Chronic Inflammatory Diseases Of The Larynx

Chronic Inflammatory Diseases Of The Larynx
By C. E. DE M. SAJOUS, M.D.,
OF PHILADELPHIA.
CHRONIC LARYNGITIS.

As here understood, the term chronic laryngitis simply means a condi tion of the larynx brought about by chronic inflammation affecting either the superficial or deep tissues of this organ, and involving either a restricted portion or the totality of the parts concerned. Syphilis and tuberculosis of the larynx, sometimes termed " syphilitic " and " tubercular " laryngitis, are considered elsewhere in this volume.

Etiology. In the vast majority of cases, chronic laryngitis represents but an anatomical subdivision of a chronic inflammatory disorder involving the respiratory tract, the nasal cavities anterior or posterior the pharynx, the tonsils post nasal, pharyngeal or lingual the trachea, and the bronchi representing as many foci. Indeed, chronic laryngitis per se, involving no other portion of the respiratory surfaces, is rarely met with, except in persons such as singers, clergymen, public speakers, officers, hucksters, etc., who are called upon to use their voices excessively and vigorously. Occupations such as those involving arduous labor in a dusty or smoky atmosphere are also capable of inducing a chronic inflammation of the larynx, but in these, likewise, the vocal organ is but a part of the area involved, the nose, nasopharynx, and pharynx being also kept inflamed through contact with the extraneous irritants. Gastric and hepatic disturbances, especially those caused by the abuse of alcoholic drinks, are frequent causes of chronic laryngitis, as evidenced by the hoarseness of drunkards and the laryngoscopic image presented by the larynx in such cases. Here again however, the glottic turgescence and hyperemia but represent what might be seen along the entire mucous surfaces the active manifestation of a general vascular engorgement.

Four prominent subdivisions of the general causative factors will best serve to clearly define the limits wherein each line of remedial measures will find its most effective application. Starting with the source of congestion most benign in giving rise to local manifestations, we have first, contact of the mucous surfaces of the larynx with a dust , smoke , or fume laden atmosphere capable of eliciting a marked hyperemia of the parts. In this class may be included smokers who indulge their habit immoderately and who spend much of their time in the vitiated atmosphere of bar rooms, smoking cars, etc. In these cases the mucous membrane of the entire mucous tract is, as it were, bathed in fresh smoke with each inspiration, the respiratory act thus serving to maintain the contact between the irritant and the mucous surfaces. The constitutional effect of tobacco nicotism enters but slightly in the causation of local congestion. The local irritation produced is further aggravated in smokers who expectorate freely, the main factor in the causation of the congestion being an abnormal dryness. In individuals who make it a practice to inhale smoke deeply, a whistling rale resembling that observed in mild asthma is frequently heard. Singers, public speakers, etc. often suffer from hoarseness after a long railroad trip, during which their organs of phonation and respiration have been exposed to the drying and irritating influence of smoke and dust. Workers in tobacco, weavers, mill hands, etc., may be included in this category of cases. That deficient lubrication of the upper respiratory tract plays an important part in these cases is shown by the thirst which attends them. Alcoholism is thus sometimes engendered, the alcoholic beverages tending in turn to aggravate the trouble.

The second class of causes, and one which, as already stated, furnishes by far the greatest number of cases of chronic laryngitis, is represented by all disorders of the nasal cavities, anterior and posterior, which interfere with their normal physiological functions. To allow the ingress of a sufficient quantity of air, to warm the latter and rid it of its irritating particles or noxious micro organisms, are functions which, interfered with, promptly give rise, directly and indirectly, to morbid processes in the regions which they were intended to protect. Chronic catarrhal affections, stenotic or atrophic, septal deviations or tumors by compromising the lumen of the upper respiratory passages and reducing or arresting the outpour of nasal mucus, by limiting the powers of the ciliated epithelium, transform parts which formerly acted as guards above the larynx into centers of morbid changes. These may exert their influence directly by continuity of tissue and the irritating action of muco purulent secretions which find their way into the larynx ; indirectly, by imposing more or less mouth breathing dusty, unwarmed, and perhaps septic air thus coming into direct contact with the laryngeal mucous membrane.

