TUBERCULOSIS OF THE 
UPPER AIR-PASSAGES. 
ETIOLOGY. 
BT 
JONATHAN WEIGHT, M.P., 
BROOKLYN. 
Ktto ¥orit IHcDtcal Journal 
REPRINTED FROM THE 
for September 21, 1895. Reprinted from the New York Medical Journal 
for September SI, 1895. 
TUBERCULOSIS 
OF THE UPPER AIR-PASSAGES.* 
AETIOLOGY. 
By JONATHAN WRIGHT, M. D., 
BROOKLYN. 
I have been asked to discuss that part of the subject 
of tuberculosis of the upper air-passages included under 
the heading of aetiology. This can not be successfully 
done without considering the aetiology of tuberculosis, to 
some extent, in its general aspect. That is a broad field 
which reaches out in all directions. Much of it is unex- 
plored. Perhaps some of it is not accessible at present. 
Eight or ten years ago it seemed as though that tiny or- 
ganism, the tubercle bacillus, filled the field completely. 
Of late I have been looking back to my bacteriological 
days and wondering a little that we now hear no more of 
the three “ postulates of Koch ” which were so familiar to 
us then. They have not been heard of for so long that I 
have almost forgotten exactly how they were worded. As 
I remember them, however, they were that no micro-or- 
* Read before the American Laryngological Association at its seven- 
teenth annual congress. 
Copyright, 1895, by D. Appleton and Company.  TUBERCULOSIS OF THE UPPER AIR-PASSAGES. 
ganisra could be considered an aetiological factor in any 
disease unless— 
1. It was always present in that disease. 
2. It was never found in man without the disease. 
3. Inoculation with it would always cause the disease. 
These proud legends were inscribed on the banner of 
the “ high contagionists.” This is not the place to speak 
of the history of the researches into the activities of other 
disease germs than the tubercle bacillus, but suffice it to 
say that in that history also may be observed the downfall 
of the postulates. As regards the tubercle bacillus, it is 
now always present in tubercle, somewhat on account of 
similar tactics to those used by Mohammed with the moun- 
tain. The old clinicians had been in the habit of calling 
many things tubercle, hut the new bacteriologists ruled out 
all those pathological structures not due to the action of 
the bacillus. And this has proved a great gain in clinical 
classification, but, like all classifications in medicine, it 
has wrought some evil in crystallizing a certain order of 
mental process into a form of intellectual non-recep- 
tivity which renders further advance in individual cases 
impossible. 
As to the second postulate, it has disappeared so com- 
pletely that hardly any traces of it can be found in contem- 
porary medical thought. The tubercle bacillus is found 
not only dormant in animal tissues, entangled in the 
meshes of lymph glands and in unsuspected foci in the 
lungs, but it has lately been found, as has the diphtheria 
bacillus, in the upper air-passages of healthy people. 
It must have occurred to many others as well as to my- 
self that the principal reason it has not been found before, 
and is not now found more frequently, is the difficulty of 
technique attending its demonstration. This suspicion is 
strengthened by a very suggestive bit of medical news that TUBERCULOSIS OF THE UPPER AIR-PASSAGES. 
