciating, and toward the last, even the act of breathing, as well as speaking and swallowing, may amount to torture.
The constitutional disturbance in the acute varieties takes place early, so that even before the appearance of marked laryngeal disease debility, slight emaciation, more or less insomnia, limited anorexia, hyperpyrexia, a rapid pulse, and frequency of respiration may be observed. Indeed, so insidious is the attack sometimes that the serious import of the hemming, backing, and throat uneasiness, coupled with poor appetite, restless nights, debility, etc., may go unrecognized for quite a while, especially when, as is often the case, the complexion and display of personal ambition of the patient seem toremain unchanged. I have known several cases of this sort in whom ambitious tyros have mutilated the turbinals in the belief that these unoffending adnexa were obstructing respiration and otherwise preventing the well being of the patient.
In one such case brought to me for consultation after severe sanguinary surgical attacks had been made upon thle turbinals and nasal septum, there were no subjective symptoms of laryngeal disease worth noting; and yet laryngoscopical examination showed a considerable infiltration of the left arytenoid region with corresponding infiltration at the apex of the left lung.
Another case worth alluding to briefly was that of a young girl of eighteen years, of ruddy complexion and plump appearance, who bad been complaining for about two months of debility, slight dyspepsia, anorexia, and a very moderate hacking cough with soreness of throat, and whose voice was but very slightly altered. Examination showed slight swelling of the arytenoid region and very slight evidences of condensation at the upper right lung. Further infiltration and ulceration of the larynx rapidly supervened, and she died four months after. Such cases are also treated sometimes as "malaria ! "
The anemic, diffuse, infiltrating type of the disease is usually preceded for a considerable time bv constitutional symptoms of unmistakable significance, although exceptionally these cases may have been long preceded by symptoms of pharyngo laryngeal catarrh only, without showing much systemic disturbance. As before remarked, there are many gradations of severity giving rise to corresponding modifications in the symptomatology. But too much confidence must not be placed in the apparent mildness of the symptoms as a basis for prognosis.
Besides, a large number of these cases show exacerbations and remissions which greatly alter both the subjective and objective symptoms from time to time. As a rule, however, when a patient exhibits persistent alterations of voice, with cough and other symptoms relating to the larynx, together with nocturnal elevation of temperature, frequent pulse, and otherwise unaccountable debility and malnutrition, the actual advent of laryngeal plithisis may be suspected, whether the physical signs elicited from an examination of the chest are corroborative or not.
In a large proportion of cases, especially if advanced, the tubercle bacilli may be found in the sputum; but early in the disease, especially when more or less localized, this micro organism Hill very often not be found, however carefully the search may be made.
Objective Symptoms. The laryllgoscopical appearances belonging to laryngeal phthisis or tuberculosis may, for purposes of description, be presented in five groups. The first (see Fig. 609) includes those cases which resemble chronic laryngeal catarrh somewhat, and are characterized by more or less diffuse hyperemia inflammation and swelling of the mucous membrane. The intensity of the hyperemia and swelling, however, is generally confined to either the base of the arytenoid bodies and interarytenoid space, the epiglottis, or, exceptionally, to the aryepiglottic folds, ventricular and vocal bands. The latter, however, are not affected to so great an extent by tumefaction, on account of their anatomical character. The tumefaction is not at all evenly distributed, but preponderates in one region or another. The more acute as well as localized varieties show this appearance very soon, and small roundish ulcers appear sometimes over the vocal cords near the posterior vocal processes first, or upon the epiglottis or toward the bases of the arytenoids very soon. They may be many in number or only two or three.
The second group of cases is marked also by hyperemia (see Fig. 610), but more localized; and the tumefaction may affect either the epiglottis or the arytenoids, generally the latter region particularly. These parts appear as pyriform or “club shaped " swellings of brownish red color, with the deeper tint toward the base. The vocal bands are usually a grayish or brownish white. The infiltration of the tissues may not be extensive, at first affecting mostly the arytenoids and aryepiglottic folds. The tumefaction gives to the parts in the laryngoscopical image a rather tense, smooth appearance, of a yellowish red or salmon color, until ulceration supervenes, when the color mav grow even paler, with reddish blotches. The epiglottis may be the part most affected in such cases, and is never so intensely colored as adjacent parts.
The third group (see Fig. 612) comprises those cases which are slow and attended with exacerbations and remissions. The color of the mucous membrane varies from a salmon to a dark red or brick red, while the tumefaction presents itself in rugae, folds, or projections (tumors). One or the other arytenoid body is more or less fixed in position and usually bounded by ragged or papilla like projections. The vocal bands are thickened, roughened on their edges or surface, and of a dirty gray or brown color. Many vegetations simulating papillomata may jut out from around the base of one or the other arytenoid body, or from the interarytenoid space, the epiglottis, or the vocal bands. The edges of the latter may appear notched, either from actual ulceration or from the effects of' former ulceration, granulation, or cicatrization of the same.
The fourth group includes cases of diffuse tubercular inflammation (see Fig. 613). The mucous membrane appears in' the image pale, bloodless, swollen, and glistening. The tumefaction varies in degree and extent, and like other forms it may be more marked at the arytenoid bodies, which will then show the " clubbed " appearance, or at the epiglottis, which will then show the " turban like " appearance (see Figs. 613, 614). The swelling may be so great as to give the appearance of edema, and may entirely obscure the view of the interior of the larynx. The ulcerations are likewise small, and may be numerous, close together, or scattered; they are roundish or lenticular in shape until the deeper structures become involved, when they assume various shapes with ragged edges. When situated on the edge of the epiglottis, that appendix appears as if gnawed or “worm eaten."
Group five (see Fig. 615) shows the results of extensive ravages ill the advanced stages of the disease. After the destructive process has reached the deeper parts, such as the submucous connective tissue, perichondrium, or even the cartilages themselves, necrosis of the cricoid, arytenoid, or thyroid cartilage may be present. The ulceration in such all events is irregularly serpentine, deep, and extensive, with borders surrounded by granulations and sear tissue, while the floors consist of sloughing dark gray or greenish masses, more or less bathed with pus and sputum. The intervening mucous membrane is thickened and irregular in contour, of dark color, and in patches consists of little more than granulation tissue.
There are, of course, gradations between these types of local disease, which give varying and sometimes quite anomalous pictures. For instance, the hyperemia, swelling, or ulceration may be limited to just one arytenoid body, or one aryepiglottic fold, or one side of the epiglottis; or the infection may be almost confined to one side of the larynx, especially when the process first takes place in the deeper tissues; while in other cases there may be the appearance of considerable inflammation or hyperemia of one part, with an anemic infiltrated appearance of another part. There are also great variations in the distribution of the ulcerations. They may be confined to the laryngeal surface of the epiglottis or its very edge; or the posterior wall may be the seat of undetected ulcerations. It is therefore advisable in many cases to resort to Killian's method of examining this wall (see page 872) in order to ascertain its condition. There may be only two or three ulcers visible, and those situated on the vocal bands only ; or, on the other band, small ulcers may be scattered over the epiglottis, ventricular bands, arytenoid bodies, or vocal bands respectively, as if sprinkled into the vestibule of the larynx. Necrosis and ulceration of the tissues will surely take place more or less extensively in the natural course of events. But either under appropriate treatment or spontaneously, in the cases of slower march, retrogression and healing of ulceration may occur. When this event transpires, granulation and cicatrisation with their attendant contraction will mark the, retrogression of the disease. The cicatricial tissue is not nearly so abundant as in syphilis or lupus, because the patient does not usually live long enough to recover from extensive destruction of the tissues in tuberculosis. Yet there may be enough found to cause at least uncomfortable if not dangerous interference with respiration from stenosis or enough to produce troublesome aphonia. The vegetative proliferations also may become threatening, requiring removal, for sometimes they amount to tumors of considerable size (Figs. 616, 617). These vegetations are sometimes ejected spontaneously (J. Solis Cohen). Again, the function of the larynx may be compromised by hypertrophied (reparative) tissue (superior and inferior hypertrophy) organized in folds or ridges (as seen in Fig. 618), or the action of the vocal bands may be impaired by adhesions. When ulceration begins the parts are usually freely bathed with muco pus, which is more or less adherent to the roughened surfaces, and shows usually in the image as partially desiccated or coagulated clumps, or as stringy bands or threads. The interarytenoid space is nearly always so covered; while the posterior wall of the larynx, as well as the walls of the trachea, may be plastered with clumps of sputum.