The third class includes the various visceral or diathetic disorders frequently overlooked as causative agents. In a large proportion of these cases the larynx but furnishes the most salient evidence of a general hyperemia of the mucous membranes. This hyperemia may be incident upon some disorder compromising the functions of the vascular system, either by causing on the one band changes in the elements of the blood itself, or by offering a mechanical impediment to its circulation, especially in the capillaries, the result of a localized engorgement. The liver is the organ of predilection in this particular, the hepatic engorgement being in turn frequently secondary to a gastric disorder. Such cases commonly stiffer also from hemorrhoids. As to diatheses, it is quite certain that in gouty subject’s general treatment calculated to antagonize the effects of the dyscrasia acts promptly when local treatment will utterly fail. As regards syphilis, a chronic laryngitis occurring in an infected individual will be materially benefited and frequently cured by a course of iodid of potassium after all topical measures have proven futile. Again, cod liver oil and iodin will do more to cure chronic laryngitis in lymphatic children than any direct medication. All these undeniable fact's point to the influence of general affections upon laryngeal tissues a point too frequently overlooked (see also page 875).

In excessive professional use of the larynx, coupled with faulty methods of tone production, we have the fourth variety, and the most pernicious etiological factor as regards local anatomical changes. A peculiar feature of these cases is that they do not always present active symptoms, baritones and bassos frequently showing laryngoscopically every evidence of active inflammation intense redness of the vocal bands, marked thickening of the margins of the glottis, etc. without suffering from the least hoarseness to attract attention to the vocal organ. These cases point to the effects of overuse namely, a localized engorgement of the superficial blood vessels caused by intense and prolonged muscular contraction. The vessels beneath the surface being, as it were, supported by surrounding tissues, the superficial capillaries bear the brunt of the undue blood pressure, owing to the absence of resistance afforded by their location, and become inordinately and permanently dilated. Years are doubtless required to produce this varicose condition in the average case, but an undue effort at a time when a singer is not in his usual good health may in an instant cause a vascular dilatation presenting the same redness, but attended by all the phenomena of an acute inflammation, the precursor of a tedious chronic catarrhal disorder susceptible to frequent exacerbations.

Chronic inflammatory disorders of the larynx are more frequently observed in men than in women, because they are more exposed to the etiological factors outlined than the latter. Smoking and drinking are prolific indirect causes, as stated, and these habits are most generally indulged in by the male sex. Chronic laryngitis can occur at all ages;

Symptoms. Impairment of the voice is naturally the most prominent symptorn one but little, if at all, influenced by the nature of the primary cause of the laryngeal disorder. A sensation of rawness or tickling gives rise to the desire of hemming or hawking a voluntary effort to rid the larynx of a supposed offending mass of mucus. The hoarseness may not be continuous, but occur only after the voice has been used for a short time. In some cases the voice is at first quite veiled or hoarse, and after a few words or Sentences have been spoken it becomes temporarily clear. The vocal disability, however, is sometimes shown by a feeling of local fatigue, beat, and constriction. In singers all these symptoms may be present simultaneously, the least effort at singing inereasing the trouble. The voice is usually lowered in pitch. Complete aphonia occasionally occurs. Pain is an occasional symptom, denoting the probability of rheumatic diathesis. Cough provoked by the sensation of itching already alluded to is present in the majority of cases and is occasionally spasmodic. The expectoration is scanty, however, unless tracheal or bronchial trouble is also present.

The laryngoscopic appearances vary considerably and are proportionate to the degree of active inflammation. The evidences of local hyperemia are nevertheless always present, and vary from a slight arborescent and light pink tinge, suggestive of congestion, to a bright red hue, indicative of violent inflammation. The epiglottis is also congested, enlarged vessels coming over its posterior surface, while the aryteno epiglottic folds appear thickened, the tumefaction involving the entire larynx in marked cases. The general redness, however, is not so marked as in some cases of acute laryngitis. The vocal bands are also more or less congested; the congestion may either be limited to a small portion of their surface or involve their entire area. Small masses of stringy cream like mucus are frequently to be seen forming films when the glottis is opened.

