ON THE Elements of Prognosis —AND OF - T HERAPEUSIS IN— Tuberculosis of The Larynx. BY J. Solis Cohen, M.D., Philadelphia, Pa. Read before the Section on Practice of Medicine and Materia Medica of the American Medical Association, June, 1883. Reprinted from the Journal of the American Medical Asso- ciation, Sept. 8, 1883. ON THE ELEMENTS OF PROGNOSIS AND OF THER- APEUSIS IN TUBERCULOSIS OF THE LARYNX. While acknowledging the stern truth that the prog- nosis is always bad in tuberculosis of the larynx, it may be maintained that the prognosis is less unfavor- able in certain groups of cases than in others; and that systematic therapeutic measures are capable of doing much more good in such cases than is gener- ally admitted, even to the establishment of repara- tive processes in occasional instances. A case mentioned in the edition of 1879 of a trea- tise by myself on Diseases of the Throat and Nasal Passages, as having lived more than eight years after the re-establishment of comparative health, is still' alive and doing well; and several others that have been under my observation have recovered so far as to resume their occupations, and maintain a tolerable degree of health, and of enjoyment of their impaired lives. The proportion of such recoveries is exceedingly small, less than one per centum; but the very fact of occasional recovery under treatment affords sufficient satisfaction to indulge the anticipation of considera- ble increase, as the elements of prognosis are more accurately ascertained and the institution of appro- priate remedial agencies more thoroughly determined. The probable hold upon existence, in cases of tuberculosis of the larynx, or the period to which the probable death of the patient may be protracted, are important subjects to the domestic circle in any indi- vidual instance; and any investigation is valuable which may throw light upon this important point in prognosis. In collating the cases which have occurred in my own practice, I am appreciating the fact that there are certain objective indications, which, studied out and compared with future observations to the same purport, will aid us in estimating the length of days remaining at the disposal of the sufferer, and in pro- longing the remnant of his existence by judicious therapeutic measures. Acute tuberculosis of the larynx is almost certain to terminate fatally at a period varying from six weeks to six months. Some cases terminate still more rap- idly, others linger a few weeks or months longer. Recovery is so rare that the accuracy of diagnosis may be fairly questioned in the few instances on record; especially in the face of the fact that the aspect of the disease and its immediate ravages bear very close physical similitude to the progress of acute latent, and tertiary syphilis. So close is this resem- blance in many instances, that the test of anti- syphilitic medication must be applied before a positive opinion can be pronounced as to the tuber- culous or syphilitic character of the case. Previous to the discrimination of acute tuberculo- sis of the larynx these cases were regarded as syphil- itic, and the failures to cure it were attributed to the profound dyscrasia under which the patient labored. 3 Hence the comparatively recent addition to nomen- clature of acute tuberculosis of the larynx. Acute tuberculosis of the larynx is usually indicated by acute laryngitis following exposure to cold and wet, in which deglutition first becomes difficult and subse- quently very painful. Intense pain in swallowing is often the only marked characteristic subjective symp- tom. Swelling of the epiglottis, with progressive ulceration from one or both sides, as revealed by laryn- goscopic inspection, account both for the difficulty and pain in deglutition. Pulmonary symptoms of tuberculosis are evident on careful physical explora- tion of the chest, and serve to confirm the diagnosis of the disease, which steadily progresses as acute tuberculosis, and terminates fatally, as has been men- tioned, at a period extending from six weeks to six months; secondary tuberculosis having taken place meanwhile in other organs adjacent and at a distance. Painful deglutition, therefore, supervening upon an attack of acute laryngitis, and due to tumefaction and ulceration of the epiglottis, and of the fold of tissue uniting the epiglottis to the pharynx, is indicative of acute tuberculosis, with rapidly fatal termination. The local use of morphia by insufflation, or of morphia and iodoform in powder, presents the most efficient means available of diminishing the pain on deglutition. Before the sedative powder is blown upon the parts they should be thoroughly cleansed by an alkaline douche or spray, to enable the medic- inal agent to h? applied to the diseased surface, in- 4 stead of being merely commingled with the secre- tions which cover it. The solution used most fre- quently for this purpose in my own practice, consists of five grains of borate of sodium, one drachm of glycerine, and seven drachms of tar water. Far more frequent than acute tuberculosis of the larynx is the chronic form of the disease, of which we may