Diagnosis. Laryngeal tuberculosis is often difficult to differentiate from chronic laryngeal catarrh, syphilis, lupus, and sometimes certain forms of epitheliorna; and, as Sehech says, may baffle differentiation in some instances. When a clear and satisfactory history of the patient can be obtained, the difficulties are very much lessened, if not removed. There are numerous instances on record of a mixture of these diseases taking place; as, for instance, syphilis becoming implanted upon a subject suffering from laryngeal tuberculosis (see Fig. 622), in which case the difficulty of diagnosis is great. It is often confounded with ordinary hypertrophy of the laryngeal mucous membrane accompanying chronic catarrhal laryngitis or syphilitic laryngitis. Syphilis of the larynx, however, is usually preceded not only by its own peculiar clinical history, but by the occurrence of the local disease somewhere in the upper structures of the throat, such as the soft palate, pharynx, tonsils, or the nasal septum. This is especially true of the tertiary form, which shows preferably in the soft palate; whereas the lesions of laryngeal tuberculosis usually begin and remain in the larynx: but in the advanced stages the local appearance of this affection frequently simulates tertiary syphilis, lupus, or epithelioma. In secondary syphilis the ulcers are of a somewhat different character being deeper, kidney shaped, or irregular, with sharp cut, everted edges, but they may be situated, as in laryngeal phthisis, on the epiglottis or aryepiglottic folds, vocal or ventricular bands. The tumefaction of the surrounding tissues is generally much less than in tuberculosis, and the inflammatory areola about the ulceration is usually present and characteristic. The parts are generally less painful than in laryngeal tuberculosis. In tuberculosis the ulcers are commonly shallow, of lenticular shape, with smoother edges, and with fewer dispositions to immediate sloughing than syphilis. Syphilitic ulceration is attended with less tumefaction, and is in preference located on the epiglottis or vocal cords; whereas tubercular ulceration usually appears first in the region of the arytenoid cartilages or interarytenoid space, and is attended with tumefaction.' The grayish or yellowish tubercular spots sometimes described by authors as visible just beneath the surface of the mucous membrane (miliary deposits) are very rarely observed, although sometimes a mottled appearance does accompany the early stages of tubercular infiltration. In lupus, while the nodular growth is not as plain as if occurring on the skin (see Lupus, page 1060), yet the papillomatous or granular appearance is well enough marked. Its course is very slow, and after softening has taken place the ulcerations soon coalesce to form a few discrete plaques, the everted, red, granular, ragged or papular edges of which are characteristic. Outside of these spots may be seen zones of thickened papillomatous membrane of varying hues of red. Besides, the parts are not painful to the touch, nor is there much pain in swallowing. Pyrexia is usually absent, and during remission the cicatricial tissue is prominently visible. In the so called secondary form of tubercular laryngitis (Fig. 618), the peculiar paleness of the mucous membrane, with characteristic swelling of the arytenoid bodies, known as the " clubbed appearance," will serve, when present, to settle the diagnosis at once, even without the presence of pulmonary symptoms.
Epithelioma usually invades the larynx pharynx, the tongue, or the esophagus, very affection in the larynx unless preceded by some benign neoplasm or lupus. It is of slow growth and without much constitutional disturbance. When it does occur in the larynx it is usually in the deeper regions of the organ, and will be found as a mass of tissue raised above the surface of the mucous membrane. It will be of a very deep red color, of velvety contour, with fissured and sinuous channels bordered or filled by sloughs coursing through the mass here and there. It presents no definitely bordered ulcerations, but irregular pockets I and readily bleeds upon being touched. it conveys the idea of an excrescence from the first. The cervical glands are usually very early enlarged and hard. Sarcomatous tumors of the larynx are more rare than the myxo sarcomatous. Their growth is rapid and presents the smooth appearance and contour of a vascular tumor or polyp. The growth is prone to bleed upon the slightest provocation, and does not present a lobulated appearance nor any of the characteristic ulcerative details of either syphilis or laryngeal tuberculosis. It appears as if independent of the surrounding tissues not blended with them. Besides, there are Do constitutional Signs presented, at least for a time, if we except the cachexia.
Glanders and leprosy sometimes simulate, in their local manifestations and appearance, laryngeal tuberculosis; but the history of the case and the preceding lesions of the skin or lymphatic glands in leprosy, and of the nose or mouth in glanders, will serve to distinguish these affections from each other. In the advanced stages, when the destruction of tissue has been considerable and perichondritis or cicatrization has been concomitant, it is often very difficult, from appearances alone, to distinguish syphilis or lupus from laryngeal tuberculosis; especially is this true of the former affection. Yet, generally by an exploration of the chest, taken together with the clinical history of the case, one may clear tip all doubt.
Prognosis and Course. The prognosis is always grave. The form described as acute tuberculous laryngitis, or inflammatory tuberculous laryngitis (tubercular infiltration), offers practically no hope, because it is merely a local manifestation of a general miliary tuberculosis which may possibly be affecting any or all of the glandular organs of the body. This form of general infection sometimes attacks persons in apparently robust health, whom one would think from their appearance would be able to resist, for a time at least, any sort of general infection or sepsis. In such persons, however, its course may be, and indeed usually is, as rapid as with those appearing more delicate. The larynx soon presents evidences of great inflammation, and its tissues soon break down. We meet with cases, however, which might properly be classified as acute, in which the disease becomes limited and retrogresses for a time, even though there may be well marked physical signs of involvement of the lungs. I have met with several such cases which, contrary to expectation, have remained passive for a long time. In the more chronic forms, manifested by pale, anemic mucous membranes, the disease usually runs a slower course, but is almost always fatal. These cases are frequently accompanied by systemic infection of the bronchial lymphnodes or spleen. Such cases may run an inactive course, however, usually unaccompanied by either the intense odonphagia or dysphonia of other forms; yet the voice is nearly always more or less impaired. Tile limited forms of the disease usually respond to appropriate treatment and regimen, and, excepting for exacerbations of acute laryngitis the result of attacks of influenza, etc. may be kept more or less passive for years, if not permanently checked.
Treatment. The treatment of this affection is generally classified as general and local. The general treatment maybe considered as climatic, hygienic, specific, and symptomatic; and the local treatment may be discussed under the following captions local medication by inhalation, sprays, or insufflations, and surgical treatment.
The influence of climate in modifying all of the tuberculous diseases is well known and need not be discussed at length. However, in no form of phthisis is it more disappointing than in that of active laryngeal tuberculosis. Usually a warm moist climate is the most beneficial to the majority of cases, provided it is not too enervating, such as a tropical or subtropical one. The dry warm climates, such as those of Arizona, New Mexico, and some parts of California, do not seem to suit many of these cases, perhaps on account of the dryness of the air, for in many instances the laryngeal symptoms seem to grow worse after entering such localities. When a dusty or wind feature is chary acteristic of the climate of the locality, the discomfort and distress is sure to be increased (Ingalls). With regard to altitude, it may be pointed out as a rule that only a moderate elevation is well tolerated by many subjects. A large majority of those who dwell above 3000 feet are apt to suffer extra distress, if not exacerbations of inflammation of the larynx ; this is especially true of the well marked inflammatory cases. There are, however, many exceptions, especially when the local lesion is in a primitive state, or when much infiltration or ulceration is present. Strange as it may seem, cases showing but little involvement of the lung are not as much relieved as those in which there is notable involvement of the lungs, such as commencing softening or excavation. A cold dry climate with plenty of sunshine has been found even more generally beneficial than a highly elevated dry or dusty one. Sometimes, however, when the cold is very intense, the laryngeal mucous membrane seems to be irritated thereby, especially if there be much hyperemia. In short, according to experience, a windy, dusty locality is not suitable for cases of laryngeal phthisis, except when there is more or less ulceration of the larynx or caseation of the lungs going on. A moist warm climate or ocean voyages would therefore seem preferable as a, rule. Of course, it will be understood that the individual and the individual circumstances may furnish valid exceptions to any rule.
The hygienic treatment consists for the most part in proper clothing, not too frequent bathing, and the administration of nourishing but digestible food ; out door life as far as possible during the day, with a cool (but not too cold) sleeping apartment. Patients with this disease should be very careful about exposure to coal gas for any length of' time. The use of tobacco, either chewing or smoking, ought to be prohibited, also the too frequent use of cold and hot drinks in close alternation, such as ice water and hot tea or coffee at meal times. The full quota of sleep each twenty four hour, , should be obtained. Patients should be enjoined to spare the voice as much as possible in conversation ; singing and public speaking ought to be prohibited. I have known several instances where patients in the early stages of laryngeal phthisis, presenting certainly good prospects for at least temporary recovery, have been thrown into almost a fatal exacerbation by the strenuous use of the voice. One of these cases, I may briefly state, was that of a clergyman who was making an apparently good recovery. He had been away for some months from his duties and bad returned to his residence in a district containing a great many friends among the congregations of several churches where he was well known. About the time of his return there was considerable church activity and public agitation on special moral questions concerning the district in question. As be had been a popular and efficient pulpit orator, lecturer, and worker, be was persuaded to take an active part in these events. After making three prolonged and rather vehement orations in three adjacent towns during a period of a week or so, be contracted a violent inflammation of the larynx, which renewed the exudation into the tissues, and ulceration affecting permanently the integrity of the larynx and necessitating his immediate removal to the South, where lie expired in about Dine months. A similar effect occurred in the case of a prominent lawyer who was a patient Of mine and whose case bade fair to end in recovery. He was induced to return from a needed sojourn in the West Indies (where lie was sent) to take part in some important cases that be bad been engaged for, and after finishing this task a severe inflammation of the larynx with extreme tubercular infiltration followed. Many other like instances could be given to show the necessity of rest as absolute as may be in the management of laryngeal phthisis.
The specific treatment of laryngeal tuberculosis has not yet arrived at the perfection which we would wish. A great many agents have been brought forward from time to time which have undoubtedly been attended by a modicum of good results; but owing to numerous failures they have been gradually put aside. The seekers of truth in this field of discovery are numerous, however, and we may with reason hope that guided by past failures and partial successes the right series of therapeutic measures may yet be reached. Among the more modern agents of supposed specific value may be mentioned creosote, guaiacum, tuberculin and its various modifications, dog serum, horse serum plain and tuberculized nuclein, chlorid of gold and sodium, cantharidid of potassium, chlorin water with chlorid of sodium, oil of cloves, cinnamon and other essential oils, chlorid of zinc, the formates, iodin, etc. There are many cases on record of moderate and even brilliant results following the use of each of these agents, both in laryngeal and pulmonary tuberculosis; but, as said above, the effects have been short of general utility. I am led to the conviction, from my own experience with these several agents, that they are perhaps less useful in a specific sense in laryngeal tuberculosis than in pulmonary tuberculosis. These agents have all been used in the general belief, of course, that all cases of laryngeal tuberculosis were simply the expression of a general infection. But undoubtedly some of the cases reported to have been cured have been aggravated forms of ordinary chronic inflamma tion of the larynx; while some may have been cases of chronic laryngitis complicated by syphilis. 11 have myself been deluded once in a while by such erroneous diagnoses, and undoubtedly others have met with the same misfortune. These remedies have been used both hypodermatically and per os. While the hypodermatic use of such remedial agents is manifestly more desirable, the attendant pain and difficulty of properly carrying out this plan of medication render its general adoption of doubtful practicability, especially in private practice.