In some cases the vocal bands appear relaxed and their thickened edges do not seem to come accurately together, an elliptical opening being occasionally observed between them. This want of parallelism is due to muscular paresis (see Plate 15), affecting usually but one side. Shallow abrasions of the epithelial covering are occasionally met with, especially in the interarytenoid space. Deeper ulcerations, sometimes leading to perichondritis, have been observed by various clinicians.

In some cases the secretion, besides being muco purulent or purulent, is prone to adhere firmly to the mucous surfaces and to become partly desiccated in this situation. The dry crusts formed, by impeding the free passage of air, give rise to more or less dyspnea. Laryngoseopically examined, the larynx appears red and dry, with greenish crusts closely adhering to parts adjoining the vocal cords either above or below. Owing to the appearance of dryness, a special name, laryngitis sicca, is frequently given this disorder. The breath expired from the mouth is usually very fetid, hence another name, ozena laryngis, given it by observers who considered the disease as invariably associated with atrophic catarrh of the naso pharynx. It is probably a rare manifestation of chronic laryngitis, but it appears to me one possessing an insufficient number of known characteristics to warrant for it a special position in our nomenclature.

Hemorrhage of the larynx sometimes occurs in the course of chronic laryngitis in connection with severe cough and copious expectoration. In a case related by Michael Pleskoff the expectoration bad been bloody on several occasions. Laryngoscopy revealed the ordinary diffuse redness of the vocal bands common to chronic laryngeal catarrh ; but in the region of the left vocal process, near the ventricle, there was an elongated, submucous, circumscribed bloody patch, which covered half the breadth of the vocal baud., and which was evidently due to rupture of a blood vessel. The treatment instituted consisted solely in suppression of the voice, and gradual absorption of the effused blood took place with its disappearance in three weeks.' Another marked case was recently reported by Compaired .2

The infraglottic space is frequently involved in the inflammatory process, and the mucous membrane of its walls sometimes projects slightly beyond the margins of the glottis, especially when the vocal bands are abducted. In the so called laryngitis sicca this region is one of predilection for the formation of crusts.

Pathology. . Whatever the primary causative factor, the main pathological feature of these cases is dilatation of the vascular supply, the vessels of the bands reaching in some cases, as already stated, a condition of varicosity. The chronic character of the disease is mainly due to paresis of the vascular walls and to the hyperplastic character of the chronic inflammatory process. In mild cases it is probable that there is merely deficient lubrication, especially when an atrophic rhino pharynvitis represents the primary cause, hyperesthesia of the surface taking an active part in the production of the subjective symptoms. Prognosis. Marked cases of chronic laryngitis seldom tend toward recovery. In cases in which the disorder is due to irritation by inhaled irritating substances, the continued use of the voice and the inhalation of dust and smoke attending everyday life are as many conditions tending to keep up the trouble, if not to aggravate it. These sufferers are seldom willing or perhaps able to give up an occupation in order to counteract a disease the symptoms of which do not involve marked suffering or danger to life. This is especially the case in patients in whom the voice is not a source of livelihood, as it is in singers, speakers, etc. In the great majority of these cases, therefore the chances of recovery are to a degree compromised by circumstances beyond the physician's control. When they are within his control, the prognosis is at once modified, appropriate treatment and a judicious change of occupation leading to recovery in many uncomplicated cases.

Cases of chronic laryngitis in which the primary causative agent is represented by some disorder of the naso pharyngeal tract generally respond promptly to measures capable of favorably influencing the morbid, process. The prognosis of these cases, therefore, depends upon that of the primary disease. The same can be said of cases in which visceral or diathetic disorder plays an active role as an etiological factor. Hepatic torpidity added to gastric insufficiency are with difficulty overcome, and a chronic laryngitis due to these conditions, while yielding to judiciously directed measures, frequently reappears with much greater suddenness than it departed.