3 
comes from Paris by way of the Lancet of May 11, 1895 
(p. 1220): 
Latent Tuberculosis of the Tonsils.—Professor Dieulafoy 
calls attention to a torpid variety of pharyngeal tuberculosis 
the favorite seat of which is the adenoid tissue of the naso- 
pharynx. This tuberculosis manifests its presence by an ex- 
uberant growth of the lymphoid organs of that region—in 
other words, by hypertrophy of one or more of the palatine 
and pharyngeal tonsils. This view of Professor Dieulafoy 
would, if confirmed, lead us to regard hypertrophy of the 
tonsils and adenoid growths as, in many instances, cases of 
tuberculous overgrowth of adenoid tissue. He bases this be- 
lief on the results of inoculations practised on guinea-pigs of 
fragments of enlarged tonsils and adenoid vegetations. Of 
sixty animals thus inoculated with tonsil tissue, eight, or 
thirteen per cent., succumbed to generalized tuberculosis, 
while of thirty-five inoculated with adenoid tissue, seven, or 
twenty per cent., became tuberculous. In all the persons 
who furnished the material for inoculation (enlarged tonsils 
and adenoid growths) the pharyngeal tuberculosis was pri- 
mary and not consecutive to the pulmonary variety. It is to 
be supposed that the young subjects who have enlarged 
tonsils, etc., provide a favorable soil for the growth of the 
bacillus of Koch, which finds access to the adenoid culture 
medium either with the food, milk especially, or with the air 
respired (sojourn in a bacillary atmosphere). Professor 
Strauss, of Paris, has, indeed, demonstrated the presence of 
virulent tubercle bacilli in the nasal cavities of individuals 
habitually breathing the same air as phthisical patients. An 
open wound is not necessary for penetration, since the bacilli 
can find an entrance through the epithelium. In some in- 
stances the bacilli present in the adenoid tissue are, after a 
sojourn of months or years, destroyed by phagocytosis, which 
determines an indurating, fibrous process in the tonsil. In 
other cases, however, the bacillus finds its way into the 
lymphatic vessels, and enlarged submaxillary and cervical 
glands are the result. This lymphatic infection is often 4 
TUBERCULOSIS OF THE UPPER AIR-PASSAGES. 
started by the occurrence of measles, scarlet fever, whooping- 
cough, etc. This glandular tuberculosis may, in its turn, re- 
main local, and finally end in recovery; but in other instances 
rapid generalization may result. The third stage of tonsillitic 
tuberculosis is the spread of the process to the lungs, the 
bacillus reaching those organs from the cervical glands via 
the lymphatics, thoracic duct, and the right heart. In the 
course of the discussion raised by this most interesting com- 
munication M. Ohauveau stated that in animals fed on tuber- 
culous matter infection may take place by inoculation of the 
adenoid tissue of the base of the tongue and the isthmus of 
the pharynx, this inoculation being proved by the swelling of 
the cervical and submaxillary glands. Sometimes a minute 
erosion explains their inoculation, but often the sui’face was 
found intact. 
I have read this extract in its entirety, but it is too 
early, without having seen the original paper of Dr. Dieu- 
lafoy, to make any comment on the subject beyond saying 
that, although Lermoyez has reported two cases of tuber- 
culosis following operations for post-nasal adenoids, we 
are not accustomed to expect any such result either from 
an adenotomy or from an amygdalotomy. I only quote it 
here to show how far we are from the second postulate 
mentioned above. 
Now in regard to the third article in the early bacterio- 
logical creed. It has been invalidated somewhat indirectly 
by the general trend of facts recently ascertained such as I 
have just instanced. It is doubtless true that a Pravaz 
syringeful of broth swarming with tubercle bacilli will 
kill any guinea-pig. It is very likely true that it will kill 
any man, though direct evidence on that point is lacking, 
but clinically a Pravaz syringe thus used does not enter 
into the fetiology of tuberculosis. 
I need not pursue ancient history further. Indeed, 
some of you are doubtless already saying that I am setting TUBERCULOSIS OF THE UPPER AIR-PASSAGES. 
5 
up men of straw for the pleasure of knocking them down. 
Until lately, however, they were not thought men of straw, 
and I have taken these early postulates as an excuse to 
place before you a little of the evidence which we have 
clinically and experimentally, that the tubercle bacillus, al- 
though being the “ sine qua non ” of tuberculosis, is after 
all practically, especially from a prophylactic or hygienic 
point of view, a minor element in its multitudinous tetio- 
logical factors. I think we are gradually approaching a 
belief that every one at some time in his life comes in con- 
tact with such a dose of the tubercle bacillus that, were the 
other setiological factors also present, he would die of tuber- 
culosis. We know that one in seven deaths are due to 
tuberculosis. The autopsy table has shown that in one in 
two or three of all the cases examined there is evidence 
discoverable of the active or the conquered onslaughts of 
the bacillus. Now there must be a good many other cases 
in which the tubercle bacillus has perished without leaving 
a trace behind him—on the skirmish line as it were. 