differentiate several varieties of progressively protracted duration. The shortest of these varieties becomes engrafted, so to speak, upon that variety of pulmonary tuberculo- sis characterized by rapid caseation of the pneumon- itic foci. It occurs early in the malady, coinci- dently, perhaps, with the giving way of the pulmon- ary tissue, and runs its course to a fatal termination in from six to eighteen months. It may be regarded as a sub-acute tuberculosis of the larynx, or as florid chronic tuberculosis. It is a secondary tuberculosis in the true sense of the term, although the subjective and objective laryngeal symp- toms may precede those of the lung disease. It is indicated by congestive catarrhal laryngitis, associated with localized or catarrhal pneumonitis, and followed by multiple minute ulcerations of the laryngeal mucous membrane. These ulcerations take place most frequently upon the posterior or lower face of the upper or free portion of the epiglottis, but they occur upon other localities also. These ulcerations extend in depth and in periphery, and coalesce when contiguous. Intumescence of the epi- 5 glottis gradually supervenes, followed frequently by intumescence of the ventricular bands and of the vocal bands. Similar intumescence takes place, but less frequently, in the inter-arytenoidal and aryteno- epiglottic folds. The breathing space is often so se- riously encroached upon by these tumefactions, that considerable dyspnoea ensues. Meanwhile existing ulcerations extend, and new ulcerations occur and extend likewise, until in some instances the internal surface of the larynx is al- most surrounded by irregular zones of tissue losses, ren- dering its aspect exceedingly ragged. Fungous gran- ulations rise above the surface of some of these ulcer- ations, in many cases still further impeding respira- tion, and interfering with expectoration of the vari- ous products of hypersecretion and ulceration. The destructions of tissue, tuberculous and suppurative continue progressively throughout, involving all the component structures including cartilage, portions of which become detached, and become partially ex- pectorated in detritus, fragments, or in masses. The destruction of the epiglottis takes place from above downward as the rule, but occasionally laterally, as in the acute variety proper. Secondary tuberculosis takes place in other organs, adjacent and at a dis- tance. The differential indication of this form of tuber- culosis, in which the tenure of life may be estimated at from six to eighteen months, according to the ac- tivity of the process, and the existing pulmonary com- plication, is to be recognized by the initial multiple minute ulcerations upon the epiglottis, particularly, in the early stages, and the subsequent tumefactions at the anterior portion of the larynx, followed by progressive extensive ulcerations, tuberculous and sup- purative. Ulceration limited to the epiglottis indi- cates much more rapid progress to the fatal issue. Impairment of voice, dyspnoea, and later in the case dysphagia and painful deglutition, are the most char- acteristic subjective local symptoms. Much more relief can be afforded by treatment in these cases than in the acute variety previously de- scribed. The constitutional treatment required is that adapted to tuberculosis of the lungs, irrespective of the laryngeal complication. Locally, much can be done to afford comfort by keeping the parts as cleansed as possible from products of secretion and ulceration, by alkaline sprays propelled upon the parts at regular intervals. For this purpose the solution of borax in tar water, previously mentioned, may be employed by the patient several times a day, a few drops of the sedative solution of opium being added to relieve pain and repress cough. Inhalations of terebinthinates, creosote or carbolic acid, in spray or in vapor, to follow the cleansing process, are ben- eficial both for antiseptic and for astringent and slightly stimulating purposes. Insufflations of powdered iodo- form propelled directly upon the parts after previous cleansing, are grateful and soothing. The disagreea- ble cdor of iodoform' can be tolerably well masked 6 7 by the addition of a minim of attar of rose to the drachm, or five or more minims of essence of rose geranium. Harrassing cough from the local irritation of the ragged mucous membrane and the secretions adher- ing to it, can be much diminished by wearing a light respirator of perforated zinc, or of buckram, or some similar contrivance, in front of which a small frag- ment of sponge can be confined, upon which five or more minims of terebene, oil of turpentine, creasote, carbolic acid, or eucalyptol may be dropped from time to time, as it evaporates, with the occasional ad- dition of a rather smaller amount of chloroform. In the earlier stages of dysphagia the preliminary deglutition of a teaspoonful of sweet oil often facili- tates the immediate deglutition of nourishment, by coating the parts with protective fluid and by lessen- ing the friction. When extensive ulceration prevents this relief, the best reliance is upon morphia, as in the acute variety. The