The prognosis of chronic laryngitis in singers is often a question of great moment, a brilliant career being frequently at stake. Fortunately, advanced laryngeal therapeutics enable us to satisfactorily treat even the worst of these cases, provided our instructions are properly carried out.

Another question of importance is the possibility of complications during the active inflammatory process, and particularly the likelihood of a simply chronic laryngitis being transformed into benign or malignant growths or into tuberculosis of the larynx. As to benign growths it is undeniable, judging from clinical evidence. Still the proportion of benign neoplasms as compared to that of cases of marked chronic laryngitis is so small that the presence of a concomitant dyscrasia capable of manifesting itself when hyperemia is prolonged beyond a certain limit can but suggest itself. The same might be said of malignant growths until we are better acquainted with their pathology. As regards tuberculosis of the larynx, no case so far reported warrants the assertion that a catarrhal inflammation can at any time give rise to a local tubercular process. Indeed, a careful clinical study of the subject has led me to conclude that tuberculosis of the larynx is primarily due to precisely an opposite condition, local adynamia, and that what benefit topical applications afford in the treatment of " tubercular laryngitis," socalled, is in a measure due to the local stimulation produced.

Treatment. To properly treat chronic laryngitis the predominating etiological factor of each case must be clearly determined. The local application of astringents to the larynx in a patient in whom a disordered digestive system plays the leading part can but finally prove ineffectual; the relief obtained is soon attended by a return of the symptoms. To treat the larynx alone when a nasal disorder is also present is as futile, unless the laryngeal inflammation be a mere exacerbation of a latent catarrhal process that is soon to yield of its own accord. In other words, to merely treat the larynx without seeking for the primary cause, proximal or remote, is to court defeat or to accept time as an ally in the great majority of cases. In this disease, probably as much as in any other that could be named, the removal of the active cause is the most important feature of the treatment; the application of topical remedies playing a secondary although important role in hastening the successful issue. Briefly, in cases due mainly to continued irritation of the larynx and adnexa by such extraneous elements as dust, smoke fumes, etc., a change of habit or occupation should be enjoined; when the laryngeal disease is due to a morbid process of the nose, naso pharynx, pharynx, etc., this morbid process should be corrected; when a gouty or rheumatic diathesis, a gastric or hepatic affection, etc., is at the bottom of the trouble, general treatment of the condition is all important; when in singers, speakers, etc., the organs of phonation are improperly and excessively used, the paramount indication to insure success is to correct the errors. The prognosis of the case depends mainly upon the perfection with which all these indications can be carried out.

The topical measures vary but little, whatever the primary cause of the local trouble, and common to all forms is the maintenance of cleanliness, not only of the larynx itself, but of the naso pharyngeal cavity as well. For this purpose, a drachm. of bicarbonate of soda dissolved in a pint of lukewarm water serves an admirable purpose. A few tablespoonfuls of this solution being placed in an atomizer, the pharynx and larynx are freely sprayed at short intervals during two or three minutes. The balance of the solution is then employed to cleanse the naso pharyngeal cavities, the palm of the hand being used as a dipper from which the liquid is inhaled. The patient should do this morning and evening and on reaching home from work, if his occupation happens to be one capable of causing irritation of the mucous tract. After using the warm detergent spray, the patient should employ in the same manner a solution of resorcin, 5 grains to the ounce.

To obtain contraction of the superficial blood vessels, local applications of active astringents must be made. The most satisfactory of these is still nitrate of silver, employed in solutions varying from 10 to 60 grains to the ounce. When erosions are present the latter solution should be preferred and applied after slightly anesthetizing the laryngeal surface to prevent spasmodic contraction. A small pledget of cotton should be used, and after being adjusted in the grasp of the forceps and dipped in the solution it should be lightly squeezed between the folds of a towel to prevent dripping. When another remedy is preferred, a solution of sulphate of copper, 30 grains to the ounce, may be employed. In cases uncomplicated by erosions, etc., weaker solutions of nitrate of silver or a 10 grain solution of tannin in glycerin applied every other day, besides the measures to be carried out at home by the patient, usually suffice to bring about recovery, provided the original cause has been properly treated. Important in this connection, especially when treating people who use their voices professionally, is always to include the infraglottic region, the portion immediately below the vocal bands, in the remedial measures adopted. A peculiarity of the mucous membrane of' this region is to form creases or longitudinal folds when the bands are not in extreme adduction. Upon the integrity of this crease forming quality greatly depends the character of the voice. In the treatment of singers, local applications including the infraglottic space and calculated to reduce congestion and irregular traction upon the edges of the vocal bands will be found to control much more readily a case of hoarseness due to an acute, subacute, or chronic disorder than when the same application is limited to the tipper laryngeal cavity. As soon as the regular formation of creases is interfered with, the tension upon the vocal bands becomes excessive or irregular, and there is added to the catarrhal or other anomalous local conditions present one of even greater mechanical moment.