Cornet showed a good while ago the high rate of mor- 
tality among those confined in prisons and workshops from 
tuberculosis, and he reasoned that it was because of the 
contact with the tubercle bacillus.* 1 need not follow the 
* Since this was written, I have lately seen that Cornet has reiter- 
ated his belief, though not quite so emphatically. He said in a paper 
read before one of the German medical societies that the mortality 
from phthisis had fallen greatly since the institution of precautions 
recommended by him against infection from tuberculous sputum. In 
the discussion which followed, Baer rather spoiled the force of this re- 
mark by expressing a doubt as to whether the mortality from phthisis 
had diminished on account of these precautions or because of the gen- 
eral reform in furnishing the prisoners with better air, food, and exer- 
cise. For a very strong plea for the side of the question opposing the 
views I have expressed here, see Cornet’s paper and the discussion in 
the Bert. Min. Woch., May 20, 1895. 6 
TUBERCULOSIS OF THE UPPER AIR-PASSAGES. 
history of clinical and experimental investigations which 
make us now believe that the high mortality is due not to 
the bacillus, but to the prison and workshop. It has been 
conclusively shown that no higher mortality exists among 
the consorts of tubercular patients than among other hus- 
bands and wives, but the page of every clinical history 
book will show a different story where the children of such 
patients are concerned. Is the death-rate of tuberculosis 
strikingly high among doctors ? Is it the impression of 
the members of this association that more than one in 
seven of our confreres die of tuberculosis ? * In the hos- 
pitals and dispensaries and in our offices we meet the 
tubercle bacillus face to face every day. It is gradually 
becoming known that a very large proportion of all dairy 
cows, especially of the Alderney breed, are tubercular. 
It is the children of the well-to-do, if not of the rich, 
that are brought up on this milk. The poor suckle their 
children themselves. It is hardly necessary to ask among 
which class we find the largest proportion of tubercular 
children. This fact has been noted for years, and so far 
as I have observed has never been satisfactorily explained 
by the “ high contagionists.” 
Experimentally Prudden has shown that he can pro- 
duce a lesion identical with tubercle without the action of 
the living tubercle bacillus, and a French author has said 
inversely: “The bacillus is not enough, we must have the 
characteristic reaclional lesion—the tubercle.” As clini- 
cians we may say, and we should say it boldly, that neither 
the tubercle nor the tubercle bacillus, nor both together, are 
enough. The tubercle bacillus is at one end of the chain 
and the tubercle is on the autopsy table at the other end of 
* Dr. Kortright, in the Brooklyn Medical Journal, June, 1895, says 
that statistics prove that the doctors do not average as high a mortality 
from phthisis as other classes in the community. TUBERCULOSIS OF THE UPPER AIR-PASSAGES. 
it. Tuberculosis to us does not mean either of these. It 
means to us both of these, plus the vital energy of the 
bacillus on the one hand and that of the resisting human 
organism on the other. 
We group all the other factors in the general aetiology 
of tuberculosis under the head of “ predisposition,” divided 
into such vague terms as low vitality, heredity, scrofula. 
And apropos of scrofula, before leaving the subject of gen- 
eral aetiology for that of the special aetiology ef tubercular 
disease of the nose and throat, I desire to quote some words 
of Ziegler (Allgemeine Pathologic, etc., Ble Auflage, Band 
i, S. 614) : 
“ According to our experience, the disposition to tuber- 
culosis is in the human race a greatly varying one, since 
only a part are predisposed to it. According to current 
views, scrofula—i. e., a sickly condition of the organism, 
which is revealed by a tendency to certain disturbances of 
nutrition of the skin, of the raucous membranes, of the 
joints, of the bones, and of the lymph nodes—predisposes 
to it. It may here be remarked that many of the mani- 
festations which are ascribed to scrofula are really already 
manifestations of a tubercular diseased 
Of course, in these few remarks I have not pretended even 
to touch on all the points in the general a3tiology of tuber- 
culosis, but have only hinted at some of them, and we must 
now consider those special influences which determine its 
primary and especially its secondary location in the upper 
air-passages. 