I am still of the opinion that among these agents iodin, when conjoined with some proteid substance, furnishes the best results so far as specific medication is concerned. It seems to make some difference in the ulterior effects whether the drug is administered in connection with iodid of potas¬sium, glycerin, and water, without some proteid material or not, for I have found repeatedly in the same patient that the administration of the drug, either hypodermatically or by the mouth, in a mixture with sterilized bouillon will produce more lasting benefit than when given otherwise; so that we have adopted the habit in hospital practice, of administering it in bouillon or milk. It may also be given advantageously in combination with glycerin and extract of malt. I have also used creosote and guaiacol in the same way with apparently better effects than when given alone; and we may therefore be pardoned for the suggestion that perhaps the majority of remedies admin¬istered for constitutional effects if there are no chemical contra indications¬ would be more efficacious when so combined. Whether a chemical combina¬tion actually takes place between these agents and some unknown proteid of the animal fluid used, I am unable to say; but possibly at some future time this point may be satisfactorily demonstrated. Guaiacol and oil of cloves are both very useful when administered in an emulsion, in suitable doses, three or four times daily, or (sometimes a better way) in very small doses repeated every hour for a certain number of times, according to the tol¬erance of the patient. The former agent as "benzosol” has given very good results. In the more chronic cases characterized by anemia of the mucous membrane, phosphorus administered in solution with olive oil in capsule is highly beneficial. This combination may be found on the market in the form of capsules containing from one one hundredth to one thirtieth of a grain of phosphorus in 10 or 15 minims of oil. It should be administered always just after food has been taken, and if irritation of the stomach, urticarious eruption, or aphrodisiac effects follow its use, the dose must be materially modified or the administration of the drug stopped. Arsenic, especially the arsenate of iron, chlorid of gold and sodium, salicin, and strychnin are very valuable tonic agents. Strychnin and salicin are among the most useful agents for general effects. When there is much hyperpyrexia, salol or sodium salicylate may be substituted for salicin. For the temporary repression of temperature, acetanilid, or aconite, or judicious bathing may be resorted to. The somewhat prevalent practice of combining either of these agents with other things sometimes not synergistic is certainly a bad one! Of course, this criticism does not apply to mixtures containing sedatives, such as codein or hyoseyamus. But, as a rule, it is preferable to administer all drugs designed for temporary effect, alone. The use of alcoholic beverages in this disease is fraught with perplexity: for while in many instances alcohol in one form or another is indicated, yet the condition of the throat may be such as to prohibit it, either on account of the local pain attending its deglutition, or on account of its decided and directly deleterious effects upon the diseased larynx. It will be found better generally to select the malt beverages and preparations, rather than the spirituous. The administration of a little rectified spirit with milk, however, will be found useful when large draughts of whiskey, brandy, rum, etc., cannot be consumed without distress or evil effects.
The symptomatic treatment of laryngeal tuberculosis can scarcely be formulated, and will depend upon a variety of circumstances which will indicate the agents to be selected for each individual case in order to allay cough, pain, hyperpyrexia, diarrhea, mental perturbation, etc. As laryngeal tuberculosis when advanced is perhaps one of the most painful affections to which flesh is heir, the practitioner may be sorely taxed to meet the constant demand for relief without incurring other mischief. However, opium and its salts, for internal medication in such cases, still retain their popularity codein, morphin, or the powdered drug seems best. Cough may be mitigated by the milder anodynes, such as codein, tincture of opium, hydroechorate of cocain, hydrate of chloral, etc., together with the various expectorants and balsams (see Formulary). Care should be taken that syrups are not used too freely, lest nausea, vomiting, and anorexia be favored. Chlorid of ammonia and other chlorids may cause severe pain when the mucous membrane is ulcerated, otherwise they may be used. Sleep may be secured by the administration of sulfonal, trional, chloral, the bromids, or some preparation of opium, alone or in combination with one of the other anodynes mentioned.
The local treatment consists of inhalations of gases or medicated air, sprays, and powders. Inhalations of medicated air are of little permanent benefit excepting in the early stages, or when there is an unusual amount of salivary or other expectoration. There are a number of suitable inhalers in the market, from which volatile substances may be inhaled either with or without the aid of hot water. A simple instrument may be made of tin, with a perforated receptacle at its distal end for containing a piece Of sponge, upon which may be dropped preparations of creosote, carbolic acid, menthol, camphor, creolin, tinct. benzoin, tinct. myrrh, etc., combined with chloroform, ether, alcohol, or spirits of ammonia. These agents may also be dropped into hot water contained in a hot water inhaler. These instruments can be used by the patient several times a day, with sometimes very good effect in the early stages of disease. When, however, this form of inhalation increases the sensation of” dryness," ”stiffness," or pain referred to the throat, they should be discontinued. A preferable method of inhalation in general is accomplished by spraying the medicament into the throat from either a steam or a hand ball atomizer. The spray may be projected directly into the throat, or it may be projected (especially if it be oleaginous) into a globe inhaler (see Fig. 619), from which it can then be inhaled through a faceshield which will completely enclose the nose and mouth. This is a much more thorough method of local treatment in laryngeal phthisis, especially when the agent is in the form of an oleaginous solution. All such agents as creosote, camphor, menthol, carbolic acid, guaiacol, creolin, phenol, oil of eucalyptus, etc. may be dissolved in a pure fluid petrolatum or olive oil and projected into the inhaler, whence they can be carried into the larynx by the ordinary process of respiration. Although this means of' local medication may fail in many instances of producing radical change, it, nevertheless, affords a very practical and efficient method of relief. The watery solutions are best used by spraying directly, as near as possible, upon the parts. In this manner there may be used with tolerable efficiency solutions of formate of soda, biborate of soda, alum, boric acid, carbolic acid, cocain, morphin, hydrochlorate of coniin, tannic acid, sulphate of iron, sulphate of zinc, nitrate of silver, chlorid of zinc, etc. These chemicals may be used in varying quantities according to the requirements of the case (see Formulary). lnsufflations of powders upon the larynx, although of great value, especially when ulceration has taken place, are sometimes not well tolerated on account of the desiccation of the secretions or the prolonged and distressing paroxysms of cough which they produce. Among the agents most useful as insuffiations in laryngeal tuberculosis may be mentioned iodoform, iodoform with boric acid or bismuth, naphthalin, aristol, europhin, boric acid, tannic acid, ammon. citrate of iron and potassium, stearate of zinc or alum, subnitrate or tannate of bismuth, morphin with gum acacia, etc. The insufflations should always be preceded by a thorough spraying of the parts with some detergent solution, such as biborate of soda or phosphate of soda; and care should be taken that the amount of powder propelled upon the larynx is not too great, otherwise distressing spasm and cough may supervene, lasting a considerable length of time and producing not only extra congestion and irritation of the parts, but, perhaps, vomiting and exhaustion. It is often desirable to apply directly with a brush or pledget of cotton certain medicaments, in the form of pigments, to ulcerations. This may be done preferably by using the Wagner laryngeal brush or a pledget of absorbent cotton, either held by forceps or wound around the roughened end of a probe or applicator. In this way strong solutions of nitrate of silver, chloracetic acid, lactic acid, carbolic acid, chlorid of iron, chlorid of zinc, formaldehyd, creosote, formate of sodium, etc., may be carried to the part.
The range of surgical measures for the relief of this disease is necessarily limited. The papillomatous excrescences which sometimes accompany progressive ulceration may have to be removed by evulsion, snaring, or escharotics. Especially is this the case when such protuberances occur about the vocal cords or ventricular bands, and by their presence obstruct respiration or produce great mechanical irritation of contiguous parts. A few years ago Dr. Heryng adopted and promulgated the plan of thoroughly curetting tuberculous ulcers and afterward applying to the surface so abraded lactic acid in the proportion of 20, 30, or 50 per cent., solutions, or stronger, according to effects. This met with considerable favor for the treatment of some cases. There is no doubt that it may be a very efficient and practicable measure in cases of isolated ulcerations in the upper part of the larynx ; but for a large proportion of cases of laryngeal tuberculosis presenting no limited lesions, but a simultaneous breaking down of many spots separated from each other, this plan of treatment will necessarily be limited in its application. Besides this, many times the lesions will be found out of reach. Then, too, there are individuals in whom, for some reason, these parts are too physically sensitive for interference of that sort, even under the influence of cocain, without exciting a general disturbance which is not easily allayed. This was my experience in two favorable cases, when I was obliged to desist after early manipulation. The application of lactic acid without the curettement is generally well borne and efficient. Scarification of the larynx in the chronic form is a measure of relief which is not practised, perhaps, as often as it ought to be. The writer called attention to this plan of relieving the tension of the parts some twelve years ago; and many practitioners who have adopted the plan have reported good results from it. It ought not, however, to be indiscriminately adopted, because the objection urged against the practice, that it opened up the deeper tissues to probably further infection, holds good in many instances. However, as ulceration in any event is inevitable, especially after great infiltration, it will be found that the anticipation of nature's step in this direction by scarification will greatly modify the subsequent necrosis of the tissues, and at the same time enable the practitioner to meet the prospective condition by more thorough medication. I would therefore still advise in some cases of inordinate effusioneven though it be not considered edematous a reasonable amount of' scarification over the tumefied parts, whether it be the arytenoid cartilages, interarytenoid space, ary epiglottic folds, or epiglottis.