These cases are frequently characterized by what might be termed a subacute exacerbation. The benzoate of sodium, 5 grains every three hours, usually suffices to arrest this intercurrent trouble. If the attack is a sharp one, the patient should remain at home and inhale every hour the steam of a mixture of two teaspoonfuls of the compound tincture of benzoin and a pint of boiling water. The vessel containing the water should be covered with a towel folded into the shape of a Cone; into the upper opening Of this cone the patient introduces his nose, mouth, and chin to better confine the benzoinladen steam inhaled and prevent too rapid a dissipation of the beat.

In cases of long standing the superficial blood vessels are sometimes permanently dilated to twice their normal caliber and are increased in length in proportion. Astringents here are useless. The only measure likely to procure a return of the voice is to cauterize the varicose vessels of the surface of the vocal bands. Chromic acid is the best agent for the purpose. After thorough anesthetization with a strong solution of cocain, the acid, fused by heat to the end of a covered probe, is applied to one of the bands while the patient in his effort to make a sound brings the bands in apposition, and thus renders accidental cauterization of their edges impossible. An abrasion the size of a small pea is the result, and this spot, after healing, is distinctly whiter than the surrounding parts. The applications are to be renewed every few days, each band being treated alternately, until all the areas of superficial congestion have been destroyed.

Krause of Berlin, in stubborn cases occurring in singers, recommends a method considerably employed in the United States many years ago i. e., minute longitudinal incisions made with a lancet shaped laryngeal scarificator into the hyperplastic tissues of the bands. The bleeding is slight, and rapid improvement ensues. In the same class of cases Massei of Naples recommends spraying with a 2 per cent. solution of lactic acid, used frequently, eight to ten times daily. Hygienic measures and tonics form important adjuvants.

In mild chronic laryngitis frequently attending an overworked professional vocalist, an exacerbation of the local trouble is often due, as already stated, to deficiency in the lubrication of the vocal bands. This condition is successfully combated by the administration every two hours of 10 grains of ammonium. chlorid in a tumblerful of water, and the topical use of warm sprays of a saturated solution of potassium chlorid at the same intervals. The doses are so managed that the last one should be taken at least about three hours before a performance. This avoids exposure during the subsequent stage of perspiration. A lozenge containing one grain of the ammonium chlorid taken between acts is of benefit in some instances, mainly owing to its effect upon the pharynx.

Of importance in these cases is the question of rest. This is always indicated, especially in female voices, a fine voice being always endangered when it is used during a more or less grave local disorder. Our recommendation should be framed accordingly, taking the severity of the local trouble as our guide as regards the duration of the resting period and its degree. Unfortunately, rest is rarely possible in professional singers, and as long as a vestige of voice remains they insist upon a continuance of their work. What are we to do in these cases? Without doubt the most advantageous plan to all concerned is frankly to disclose to the patient the dangers incurred; to recommend abandonment of rehearsals; limitation to the smallest degree possible of the part to be sung or spoken ; to transpose, when possible, all high notes, or, if this is not possible, to shorten the chest register a couple of Dotes, thus changing to the bead tones without having to throw upon the larynx the strain of the two highest notes of the chest register; in other words, to limit as much as practicable the work of the vocal apparatus.