more chronic varieties of laryngeal tubercu- losis occur in the more torpid cases of pulmonary tuberculosis beginning in localized pneumonias. The larynx does not become involved until the disease has considerably advanced in the lung, and softening is imminent, or is already in progress. These cases last from two to four years on the average, and some- times much longer. Pallor of the mucous membrane is perhaps the earliest marked characteristic of this variety. The 8 participation of the larynx is passive, so to speak, rather than active, and the tuberculous process is much slower in its manifestation and its progress. Little by little the component structures of the borders and interior of the larynx lose their marked outlines and become more and more tumid. The sharp edges of the aryteno-epiglottic folds and other tissues become thickened and rounded off; while circumscribed tumefactions of much more marked character take place at different points literally supplied with normal lymphoid cells. The supra-arytenoid cartilages and the aryteno- epiglottic folds undergo this tumefaction much more frequently than any other tissue. The epiglottis and the interarytenoid fold are two other prominent points for the process. The sharp and peculiar outlines of the supra-ary- tenoid cartilages become transformed into character- istic globose tumors tapering off pear-shaped-like into the aryteno-epiglottic folds, with gradual obliteration of all the lines of demur cation between the folds and the contained cartilages; a transformation so charac- teristic as to be almost sufficient in itself to indicate pulmorary tuberculosis, aside from investigation of the chest. In the inter-arytenoid fold a tumid projection gradually develops, sometimes condylomatous, more rarely acuminated, which prevents approximation of the posterior portions of the vocal bands, and thus entails aphonia or great impairment of voice. 9 The epiglottis increases in thickness to several times its normal dimensions, fails to occlude the larynx in deglutition and incites great care in swal- lowing, lest particles enter the air-tube. The tumefaction in the epiglottis and aryteno- epiglottic folds is sometimes increased by collateral oedema, which may be so great as to produce verita- ble stenosis, threatening asphyxia. These cases are slow in progress as a rule, unless the patient be the subject of marked cachexia, when the destructive process may ensue as rapidly as in the slower cases of the subacute variety. The tumefac- tions may remain the only visible objective indica- tions during the entire malady, but in advanced stages ulcerations are liable to ensue as in the other varieties, and not only at the points mentioned but in other parts of the structures. Pallor of the mucous membrane of the larynx ot a phthisical subject, followed by the circumscribed tumefactions just alluded to, form the chief indica- tions of the slower variety of tuberculosis of the larynx in which the prognosis of a more prolonged existence may be given. The tardy progress of the morbid process affords better opportunity for beneficial results from thera- peutic measures; and their judicious selection at an early period in the disease may not only prolong the life of the patient, but even start him on the road to recovery. The pallor of the mucous membrane of the larynx, evident as it often is before anaemia is recognized else- where, indicates the advisability of the administra- tion of meat as food and iron as medicine. A meat diet requires more or less exercise in the open air, or its substitute. Inhalations of compressed air by some of the methods now in vogue, massage of the limbs, and similar methods promote oxidation of the products of meat digestion, and thus invigorate the patient. Enrichment of the blood by the meat may be supplemented by the administration of iron. Tinc- ture of the chloride of iron in ten minim doses, with fifteen minims of dilute phosphoric acid and a tea- spoonful of the best syrup of the hypophosphites, preferably of lime in most cases, if that is at his com- mand, is the prescription most relied upon by myself, given after meals in a tablespoonful of water. The tumefactions are well painted every two or three days with equal parts of the compound solution of iodine and glycerine, or with a few drops of solu- tion of iodine and of carbolic acid to the ounce, and the parts kept free as possible from secretory products by the alkaline spray already mentioned. When ulceration takes place, antiseptics are added to the treatment locally and by inhalation. Compressed air, alkaline sprays, iodine locally, iron internally, animal diet, and as free exposure to the air as practicable, constitute the therapeutic meas- ures which have been followed by the best results in my own hands; and by these means modified or sup- plemented, as occasion may indicate, with such gen- eral measures, hygienic and remedial, as are indicated from time to time, I have reason to believe that the course of certain forms of tuberculosis of the larynx may be retarded in occasional instances to such an extent as to give the patient a chance to recover.