Hypodermatic injections of creosote or other agents into the laryngeal mucous membrane have been in my bands very disappointing. It must be confessed that local treatment in many cases is of little value, excepting for the palliation of pain and other phases of distress, mainly, perhaps, because the lesions are more or less out of reach and too deep in the mucous membrane. On the other band, in some of the slower going cases, characterized by limitation and accessibility of the lesion, a judicious local treatment constitutes our principal means of assisting nature to resist the progress of the disease. We must agree with Gleitsman that, theoretically, the thorough removal by surgical means of the diseased tissues and the induction of a healthy reparative process is the ideal desideratum; but, unfortunately, there are as yet no practical ways of successfully carrying out such laudable aims. So we are still, as it were, obliged to drift along empirically, without any exact principles of therapy to follow in the management of this disease. It will, therefore, be impossible to lay down any rules for the application of this, that, or the other agent or preparation; and the question of the selection of topical medication must be left to the skill and experience of the practitioner. It may be added, however, in conclusion, that of all agents for general use, perhaps none surpasses iodoform, aristol, resorcin, tannogen, or mercury protochlorid, used either by insufflation or in solution or in mixture with petrolatum oil. Next in value, especially when ulceration has begun, may be ranked lactic, chloracetic, and carbolic acids; and after these, chlorin water, sodium formate, silver nitrate, zinc chlorid, mercury bichlorid and biniodid, creosote, and oil of eucalyptus. The inhalation from a face shield inhaler of I ounce of solution of mercuric chlorid (I: 3000), immediately followed by an inhalation of from 2 to 4 ounces of a solution of (1 to 2 per cent.) iodoform in petrolatum oil, will oftentimes prove highly beneficial to a large number of cases. The inhalation of chlorin water combined with a solution of salt in water is also very efficient when it does not cause much pain or coughing. Usually from 1/2 to I ounce of each (mixed) is as much as ought to be given at a seance.
One of the leading therapeutic indications is toward the assuagement of pain and laryngeal distress. For such purposes we must resort preferably to the local application of either cocain, coniin hydrochlorate, bromoform, morphin formanilid, atropin, aconitin, chloroform, menthol, ethyl bromid, creolin, or similar agents. These substances are best used in the form of spray or pigment; excepting ethyl bromid and chloroform, which are volatile (see Formulary).
In cases where much soreness is generated from a more or less continued muscular action of the pharyngo laryngeal muscles, coniin hydrochlorate, menthol, or ice (held in the mouth until melted) will be found beneficial. For promoting an antagonistic effect against the burning and rawness often complained of, either aconitin, atropin, or hyoscin will be found useful in addition to other treatment.
Cocain hydrochlorate or morphin alone, or in combination with either iodoform aristol, naphthalin, or carbolic acid, will be found to be the " sheet anchors" for the relief of pain. The frequent cleansing of the throat with sprays containing peroxid of hydrogen, boric or carbolic acid, when well borne, is a good practice and one which greatly promotes the comfort of the patient, to say the least. The formulae for the use of these several agents are appended.
FORMULARY
Sprays.
(1) Zinc chlorid, 1 3%; (2) Zinc sulphate, 1 4%; (3) Mercuric biniodid, 0.2%, and Potassium iodid, 4% in glycerin and water.
(4) Sodium formate, 2 3 % (5) Coniin hydrochlorate, 0.2 %; (6) Mercuric bichlorid, 0. 2 %, and Hydrogen dioxid, 16 % in water.
(7) Alumnol, 2 % and Cocain hydrochlorate, I % in peppermint water.
(8) Oil of eucalyptus, 3 %; (9) Menthol, 1 %, and Camphor, 1 %; (10) Creolin, 1.5 and Alcohol, 0.2 0.5 % in liquid petrolatum.
Pigments
(11) Iodin, 0.4%, and Potassium iodid, I %; (12) Formaldehyd, 10%; (13) Pyoktanin (blue), 2%, and Acacia, 2% in water.
(14) Hyoscin hydrobromate, 2%; (15) Aconitin, 0.2%; (16) Morphin sulphate, 1%, and Antifebrin, 2% in glycerin and water.
(17) Lactic acid, 20 40%, in water. (18) Carbolic acid, 12.5%, in glycerin. Insqfilalions
(19) Tannic acid, 6%; Powdered starch, 19/%; and Bismuth sulmitrate, 75%. (20)
Resorcin, 50161c, and Powdered starch, 50161, .
(21) Aristol, 50%, and Powdered starch, 50%. (22) Silver nitrate, 1 2%, and Talc powder, 98 99%. (23) Tannic acid, 3%; Cannabin tannate, 7%; Bismuth subnitrate, 45 %; and Powdered starch, 45 %. (24) Silver nitrate, 3 %; Acacia powder, 32%; and Bismuth subnitrate, 65%.
(25) Armenian bole, 25%. Sugar, 257o; and Sodium biborate, 50%. (26) Morphin sulphate, 0.3%; Mild mercuric chlorid, 20%; Sugar, 40101c; and Bismuth subuitrate, 407c; (27) Morphin sulphate, 3 %, and Iodoform, 97 7,. (28) Iodoform, 11 %; Boric acid, 34 %; Naphtalin, 55 %; and Oil of Bergamot, a sufficient quantity.
Internal Medication
(29) Compound solution of Iodin (Lugol's solution), 15 cc., and Glycerin, 15 cc. Ten drops in milk every four hours.
(30) Syrup of ferrous iodid, 30 cc., and Compound syrup of the hypophosphites, 30 cc.
Tablespoonful three times a day.
(31) Salicin, 4 gm.; Calcium hypophosphite, 6 gm.; Whiskey, 150 cc.; and Fluid extract of Malt, 210 cc. Two to four teaspoonfuls three times a day.
(32) Sodium salicylate, 412 gm.; Cinnamon water, 120 cc.; and Water, 120 cc. Two teaspoonfuls three times a day.
(33) Powdered bone, 8 12 gm.; Glycerin, 30 cc.; and Cinnamon water, 90 cc. Teaspoonful three times a day.
TUBERCULOSIS OF THE NASAL PASSAGES AND THE PHARYNX
The Nasal Passages. Tuberculosis confined to the nasal passages exclusively or primarily occurring there is extremely rare (Cohen, Bosworth, Chiari, Hajek, Risdel, Kafeman, Schaffer). The disease is more often observed in connection with pulmonary phthisis of an advanced stage, or, according to Kafeman, in cases of latent tuberculosis. This author states that the reported cases of primary tuberculosis of the nose, pharynx, or larynx, without pre existing tuberculosis or latent foci elsewhere, should be received with a great deal of skepticism. Authoritative statistics derived from autopsies are cited in support of this statement.
The more common site for the development of the disease is in the region of the cartilaginous septum of the Dose, although Chiari observed that in his six cases other parts as well as the septum were affected; in one the maxillary sinus being involved. Kasehier distinguishes a form of the disease which particularly affects the bony framework . Lermoyez cites cases of the occurrence of tuberculous vegetations at the vault of the pharynx. There are a few cases on record in which tuberculosis of the naso pharynx seemed to follow operations for the removal of adenoid vegetations in patients who were previously free from either tubercular disease or hereditary tendency. A few such cases have been reported by Kafeman and others, One or two of which were followed by tubercular meningitis. It is sought to account for the occurrence of this latter class of cases upon the supposition that the wound of the operation offered an opportunity for the entrance of tuberclebacilli, carried there either by inspired air, food, the instruments or finger of the operator. Some writers believe that in all such cases either the bacilli or some tubercular formation is already present in the glandular tissue. I have never observed a case of primary nasal tuberculosis, although having seen several cases occurring in the course of advanced pulmonary plithisis. Cases have been reported in which the disease began in the form of a few papilloma like prolongations from the mucous membrane at intervals along the septum tubercul ar tumors, as it were. These cases are notable for their slow March. The lesions oftener occur just at the vestibule of the nose.
Etiology. The majority of observers believe that the only cause of the disease in this situation, as elsewhere, is the implantation of tubercle bacilli, and that these micro organisms may be conveyed to the part either from without by contact of sputum during acts of coughing or vomiting; by means of the finger, as in picking the nose; by the inspiration of bacilliladen air; or from within through conveyance from some remote focus by either the blood or lymph (Kafeman, Chiari). The well known ubiquity of the tubercle bacillus and the frequency of catarrhal affections of the nose entailing abrasions, etc., are relied upon in explanation of these modes of origin. Chiari believes that the infection generally takes place by the inoculation of some abrasion or fissure of the epithelium with tuberclebacilli conveyed there by the finger. Although adopting the idea of primal bacillary infection, he nevertheless states that be found tuberclebacilli in four only of his six cases. Kafeman, who published two interesting cases of so called primary nasal tuberculosis, and who likewise believes in the bacillary origin of all tubercular disease, found no tubercle bacilli in either of his cases, but in one of them some stray specimens of the Langhans bacillus. This author attributes the malady in his cases to a probable infection through abrasions of the mucous membrane by bacilli laden air, as neither of his subjects were tubercular nor of a tubercular tendency. The signal immunity of the nasal passages from tuberculous disease, when so constantly exposed to abrasion and invasion by tubercle bacilli, has been a subject of much perplexing speculation. Lately, however, experimental researches of the bacteriology of the nasal passages have led to some conclusions which may account for the hitherto observed immunity mentioned. Clausen found that the nasal passages of rabbits were apt to contain quantities of pyogenic bacteria. Von Besser, Fernier, Lermoyez, and others found that the human nasal passages, pharynx, and larynx contained numerous bacteria, such as the diplococcus pneumoniae, streptococcus pyogenes aureus, tubercle bacillus, etc. ; while St. Clair Thomson, Hewitt, and others found that healthy nasal passages were bacteria free. Fernier and Bretschreiber also, making similar investigations with varying results, concluded that the nasal passages were only quasi aseptic. The conclusions of Thomsen and Hewitt were to the effect that the normal secretions of the nasal passages and throat were bactericidal, and hence neutralized immediately the virulence of any superimposed in icro organ isms. From all these observations, and from the negative results of clinical experience, it is fair to infer that perhaps some of these cases of so called primary nasal tuberculosis were really of doubtful character. Those observers (Storck, Thost, Heryng) who really believe that fissures or abrasions of the mucous membrane invite the origin and development of the disease, confess that there must be some particular change in the cell life of the part in order to consummate the establishment of the malady. Strauss has found that the nasal passages and pharynx of healthy persons who spend much time in the presence of phthisical patients, or in rooms where phthisical patients are confined, contain large numbers of tubercle bacilli. The question as to the power of tuberclebacilli to penetrate sound epithelial tissue is yet an unsettled one. A further discussion on the etiology of this subject will be found in the section on Tuberculous Laryngitis.