Besides the local measures recommended, these cases require special efforts to overcome the muscular fatigue entering for a great share in the subjective symptoms. Strychnia, 1/60 of a grain every three hours, and electricity are usually effective. The faradic current is most effectively employed in the following manner, which introduces water as a conductor for the current, thus avoiding the local irritation caused by contact with the electrode, and doing away with all gagging: The patient having taken what is usually called a mouthful of water in reality, about an ounce is told to throw his head backward and to open his mouth. The first movement of deglutition causes the water to fill the pharyngeal cavity. Light being thrown in, a Mackenzie laryngeal electrode is introduced and simply immersed in the water, the external electrode, thoroughly wetted to secure penetration through the skin, being placed over the thyroid. The circuit being then closed by pressing the button of the Mackenzie electrode, the current is allowed to flow as long as the patient can hold his breath. The mouth electrode being then taken out, he can, either by closing his month and bowing his bead forward, bring the water forward and take a few breaths through the nose, then renew the first movement, throwing the head backward, etc., or take another mouthful of water, after ridding himself of the first. The oftener the sittings which should last at least fifteen minutes are renewed, the better ; the patient may even be taught the procedure, and he can then treat himself twice or three times daily at home.

When there is a tendency to the formation of crusts, as in " laryngitis sicca," the benzoin and steam inhalations are very effective. Iodid of potassium, five grains in a glass of water after each meal, has given me the best results. Local applications of a 30 grain solution of nitrate of silver usually prevent a return of the trouble.

NODULAR LARYNGITIS, OR CHORDITIS TUBEROSA.

Etiology. This is a disorder of the mucous membrane of the vocal bands, consisting in the development of small nodules on the surface or edge of the latter as a result of chronic laryngitis. The use of the voice while an inflammatory process is present in the larynx, a faulty method of singing, friction of the free edge of one band against that of the other where the voice is considerably used, are the main primary factors to which this disease is attributed. It is almost always observed in singers and public speakers, and more frequently in sopranos and tenors than in baritones and bassos. According to Moure,' this affection is frequently met with in children from seven to ten years of age.

Symptoms. The most prominent symptom is hoarseness, or an irregular production of the voice, characterized by the escape of air simultaneously with the emission of sound. In some cases there is apbonia when the normal vocal effort is made in speaking, while sound is emitted during vigorous enunciation. lit others, again, complete aphonia exists. There is usually no dyspnea, and in fact no evidence of local trouble other than the mild chronic laryngitis which is usually present in such cases.

The nodules may be situated upon either band. In the few cases I have had occasion to treat they were situated on the free edge of the left band a mere coincidence, doubtless. In one case there was evident irritation of the same spot on the other band, caused by the friction of the nodule. In this manner secondar nodules are thought to be produced, as they are frequently symmetrically located. The growths are usually the size of a pin head; in one of my cases, however, the growth bad reached at least four times that size. The nodules are usually pinkish gray, an areola of red, from which arborescent venules sometimes project, surrounding the base. They are said to sometimes disappear spontaneously or to become changed into laryngeal growths of another variety.

Pathology. The nodules are the result of inflammatory action. The hyperplasia, at first limited to the epithelium, finally implicates the tissues beneath, the changes consisting mainly in cellular tissue hypertrophy. The epithelial elements are also largely increased.

Treatment. I am inclined to believe that the nodules reported as removed by the local application of strong solutions of nitrate of silver or of iodin were not really nodules, but merely ampullae or tortuous blood vessels, such as those occasionally observed in chronic laryngitis of old standing. In bona fide cases, the only measures found of real service in my cases were chromic acid crystals, the silver nitrate in its solid form, and the galvanocautery. Either of the former two agents may be fused upon the end of a protected probe and applied to the nodules after anesthetizing the laryngeal surfaces. Of the remedies mentioned, chromic acid has served the best purpose, applied in the manner described in the section on chronic catarrhal laryngitis. Nitrate of silver and the galvano cautery leave a sear like tissue which might ultimately compromise a fine voice.

PACHYDERMIA OF THE LARYNX.