There are certain facts which seem clearly to indicate 
that there exists in the nose and throat some special local 
resisting power exerted against the entrance of the tubercle 
bacillus, or that there exists some special local annihilating 
influence upon the bacillus after it has gained an entrance 
into these mucous membranes. If we are not disposed to 8 
TUBERCULOSIS OF THE UPPER AIR-PASSAGES. 
deny the possibility of a really primary occurrence of tuber- 
culosis in the larynx, we are certainly not in a position to 
deny that even its apparent occurrence is an extremely 
rare clinical phenomenon. Supposing that the inspired 
air is the bearer of tubercular infection to the lungs, the 
conclusion inevitably follows that the nose and throat, as 
compared to the lungs, must possess a more complete pro- 
tection, for elsewhere I have shown experimentally that the 
former retain from the Inspired air all but a fraction of the 
floating germs before they reach the bronchi. Were it not 
for some protecting factor, primary laryngeal tuberculosis 
should be at least as common an occurrence as primary 
pulmonary tuberculosis. 
Kriickman * has lately shown, by a large number of 
very carefully conducted examinations, that in adults the 
tonsils and cervical glands are usually infected by the tu- 
bercle bacillus after the lungs are the seat of disease. 
On the other hand, in children, he seems to believe,, 
and we know that clinical evidence goes to show, that the 
cervical lymphatics are usually affected before the pulmo- 
nary portachyma. Supposing, however, that the tubercular 
infection is carried by the lymphatics in both adults and 
children, we reach the same conclusion of comparative 
laryngeal immunity when we remember how extremely rare- 
tubercular laryngitis is in children. 
Now what are these protective factors in the upper air- 
passages ? So far as lymphatic channels of infection are 
concerned in the larynx, we may advance the explanation 
of the scanty anastomosis of the internal and external ves- 
sels. We have a clinical evidence of this in the late stage 
at which enlarged cervical lymphatics are discoverable in 
* Kriickman. Virchow’s Archiv, No. 138, Heft 3, p. 534. I also, 
desire to call attention to the paper published by Sims Woodhead in, 
Hie Lancet, October 2'7, 1894. TUBERCULOSIS OF THE UPPER AIR-PASSAGES. 
9 
the cases of laryngeal cancer, but this will not explain the 
pharyngeal immunity. 
If Dieulafoy’s recent observations are reliable, we may 
explain by them the origin of some of the cases of tuber- 
cular meningitis in children, for there is direct and abun- 
dant communication between the naso-pharyngeal and the 
intracranial lymphatics, but these observations, if accu- 
rate, throw no light on the cause of comparative immunity 
of the nose and throat in children to recognizable tubercu- 
lar lesions, but on the contrary would make it more apparent, 
for I imagine it will be shown that lymphoid tissue is not 
the product but the lurking place of the tubercle bacillus. 
The same reasoning applies when we remember the fact 
that only fifteen to thirty per cent.* of all cases of pulmo- 
nary tuberculosis, even at autopsy, are seen to be also vic- 
tims of laryngeal tuberculosis. As said before, all cases 
should present laryngeal lesions, were there not some pro- 
tection against the virulent cultures of the bacillus in the 
sputum which bathes the larynx. 
I do not propose to go into the history of the literature 
* Heinze is the only author who goes as high as fifty-one per cent. 