Symptomatology. The early symptoms consist, for the most part, of a mild coryza and frequent attempts at sneezing, with a sensation of fulness and uneasiness within the nasal passages. The discharge, which is at first of a mucous character, gradually becomes more serous or muco purulent, but is not apt to be very profuse. After a while the nasal passages become more or less plugged with exfoliating crusts, which accumulate just inside of the nostril and cause considerable itching, burning, and other irritation. There is rarely much odor to the discharge, such as we meet with in ozena. There may be slight swelling of the skin of the nose, redness and marked soreness. Very little pain is complained of, however, unless the internal parts be touched. The disease is usually confined to the mucous membrane covering the cartilaginous septum, although after a time ulceration of the turbinals may be observed. The ulcerations are usually small, with red rims, and discrete, although in places there may be confluence of them, and they are not disposed to heal. Slow growing perforation of the cartilaginous septum is sure to take place, and in some cases this may be the first symptom to excite the alarm of the patient. The perforation gradually extends, by a molecular dissolution of the edges, until nearly the whole of the triangular cartilage disappears. When the disease takes an exacerbation, as sometimes occurs, its extension may become quite rapid, covering more or less of the whole line of the septum and even extending to the pharynx. The local symptoms in this event are, of course, very much aggravated. In all cases pain, coryza, and lachrymation may make the patient very miserable, aside from more or less constitutional disturbance. If the lungs or other organs are also the seat of the tubercular process, the constitutional symptoms of septicemia are very much a Favored. Tubercular meningitis is to be expected as a termination of cases of true nasal tuberculosis. In the form of the disease characterized by tuberculous tumors, the surrounding tissues are slow to take on reactionary disturbance, for the ulceration is slow and confined to the little neoplastic formations. It has been observed, also, that, the general disturbance is much less in these cases, and that the cartilaginous structures escape destruction for a longer time. Pericliondritis and periostitis, with necrosis, may be expected, however, in severe or neglected cases; but, as a rule, except for the destruction of the septal cartilage, the ulceration usually confines its ravages to the mucous membrane.
The Pharynx. Primary tuberculosis of the pharyngeal mucous membrane is very rare, but does occur, and may be tolerably latent for a time. It is frequently more or less mixed with syphilitic disease or laryngeal phthisis, and often coexists with these affections or carcinoma (Baumgarten, M. Schmidt). In my own practice I have never met with an instance which was not connected with either a syphilitic taint or with laryngeal or pulmonary phthisis. TWO notable examples which came under my observation were preceded in the one case by secondary, and in the other by tertiary, syphilis. Kafeman states that there are two forms of pharyngeal tuberculosis, one a miliary, and the other a papular or tumor, form. Cases of the former class are characterized by the development in many places of small miliary tubercles, and in the latter by the formation of one or two patches only generally upon the lateral walls and posterior surface of the velum palati. The nasopharynx does not seem to participate very often in the disease, but the base and tip of the tongue and the oral cavity are more likely to do so. The ulcers are small, surrounded by a narrow red, raised rim. As the disease advances they may coalesce and excavate more or less beneath the edges of the mucous membrane, giving the edges a raised, worm eaten, or irregular appearance later on. In some cases considerable infiltration takes place ace, so that the mucous membrane in the neighborhood or all over the pharynx (if it be the miliary form) appears edematous. The pharyngeal wall suffers, and the velum palati is also very apt to participate, in which case the uvula is edematous and ver tender. The shapes of the ulcerations vary, but are usually oval, more or less elongated, and covered with muco pus, either soft or partially desiccated. When situated upon the posterior wall, which is exceptional, the surface presents a cleaner and rawer appearance. Deglutition is always very painful the patient shrinking from swallowing very hot, very cold, or salty food. In some instances the deglutition of the saliva is very painful. In advanced cases the cervical glands are more or less swollen and tender, as are also the muscles of the neck. The patient presents an anxious expression of countenance, is pallid, and emaciates rapidly after the disease has progressed for some time, owing to the difficulty of obtaining sufficient nourishment. When the tongue is involved, the parts especially affected are the tip, sides, and base. Ulcerous cracks and fissures, more or less surrounded by small papillae, are characteristic. The organ is always very sensitive. In these cases, even if confined to the pharyngeal cavity, the tonsils are apt to be involved. Indeed, the tonsils are said by Strassmann Denochowsky, Dieulafoy, and others to be extremely liable to tuberculous disease. The first named observer found the tonsils tuberculous in 13 out of 21 autopsies made upon tuberculous subjects, and Denochowsky, in each of 15 autopsies of similar subjects, found the tonsils tuberculous. Dieulafoy injected parts of extirpated tuberculous tonsils into 61 animals, 13 per cent., of which contracted general tuberculosis. Cornil, on the other hand, examined 70 cases, and found giant cells in 4 only; while Virchow has declared that tonsillar tuberculosis is very rare. It is also said that the tubercular process in these glands takes place primarily in the deeper tissues the lower endothelial lining of the follicles or crypts and lymph spaces and that ulceration does not readily follow. For this reason the surface indications are therefore wanting and the disease may escape notice. The conclusions of some observers seem to indicate that these glands are common seats of latent tuberculosis. Nevertheless, the theory that a very favorable lodgement for tubercle bacilli is offered by the crypts of the tonsils, and also that the surface manifestation of the disease may be infrequent owing to deep infection, would seem to offer to a practical mind an inadequate explanation of the infrequency of the visible manifestations of tonsillar tuberculosis. Again, why should the advent of tubercle bacilli into the deeper structures of the tonsil through the blood vessels and lyniph channels, instead of from without inward, be a selected mode of infection? The only explanation worthy of acceptance would be that perhaps an antitoxic character belonging to the secretions of the tonsil is sufficient to render the surface immune to the action of tubercle bacilli that is, supposing that the bacilli are the only cause of the tonsillar disease. It will be remembered that St. Clair Thomson and others have shown that the nasal and buccal secretions are probably strongly bactericidal; and, if this be a fact, therein may lie the explanation of the frequent escape of these glands, as well as the upper air tract generally, from tubercular disease.
The diagnosis of nasal and pharyngeal tuberculosis is not always very easy. Syphilitic inflammation of the nasal septum, lupus, and sarcoma may easily be mistaken for tuberculosis. Indeed, lupus and syphilis are often much alike in their local characteristics, as well as tuberculosis and lupus. In syphilis, besides the history of the case, it will be found that the whole nasal septum is very much infiltrated, and that the disease is taking a more rapid course. When ulceration has taken place in syphilitic disease there is breaking down of larger areas, which may subsequently coalesce, although at first remaining quite distinct. The character of the ulcera¬tion is not particularly distinctive, for we may have in either disease a serpiginous, rag ged, undermined sort of ulceration with raised red edges. In pure syphilitic affections of the septum, where the disease is confined to the triangular cartilage, the differential diagnosis is quite difficult in the absence of supporting clinical history. Nevertheless, a microscopical examination may serve to determine the diagnosis, although it will not be safe to rest always upon the discovery of the tubercle bacilli alone, for these microorganisms may be always present to a greater or less extent in the nasal secretion, even in cases which are not really tuberculous, as shown by the researches of Strauss and others. From lupus, tuberculosis may be distinguished by the much slower course of the former affection and the presence of lupous disease of the skin just external to the nose, or somewhere about the face, and the absence of any great amount of surrounding infiltration and constitutional disturbance. Then, too, the presence of the characteristic small, pointed, pinkish granulations will serve to distinguish lupus. The lupous exulceration is inclined to heal and leave its characteristic sear tissue, while the tuberculous is not. The age of the patient also may serve to strengthen the differential diagnosis, for lupus of the nose, as a rule, attacks the young or the very old; while tuberculosis of the upper air tract is very rare under fourteen years of age (Demme, Bollinger).
From sarcoma, tuberculosis may be distinguished in the course of the disease by the absence of a distinct tumor, which is soft to the touch, of red color, of considerable size, and showing a disposition to rapidly enlarge from its point of attachment outward. The sarcomatous growth bleeds easily. Sarcoma can only be mistaken for the so called tubercular tumors which sometimes appear in the nose. But the latter are usually small and multiple; while sarcoma, as a rule, is confined to one or two points.
The prognosis of tuberculous disease of the nose or pharynx is certainly very grave, although if the disease be recognized early the prospects of the patient are not so bad, because in this situation, if there be little or no general infection, there is an opportunity of entirely eradicating the. morbid process.