Although this affection is not always considered as a morbid entity, its pathological features are nevertheless such as to warrant its classification among the special complications of chronic laryngitis.

Etiology. Pachydermia of the larynx is a disease consisting of symmetrically elongated swellings of oval shape, most frequently observed near the posterior extremities of the vocal bands, especially the region of the vocal processes. It occurs especially as a result of the chronic laryngitis observed in persons addicted to the excessive use of alcohol and tobacco, and is sometimes ascribed to tuberculosis and syphilis. Judging from the cases so far observed, it occurs most frequently in men between thirty and forty five years of age.

Pathology. In a series of fifteen larynges affected with pachydermia examined microscopically, Habermann ' found connective tissue changes in the mucosa and submucosa of the vocal cords and ventricular bands, extending occasionally into the thyro arytenoid muscle involved (Fig. 596). In some spots, especially the vocal processes and the posterior wall (the interarytenoid space), individual papillae had developed into papilloma like growths. The cup like prominences due, as thought by B. Frankel, to pressure exercised by the vocal processes upon one another during phonation, were present in the majority of cases, the central depression corresponding to the point of the hyaline process. Connective tissue strands radiated in all directions from the surface of the papilla. The erosions and ulcers found occurred most frequently on the vocal processes, about equally on each side, less often on the free border of the vocal bands. Nothing Was found to indicate that these ulcerations were due to either tuberculosis or syphilis. The association of pachydermia and ulceration with diseases which cause general congestion, pulmonary emphysema, cirrhosis of the liver, etc., was, however, confirmed.

Symptoms. The symptoms vary according to the situation of the local thickening, but as a rule the disease runs its course unattended by any great degree of discomfort. The first symptom buskiness is usually ascribed to a cold, and is accompanied by frequent desire to clear the throat, owing to a sensation resembling that caused by the presence of a foreign body. Slight dyspnea is sometimes experienced; this is perhaps due to the diminished abduction observed in these cases.

Examined laryngoscopically, the larynx appears more or less congested according to the intensity of the catarrhal process that may be present. In some cases the laryngeal surfaces, except the sites, of the growths, appear normal. On the vocal bands, however, and almost always over the vocal processes, two pink or red swellings, one on each side, and sometimes involving the posterior wall of the larynx, may be seen. One of these growths is much larger than the opposite one. In a case seen by Dundas Grant the larger tumor had reached the size of a shirt button. The smaller thickening on the opposite side shows an excavation or depression at its apex, precisely where the growth of the other side comes in contact with it during approximation of the vocal bands. This cup like depression, as already stated, is due to the pressure exerted by the tumor of the one side upon the corresponding tumor of the other. There may be but one excrescence, however, and indentation of the opposite be formed at the expense of the tissues of the vocal band proper.

Prognosis. The prognosis of this affection mainly rests upon the possibility of transformation from a benign to a malignant growth. Klebs 1 considers pachydermia laryngitis as a possible primary stage of cancer; but this view has not been generally sustained, and the prevailing opinion is that degeneration into malignancy is not to be feared. Chondritis and perichondritis, however, have been observed; but as a rule the affection is considered a benign one, offering no special danger to life. As regards the voice, permanent impairment is likely unless the case be seen and properly treated in its early stages.

Treatment. The measures recommended for the treatment of nodular laryngitis are probably the best to adopt, especially the local application of chromic acid. The internal administration of iodid of potassium has been found beneficial in some cases owing to the frequent association of the disease with syphilis. The local measures indicated for the treatment of chronic laryngitis may also prove of value. A spray of a 3 per cent. solution of chlorid of sodium has been especially recommended.

Removal with forceps followed by local cauterization has been advocated by Gougenheim; while Moll states that he has obtained prompt results from electrolysis, a double needle and a current of 5 milliamperes being employed.

CHRONIC SUBGLOTTIC LARYNGITIS.