The treatment for the disease in either of these situations should be chiefly local and surgical. No time should be lost in removing, as far as possible, the diseased masses, either with the curette or the galvano cautery, wherever they may be situated within reach. After this has been done a vigorous local treatment, consisting of the application of antiseptics, such as formaldehyd, formate of sodium, carbolic acid, resorcin, iodoform, chlorin water, or guaiacol, must be adopted. Tile last agent is reported by E. Frankel and H. Bergeat to be highly useful in lupus. It is also efficient in local tuberculosis. The thorough removal of the disease, as suggested above, will be found in all cases the most efficient method of treatment. Besides local measures, great benefit will be obtained from the internal administration of iodin, chlorid of gold and sodium, arsenic, and phosphorus. Climatic changes are not as markedly beneficial as when the larynx and pulmonary organs are involved, although any regimen and hygienic measure which will promote the health of the individual will, of course, be beneficial. No attempt to repair the edges of the perforation of the septum after the disease process has become checked by such methods as scarification, trimming of the edges, or cauterization will prove efficient. It will be found far better to simply promote the covering of the edges of the perforation, however extensive it may be, by emollient applications.
LUPUS OF THE AIR PASSAGES
Luptis vulgaris, the variety with which we are mainly concerned as is well known is particularly a disease of the external skin. It appears insidiously, as a rule, and slowly extending in that apparatus, terminates in a process of exulceration. It is also not infrequently met with upon the mucous membrane, which in many respects is histologically analogous to the external skin. Indeed, some observers believe that tile mucous membranes are more often affected first in lupus of the face. One of the most frequent sites for the development of lupus vulgaris is at the angle of the nose, the mouth, the eye, or somewhere in the neighborhood of an external opening of the body. While some dermatologists assert that any portion of the skin is liable to its attack, others assert, upon an apparently equal basis of facts, that certain covered portions of the skin are invulnerable. It has been asserted, as a rule, that lupus vulgaris always primarily occurs upon the skin and affects the mucous membrane afterward. However the rule may be, there are instances enough on record of the primary invasion of the mucous membrane to constitute at least marked exceptions. It is stated that there are many instances of lupous disease of the lining membrane of the nasal chambers, which ran for a long time without being discovered, where no dermatic involvement ever took place. The point of origin of lupus of the nasal cavity is most frequently in the mucous membrane covering the cartilaginous septum. From this point it may gradually spread intranasally along the septum or extranasally to the vestibule of the nose and the skin. Sometimes the pharynx is involved secondarily from a focus on the nasal septum.
Etioiogy. the principal etiological factor in lupus of the nose, as elsewhere, is supposed to be the tubercle bacillus. However, as this question will be fully discussed under the caption of Lupous Laryngitis, it need not detain us here.
Symptomatology. The objective symptoms of lupus are usually very mild, rendered so by its well known tendency toward a chronic course. The first symptoms may be unaccountable sneezing and slight corvza, although the discharge is not apt to be profuse except in the first stages of. the disease After the histological changes incident to the first stages of the disease have become developed, the breaking down or ulceration begins to take place in small spots, and then there will be more or less formation of yellowish or brownish crusts with slight ichorous or serous discharge. The appearance of the spot is not so characteristic as when the skin is affected. In the nose the infiltration is quite insignificant, and does not present that peculiar brownish granular appearance until after ulceration has taken place. When this has happened, lines or valleys with bacon colored bases may be seen, interrupted and surrounded here and there by little pinkish red granules, all of which are more or less covered with scales or crusts somewhat adherent. As said before, perforation soon takes place, and gradually enlarges as the disease advances. The course, of the lupous ulceration does Dot differ from that of other ulcerations, advancing by infiltration and subsequent breaking down, but its trail is covered by the formation of characteristic sear tissue, which is, however, much more delicate and less characteristic here, as in other mucous membrane, than upon the skin. I have never seen a case of nasal lupus in which the adjacent skin was not involved. The destruction of the skin and consequent contraction of cicatricial tissue necessarily produce more or less deformity of the nose. Lupus vulgaris is inclined to stop before the osseous tissue, confining its ravages to the softer parts. Exceptionally, however, especially in syphilitic cases, bone as well as cartilage proves no barrier to its advance. In such cases, the destruction of the tissues being greater, the deformity is also proportionately greater.
The prognosis is quite favorable, although the disease can rarely be checked without the production of more or less destruction of the nasal septum, with at least permanent perforation. A sort of eczematous eruption is apt to persist even after the recovery from the lupoid ulceration, which is a matter of considerable annoyance to the patient and very difficult to overcome.
Lupus of the pharynx is much more rare than lupus of the nasal passages, and although appearing without any relationship whatever to syphilis, is, nevertheless, more often found in syphilitic subjects. It is stated by many author that lupus is a disease which is found in tuberculous subjects or those of tuberculous tendency; indeed, as will be seen subsequently, many authors regard the two diseases as identical. This question, however, is still a practically unsettled one, and need not detain us here. The portion of the pharynx more often attacked is the soft palate, and of this the buccal, more frequently than the pharyngeal, surface. Next in order of frequency of occurrence may be mentioned the lateral wall of the pharynx, or rather the faucial arches, especially at their junction with the velum palati. In the cases of lupus of the pharynx which have fallen under my observation, the soft palate or the faucial folds have been the primary seat of the disease in all but one instance. The course of the ulceration in this situation is usually very mild, and leads to no more constitutional disturbance than when situated upon mucous membranes elsewhere, excepting as it interferes more or less with proper deglutition. In such instances the loss of body weight and consequent development of general physical weakness is progressively marked during the period of ulceration. After cicatrization takes place, however, these difficulties disappear and the nutrition of the patient soon assumes a normal condition. In a case which has been under my treatment the ulceration and destruction of tissue was considerable for a time, and as deglutition grew extremely painful, the patient, in consequence of lack of food, became very weak. This case occurred in a woman whose family were free, as far as could be ascertained, of' any tuberculous tendency, but who had suffered two years previously from a severe attack of small pox indeed, the skin all over the body presenting the marks or pits of the disease. We were unable to trace, however, any causal relation between the eruption of lupus and the variola; neither could there be traced in this case any syphilitic taint after the most thorough investigation into the life history of both the patient and the patient's husband. I have ascertained of no instance on record of lupus of the nasopharynx.
The prognosis of lupus in these situations is favorable unless the disease circumvents the tonsil or some other hidden place where adequate local treatment cannot be pursued.
Treatment. The local treatment should be a vigorous one, consisting of thorough excision or evulsion of the morbid tissues. For this purpose curettement and the galvano cautery offer the most suitable means. After this has been done, persistent local application of resorcin, iodoform, sodium formate, guaiacol, or carbolic acid, or escharotics, such as zinc chlorid, chromic acid, etc. The general treatment by iodin, iodid of potassium, and arsenic will prove , cry efficacious, especially the former. In the case of lupus affecting the soft palate or pharynx so as to interfere with proper deglutition, 4 per cent., Solution of Cocain should be freely applied to the diseased parts just before a meal is taken, and the meal should be such as to contain the most nutritious constituents of alimentation. Out door life and proper hygienic surroundings will add material benefits to any course of treatment.
Notwithstanding the fact that the tubercle bacillus is so often absent in many specimens of lupous tissue, yet the majority of writers persist in ascribing the essential cause of the disease to the tubercle bacillus of Koch, although the same observers note the discovery of the bacillus of Lustgarten as well. To account for the diverse clinical behavior of lupus, as compared with so called tubercular affections of other tissues, Councilman believes that the quality of the bacillus and the resistance or definite reactionary characteristics of the tissue invaded are quite sufficient, holding, for instance, that the histological peculiarities of the skin will resist the development of the tubercle bacilli in its tissues. and thus give rise to the slow and heterogeneous clinical phenomena observed in lupus.
LUPOUS LARYNGITIS
Lupous laryngitis is a chronic inflammation of the mucous membrane, characterized by the formation of small nodules or tubercles in the deeper tissue the submucosa. These nodules disappear either by resolution, exfoliation, or ulceration, leaving a peculiar cicatricial tissue. There are several varieties of lupus described by dermatologists, chief of which is lupus vulgaris the variety usually found affecting mucous membranes. Lupus erythematosus has received its name from Cazenave on account of its healing with the formation of sear tissue similar to lupus vulgaris. Many modern dermatologists and pathologists, however, think that it should not be classed with lupus vulgaris, because no tubercle bacilli have been found in the tissue formation of its eruptions. Unna, for instance, suggests that it be called seborrhea congestiva, and not classed with the tubercular affections. Besmier of Paris and some others argue that it is a tuberculous affection, and should therefore retain its present name. Leloir also believes that it is tuberculosis, and capable of reproducing, itself by inoculation. The disease commonly attacks, and is confined to, the skin; but when the site is in the neighborhood of any of the orifices such as the nares, mouth, ears, vagina, or rectum it is apt to extend and involve the contiguous mucous membrane. Exceptionally, however, it affects the mucous membrane primarily, in which. case the nasal or buccal mucous membrane, or that of the soft palate, pharynx, larynx, conjunctivae, rectum, or vagina, may be the part affected. Leloir's statistics show (Morrow) that out of a total of 312 cases of lupus, mucous membranes were involved 109 times the mucous membrane secondarily yet primary lupus of the nose, a more common type than formerly supposed, may escape notice. Neisser concludes that lupus of the face is generally caused by extension from adjoining mucous tracts, especially from that of the nose. The internal mucous membranes, such as the gastric, intestinal, or bronchial, are not subject to invasion, although a case is reported where the process was observed on the mucous membrane of the trachea.
Primary lupous laryngitis is quite rare, many laryn logists of large experience not having seen a case, while others have seen but very few cases each. Among these, Bosworth mentions having seen but one, M.Mackenzie two, Lefferts four, and Rice three. As the invasion is insidious and very chronic, and the signs of the same very obscure, many observers believe (as also of the nasal mucous membrane) that the disease occurs in the larynx oftener than is supposed especially as it generally attacks the young, who do not come tinder observation as readily as older persons. Among these observers, R. De la Sota y Lastra and Rice make this suggestion. The epiglottis is generally the part attacked, according to Chiari and Richl.
Symptoms. The constitutional disturbance incident to this affection is practically slight, unless the disease is so situated or so advanced as to interfere with the functions of deglutition or respiration, or unless some complication attended by unusual inflammatory or septic processes in the neighboring glands or tissues supervene. Such complications are rare, however, until the disease has run a very long and aggravated course; for there is usually but little tendency to general infection of any sort, although Leloir and others say that it may produce partial or general infection. Hoarseness and a sense of dryness or thickening referred to the throat, with slight dysphonia or dyspnea, are among the early and, it may be said, persistent Symptoms. There is little or no pain complained of unless the disease is advanced and extensive, or ulceration with an unusual amount of inflammation has taken place, when more or less difficulty of swallowing may occur, although not even then very much. When there is much swelling, attention is required in order to prevent the ingress of particles of food into the larynx during the act of destitution. The temperature rarely rises until the disease is quite advanced and complicated, and then perhaps only to 99' F. The local appearances are usually less marked on mucous membranes than on the skin. Michelson has shown that it is almost impossible to trace accurately the limits which separate the lupous tissue from the mucosa, because it is only in the cicatrices that we find the characteristic lupous nodule when the mucous membrane is the seat of disease.
The laryngeal face of the epiglottis is usually first affected, and presents a slightly swollen hyperemic condition with a few papular projections like granulations, which afterward break down into an ulcerated patch (see Fig. 618). In some cases the free border of the epiglottis appears whitish or gray, thickened and studded here and there with dark red papillomatous patches. After a while the laryngeal vestibule becomes altered in shape from the infiltration, etc. The thickened and Misshapen mucous membrane presents irregularly circular folds or rugae, appearing similar to a slightly prolapsed and puckered membrane, and is studded here and there with grayish glistening fissures and dark red papules, which in turn may be coalesced to form a patch. These places are not very painful to the touch nor during swallowing. At a later stage these spots; become softened and soon show evidences of slow, dry ulceration bounded by ragged edges or a slightly reddened granular areola. According to Leloir and contrary to Baumgarten, suppuration of the lupous patch is not an essential characteristic, and when present is due to the combined action of the agents of suppuration (streptococci) and the bacillus of Koch. If the seat of the disease be the border of the epiglottis, it may appear as if worm eaten (Lastra). Even now the swelling and hyperemia of the surrounding parts may be quite insignificant; for the infiltration seems undulatory and very chronic, so that the general condition of the patient may remain good in every particular. The progress of the disease is so slow that it may cover a number of years, and then may terminate in pulmonary or meningeal tuberculosis or epithelioma (Morrow), although not necessarily, for many observers have never known a case in a tuberculous subject (Bosworth). At the same time, the local process during this period is subject to great variations of exacerbation and quiescence. This is true of lupus affecting mucous membranes as well as the skin.
A retrogression is marked mainly by a gradual healing of the ulceration, with the formation of a thin, bluish gray, glistening cicatrix, somewhat more moist and duller, however, than the lupous sear tissue of the skin, and surrounded by zones of thickened, rough, dark mucous membrane. Then after a period of quiescence more or less prolonged (which in some cases leads one to the conclusion that a cure has been effected) there is a recrudescence which at the time may not be accounted for by any event in the domestic or clinical history of the patient. It will now be observed that two or more foci of papillary swelling with inflammation are starting from about the periphery of the old lesion. These may perhaps go through a more rapid or aggravated course of softening, tumefaction, and ulceration, etc., and may be accompanied by more infiltration of the surrounding tissue than at the former period. Indeed, some cases present a greater severity of local action at each successive exacerbation, so that the ulceration and inflammation may become somewhat alarming, while the ulceration perhaps assumes the serpiginous form spoken of by some writers. This event is quite dangerous when affecting the larynx, and apt to be extensive in its ravages, simulating to a certain degree lupus exulcerans (lupus exedens) of the skin. Besides this, the corresponding cicatrices from such an amount of destruction leave troublesome and sometimes vicious deformities, which may endanger life through interference with the laryngeal or esophageal openings (stenosis).
Etiology. Lupus was formerly regarded as related to scrofula, or cancer if not really cancerous by the older authors, mainly on account of the observation of cases becoming cancerous. It was also considered a sequence of syphilis. Ricord held that it was an inherited manifestation of tertiary syphilis. Kaposi, however, says positively that syphilis in a parent has no connection with lupus in the children; moreover, Habra and Kaposi have found recent syphilis and lupus in the same individual. The latter (syphilitic) view is to some extent prevalent nowadays. Again, it has been considered a scrofulous disease; but as so called scrofula is generally considered to be of tuberculous nature, or practically a form of tuberculosis, this view would coincide with the opinion now prevailing that lupus is a local chronic tuberculosis! Some authorities have believed, and do yet, that lupus vulgaris, especially in the skin, belongs to the scrofuloderms; that it is essentially a scrofulous disease! Kaposi and others combat this idea, and say in effect that scrofula is entirely absent in many cases of lupus. Indeed, it is now so classed by the majority of modern dermatologists and pathologists, and may be found in the category with tuberculosis verrucosa cutis, scrofuloderma (tuberculosis of the subcutaneous tissue), tuberculosis cutis, etc.
The tubercular nature of lupus was suspected for years before the discovery of the tubercle bacilli of Koch, on account of the histological analogies between the several affections as persistently pointed out by Friedlander and others; but the hematogenetic origin of lupus was not assailed until the discovery of the tubercle bacilli in lupous tissue (lupoma) by Demme, Koch, and afterward by others, when all doubt seemed to be swept from the minds of the majority, and the tubercle bacilli (as in other tubercular disease) became the recognized cause of lupus vulgaris. Moreover, these views have been strengthened from time to time by experimental and other observations apparently showing the inoculability and infectiousness of lupous tissue, for J. Jadassohn, Leloir, and others have cited instances of the production of lupus by inoculation, and they regard every case of lupus vulgaris as due to inoculation with the tubercle bacillus, thus denying the so called hematogenous development of the disease as promulgated by Baumgarten. Koch, Leloir, and others claim to have demonstrated this by the transmittal to guinea pigs and rabbits of tuberculosis by inoculation with lupous tissuecultures. The starting point is probably the entrance into the skin or mucous membrane of the tubercle bacilli in one of the following ways: 1, indirect inoculation from without; 2, indirect inoculation by continuity from deep tuberculous foci ; 3, inoculation by way of lymphatics or the veins passing through a tubercular focus more or less remote; 4, infection of hematic origin ; 5, infection by inheritance.
Methods 1 and 2 are probably the most frequent. However, there are no instances, I believe, where lupus has been a result of contact (contagion) of one lupous patient with another, nor where the inoculation of bacilli into the skin experimentally has produced lupus. Kaposi and other European dermatologists, and Duhring in this country, are rather skeptical as to the identit of lupus with tuberculous affections. Kaposi says: “Nevertheless, the attempted demonstration of the identity of scrofula, tuberculosis, and lupus has not yet proven such identity. Cases of 'inoculating tuberculosis' are reported in constantly increasing numbers, but it seems to be regarded as immaterial that years may have elapsed between the assumed 'inoculation' and the occurrence of the tuberculosis of the skin. No experimental proof has been offered, however, that characteristic lupus vulgaris can be produced by inoculation of tubercle bacilli." Drs. Morison and Symington' examined the tissue from twenty lupous cases without finding the tubercle bacilli, and M. Cornil examined the skin of eleven lupous patients, and found only one tubercle bacillus. Dr. Henneage Gibbes believes lupus a tubercular affection, but says that the bacilli are sometimes not found in the lupous tissue. Kaposi and others deny the infectiousness and heredity of lupus; but cases have been recorded where a parent of a patient suffered from lupus, and an instance where several brothers and sisters of another patient suffered from lupus. Leloir again says that diversity in the phenomena of the several varieties may be accounted for by the mode and seat of the inoculation (inoculation from within outward or from without inward) ; the deposit of the virus in parts more or less vascular ; the greater or lesser virulence of the virus inoculated, and different degrees of reaction of the tissues. All authorities agree that it is a disease of early life. Accordin to Leloir it begins generally in infancy, and may produce partial or general infection of the system. Concerning the exciting causes of lupus, especially as regards the mucous membrane, there seems to be a paucity of positive information. Syphilis and eczema of the Dose, and fistulae leading to the site of tuberculous disease, are cited as having induced the formation of lupus in a few cases; but mechanical or chemical injuries are not spoken of as probable causes of the disease in mucous membranes, unless we accept the theory of those who believe in the direct or indirect inoculation with tubercle bacilli, and who think that a previous abrasion is necessary for the introduction of the germ. Leloir's classification of the varieties, all varieties which be believes are tubercular, is as follows:
(a) True lupus, non exedens and exedens.
(b) Atypical varieties of lupus : 1, lupus vulgaris calloide ; 2, lupus vulgaris myxomatosus; 3, lupus vulgaris sclerosis and demi selerosis; 4, lupus vulgaris erytbematoid.
(c) Scrofulo tuberculosis, gummata dermatic and hypodermatic.
(d) Ulcerative tuberculosis : 1, secondary ; 2, primary.
(e) Mixed teguinentary tuberculosis resulting from a combination of two or more of these varieties.