Etiology. This is a rare form of chronic laryngitis in which the brunt of the inflammatory process is located in the tissues, beneath the vocal bands, giving rise in this situation to more or less rapid hypertrophic changes. The nature of this disease has remained obscure owing to its rarity, but it is thought to be associated with the so called scrofulous habit, syphilis, tuberculosis, and rhino seleroma. According to Gordon Holmes,' the causes; of this disease are nearly always well defined. Exposure to wet and cold, straining efforts of the voice, and excessive indulgence in spirituous liquors are, in his opinion, almost exclusively the sources of the disease. It is also allied to certain occupations in which the vocal organ is used with vigor. Of 47 cases seen, 30 were males. Reports of cases seen by other authors would indicate, however, that the disease occurs more frequently in females than in males. It occasionally presents itself as a complication of typhoid fever.'

Pathology. An analysis of the microscopical examinations reported by Wedl,l Sokolowski,' and Kuttner' tends to show that the disease consists mainly of a chronic cell proliferation, not only in the mucous and sub mucous cellular tissue, but also in the underlying muscular layer, the epithelial lining sinking into the submucous tissue in various places. This process progressing insidiously, a dense indurated mass is gradually developed, which occasionally includes the edges of the vocal bands and the neighboring tissues. It would seem that besides a dyscrasia, lymphatism, syphilis, etc., the disease requires some exciting organism, especially the typho bacillus and that of rhino scleroma, for its development. No bacillus special to the disease has as yet been found.

Symptoms. The earliest symptom is hoarseness, which is generally attributed to a cold. The voice is muffled and labored, and is sometimes completely lost. This complete aphonia is more likely to occur in females than in males. The patient sometimes experiences; a sensation of weight in the throat, due probably to the impediment offered by the more or less solidified subglottic tissues to the movement of the vocal bands. Pain is seldom experienced, but there is often a sensation of pricking that causes the patient to frequently "hem" to clear his larynx of a small mass of mucus which may have collected over the diseased area. Such a patient, who may perhaps experience a slight difficulty in breathing during exertion, may all at once, without the least warning, become the prey of intense dyspnea, and pass away unless immediate relief is at hand, the subjective manifestations being such as to suggest other disorders, cardiac or vascular, as the cause of death.

Several such cases have been reported; others have been saved by timely tracheotomy. The subglottic enlargement on each side can usually be seen laryngoscopically, especially when the vocal bands are abducted, appearing as more or less rounded bulging masses varying from the dull, variegated pink tint of catarrhal hyperemia to the vivid red line of active inflammation. In acute attacks the latter color prevails and the glottic lumen is almost occluded. When edema is a prominent factor of the case, the grayish white color of the projecting mass suggests the presence of polypi such as those found in the nasal cavities.

Prognosis. As may be surmised, the prognosis of such a case is not encouraging, tracheotomy or laryngotomy becoming obligatory. Even then the patient frequently perishes from gradually increasing debility unless an intercurrent disease such as pneumonia should carry him off. It is probable, however, that, discovered early, the trouble might be arrested by antagonizing any condition, occupation, overuse of the voice, etc., capable of' inciting local trouble, or by counteracting the pathogenic influence of any dyscrasia that may be present.

Treatment. Change of climate, to avoid acute exacerbations so frequently caused by damp cold, is indicated, with cessation of vocal effort and any other occupation or habit acting as exciting cause. Gordon Holmes,' who has obtained some cures, states that relief may be obtained from the use of cold spray inhalations, of solutions of perchlorid of iron, sulphate of copper, etc., between paroxysms, but that during the exacerbations warm soothing inhalations, impregnated with opium, conium, or stramonium, are preferable. Local applications by the attending physician of a solution of perchlorid of iron two drams to the ounce of water directly to the hypertrophied region are of value in mild cases. In advanced cases strong solutions of nitrate of silver are recommended. Cauterization of the parts with the galvano cautery has been highly recommended by Voltolini; while Mackenzie advised scarification. Sokolowski recommends laryngofissure and thorough extirpation of the hypertrophied tissues.

CHRONIC TRACHEAL AFFECTIONS.

Unless of a neoplasm, the trachea may be said never to be independently the seat of a chronic affection, merely sharing in those which extend into it from the larynx above or from the bronchi below. Separate discussion is therefore needless.

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