A review of the conflicting literature upon the etiology of lupus from a clinical standpoint might lead to the following considerations :
(A) If lupus is due to the presence of the tubercle bacilli, and therefore of the same pathological nature as the other so called local tuberculous diseases, how can its peculiar clinical course, which is much at variance with that of other of the tubercular affections, be accounted for? Is there in the histological, biological, or chemical constituents of either the skin or mucous membranes at the orifices of the body any special antidotal property, in the form of either serum, cell, proteid, ferment, secretion, or tissue, which will so effectually resist the development or growth of tubercle bacilli or the extension of their accompanying toxins as almost to nullify their hitherto accepted destructive tendencies?
(B) What, also, is the reason that the implantation of tubercle bacilli in the mucous membrane of the larynx in one instance produces a slow going, practically non infectious local disease (lupus); while in another instance the same micro organism rapidly develops, extends, and thereby sets up a destructive local disease and a fatal general iDfection?
I confess that all the explanations with which I am familiar touching these points are inadequate to explain these clinical anomalies. The histological resisting character of the skin or its temperature and movements is urged by some observers in explanation of the very chronic and innocuous course of this disease. The paucity of the tubercle bacilli and their encapsulation contributing to render them latent is stated by Unna. Lastra, however, seeks to account for the incongruities observed by the supposition that the bacilli or their accompanying toxins may be attenuated, and in substantiating this view he reasons by analogy, and ingeniously cites the effects of attenuated doses of chemical agents on the system as compared with larger quantities or more concentrated qualities of the same, thus assuming that the cytogenesis or mitosis of a part depends upon the dosage. According to Unna, the smallest number of tubercle bacilli are able to stimulate productive inflammation, the formation of giant cells, and serofibrinous exudation; but be that as it may, could we, under even these conditions of attenuation, expect any such pathological process in the mucous membrane of the larynx, a part whose susceptibility to tubercle bacilli and tuberculous toxins are contimially alleged as a matter of fact ? Either we have not yet fully learned the morphology of the tubercle bacillus, or we must look upon the doctrine as a fiction that it (tubercle bacillus) is independently the cause of lupus of the larynx. There is no use of taking up space by theorizing, but it seems certain from the clinical history and pathological anatomy of lupus vulgaris of the larynx that its etiology depends essentially in some way upon a perverted or aberrant (karyokinesis catogenesis or nutations) process of regeneration of the constructed or formed tissues of the part, or that the bacillus of lupus, instead of being identical with the real tubercle bacillus of ordinary tuberculosis, is perhaps more closely allied to the bacillus of Fisch, which is found in rhinoseleroma.
Age. All authorities agree that lupus is a disease of early life, although there are instances on record of its occurrence at an advanced age.
Sex. The female sex seems to be more susceptible than the male. Of 79 cases collated by Bosworth, 51 were females and 18 males. Other statistics on this point coincide.
Heredity. There have been differences of opinion regarding the hereditary transmission of lupus, but unquestionably the instances of such transmission are rare.
Inoculability. I think the majority of dermatologists believe that the disease is inoculable, either directly or indirectly ; but as that question has been dealt with in the discussion of the etiology, there is nothing to be added here, excepting to recite the oft quoted verdict of the territorial jury viz., not proven."
Traumatism has been cited as a predisposing cause of the disease in the skin, and, by those who accept the doctrine of inoculability of the disease, is believed to be an important etiological factor.
Pathology. According to Prudden and Delafield, lupus consists in the presence of 11 small multiple nodules of new formed tissue, somewhat resembling granulation tissue, in the cutis mucosa or submucosa. By the formation of new nodules and a more diffuse cellular infiltration of the tissue between them, the lesion tends to spread, and by the confluence of the infiltrated portions a dense and more or less extensive area of nodular infiltration may be formed. There may be an excessive production and exfoliation of epidermis over the infiltrated area, or an ulceration of the new tissue."
In the clinical group of diseases called lupus there are other forms of lesion which are not caused by the tubercle bacilli.
Unna lays great stress upon the part played by the large so called plasmacells of Waldeyer, and thinks the giant cells are of secondary formation. He also points out that the tubercle bacilli are encapsulated in the giant cells, and therefore become latent. Jadassohn thinks the plasma cells are not of any particular importance in lupus, because occurring in other inflammatory processes.
Kaposi says that the pathology of the disease relating to the skin does not differ essentially from that affecting the mucous membrane.
In all instances of tuberculosis we find the tubercle the product of the tubercle bacilli a nodule of so called gran u lati on tissue,
composed bistologi¬cally of small round cells, deeply stained by coloring agents, together with larger cells possessing a clear nucleus that have been called epithelioid cells, and large cellular elements, with peripherally arranged nuclei and homogeneous center, the Langhans giant cells. These cells are enclosed between the meshes of connective tissue, and are characterized in distinction from normal cells by their instability. Sooner or later a modification begins in the nodule. Its center becomes necrotic i. e., the cell protoplasm is coagulated, the nuclei lose their power of responding to st aining agents, the intercellular substance also takes part in the degeneration, and there results oagulation necrosis in the Weigert sense a condition that has been called cheesy degeneration.
Diagnosis. Lopus of the larynx may simulate tuberculosis, syphilis, epithelioma, rhinoscleroma, or chronic glanders. According to Neisser (Morrow), the chief diagnostic points of lupus are the beginning in childhood and its very chronic course. If the lupus laryngis be secondary to the same disease of the skin or an extension from it to fauces and larynx, then the diagnosis may be easily made out. But when the larynx is primarily affected the task may be a more difficult one, at least in some of its stages.
The general clinical history, showing an absence of constitutional disturbances of any moment, will serve to distinguish it from laryngeal phthisis, and from syphilis by lack of the history belonging to the latter disease. On inspection, the absence of much inflammation, the dry, negative, unsuppurating appearance of the ulceration, limited in situation and not clearly defined, with rather coarse granulated edges, will usually serve to differentiate it from the sharply cut suppurating ulcers of syphilis surrounded with highly colored and tolerably well marked areola, and from the shallow roundish lenticular ulcers on a pale and swollen mucous membrane which distinguish from syphilis and tuberculosis this disease. When ulceration is active the local appearances might lead to some confusion, but in such cases the clinical history, as well as the characteristics of the local formation, will remove perplexity. Syphilitic ulceration of the nose often resembles lupus, and diagnosis in such cases may have to be suspended to await developments.
Rhinoscleroma, usually begins first on the skin of the nose. Its ulceration is flat and soon covered by a stiff crust. There is usually no softening nor ulceration, nor very much contraction, and no such melting away, so to speak, of the tissues as in lupus.
Epithelioma can only be mistaken for lupus when it is of ]oval origin in the larynx, which is not often. When so occurring it is generally situated at first either upon the epiglottis or in a laryngeal ventricle. It may be seen as a more or less reddish growth of uneven although unbroken surface and to stand out from the tissues. When breaking down it presents sinuou& slough patches or pockets and granulations, but no cicatricial tissue.
Treatment. The treatment should be both constitutional and local. The systemic treatment should be upon the tonic and so called alterative plan. The subjects of lupus more often than otherwise show the effects of privation or malnutrition. Therefore, a generous diet, out door life, and suitable clothing, together with such tonics as salicin, quinin, Fowler's solution of arsenic, tincture of the chlorid of iron, etc., should be administered.
Arsenic in one form or another has been considered highly beneficial for the last century. Indeed, it has been deemed by some as almost a specific for lupus. It certainly is one of the most useful remedies in vogue. Iodin and iodid of iron are also of great value, especially if combined with the syrup of the hypophosphites. In my limited experience the use of arsenical preparations and iodin, either hypodermatically or by the mouth, has given the best general results. Iodid of arsenic and Fowler's solution are the favorite preparations. Cod liver oil and malt preparations may also be taken with benefit. When there is a cachectic sallow appearance with tendency to lymphadenitis, phosphorus in oil should be given three times a day.
The chief indication for local treatment is the removal of the offending tissue. This has always been the desideratum. The older practitioners sought to accomplish this elimination by means of powerful caustics, such as caustic soda, caustic potassa, arsenious and nitric acids, chlorid of zinc, etc. More recently the dermatologists have resorted 'to either the knife or curette for the speedy removal of lupous tissue. This surgical plan has also been adopted in cases of lupus of the mucous membranes, but according to Bosworth with the effect of aggravating the disease. Undoubtedly, when so situated that the diseased tissues can be wholly cut away at once, such an operation would be performed.
The use of the galvano cautery ought in many cases to supersede other escharotic treatment, although strong solutions of chlorid of zinc or lactic acid are very satisfactory in their effects. The case which I have cited was treated locally, mainly by occasional applications of lactic acid followed by daily applications of a spray of a strong solution of resorcin. Pyoktanin, topically applied as Bougard's paste or injected into the parts by the hypodermatic syringe, is reported as being efficient. I have used a solution of iodin in this manner, but could not see that the effects were more striking than when introduced elsewhere under the skin. The application of balsam of Peru has been reported as giving good results. There is danger of producing edematous or phlegmonous inflammation of the larynx by rough treatment; for that reason it is obvious that the same thorough treatment as applied to the skin would be inadmissible for application to the larynx. For routine local treatment it will be found that resorcin or iodoform, or both, in conjunction with the careful use of the galvano cautery, lactic or chromic acids, will constitute the most efficient and safest treatment for this disease.
The use of tuberculin and tuberculocidin seems to have been abandoned.
LEPROSY OF THE AIR PASSAGES
Leprosy often involves the mucous membranes in the course of the general affection, and its lesions might be confused with the others here considered; but it is probably always secondary to the cutaneous manifestations of the disease, which should make clear the diagnosis, and is too rare to demand discussion here.
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