It must be remembered that these are statistics from the autopsy table, 
and these must differ materially from what is observed laryngoscopic- 
ally for three reasons : Firstly, and chiefly, comparatively few persons 
dying of phthisis have ever had a laryngoscopic examination. Many 
tubercular lesions of the nose and throat exist without symptoms refer- 
able to them. Secondly, many tubercular lesions may escape observa- 
tion even in the most thorough rhinoscopic and laryngoscopic examina- 
t ion. Thirdly, many tubercular ulcers appear in the upper air-passages 
only when the patients are “ in extremis.'1' 
Through the kindness of Dr. Arrowsmith and of the other attend- 
ing physicians, I have been able to examine twenty-five patients in the 
Brooklyn Home for Consumptives, all of them suffering from the lesions 
of the second and third stages of pulmonary phthisis. In only four of 
these, or sixteen per cent., were tubercular lesions found in the nose 
and throat. 10 
TUBERCULOSIS OF THE UPPER AIR-PASSAGES. 
of laryngeal tubercular infection. You are all familiar 
with the old theory of Louis as to the corrosive action of 
the sputum. It occurs to me that the chief objection to 
Louis’s doctrine, as he meant it, is that no one has yet shown 
that sputum from tubercular lungs possesses any chemical 
erosive properties. You know that Eugen Fraenkel has 
demonstrated the tubercle bacillus in the surface epithe- 
lium and in the superficial layers of the mucous membrane. 
This has not been confirmed by many of the workers at 
the problem, but lately has been corroborated by the in- 
vestigations of Mr. Lake, published in the April number of 
the American Journal of the Medical Sciences for 1895. 
He says, however, that the pyogenic cocci first make a 
breach by getting in between the epithelial cells and, mul- 
tiplying there, form little abscesses which result in super- 
ficial erosions through which the tubercle bacillus itself 
enters, it having been shown that the bacillus itself is un- 
able to produce abscesses. It is not necessary here to dis- 
cuss Friederich’s idea that the pneumogastric, in some cases 
of pulmonary phthisis, by becoming affected produces a 
trophic lesion in the larynx which allows the tubercle bacil- 
lus to enter. 
I must, however, refer to an excellent paper by Thost,* 
who claims that the bacillus frequently enters by way of 
the glands, in whose epithelium he claims that tubercle fre- 
quently develops. This, however, is strenuously denied by 
Fraenkel. It is well to remind you here that Yirchow long 
ago cited the larynx as the situation where typical tubercle 
structure could best be studied microscopically. 
For several years I have been in the habit, when oppor- 
tunity offered, of making sections transversely through the 
trachea and larynx of stillborn infants or of those dying 
shortly after birth. I had frequently noticed that the epi- 
* Monatschr. f. Ohrenheilk., No. 2, February, 1893. TUBERCULOSIS OF THE UPPER AIR-PASSAGES. 
thelial layer in these transverse sections had a wavy out- 
line—that it was thrown into folds ; it seemed too redundant 
as a lining for the tube. In the larynx this is especially 
noticeable in the interarytaenoid space. At first I sup- 
posed these folds were due to the shrinking from prolonged 
soaking in alcohol. Lately, however, I have examined 
specimens prepared by preliminary fixing in four per cent, 
formalin, and the same phenomenon is observable, as you 
see in this drawing of a section from just below the vocal 
cords by camera lucida and a low power (Zeiss A) objec- 
tive (Fig. 1). 
If you will examine the beautiful photographs made by 
Prof. B. Fraenkel* of similar sections in adults, you will 
note the same appearance. Both in adults and infants, 
and also in animals (I have sections of pigs’ and calves’ 
and kittens’ larynges), it will be seen that the epithelial 
and subepithelial layers are connected by very loose areolar 
tissue with the underlying firmer fibro-elastlc connective 
tissue and perichondrium of the air tube. Now this evi- 
dently subserves a very important physiological function, 
and one which has a direct bearing on our subject. When 
a child screams, when a stentorian street hawker shouts 
his wares, when a consumptive has a paroxysm of cough- 
ing, the air tube is put on the stretch, the fibre-elastic 
elements may dilate by the shortening of the trachea as the 
thorax is heaved up, but the epithelial layer would sutler 
constant damage were it a “ tight-fit ” lining. The greater 
part of the epithelium is columnar. These long, narrow 
cells lie side by side, with their ends pointing outward 
toward the enemy. Were there no folds to be smoothed 
out like an accordion pleat, those cells at some one or more 
points must be dragged apart whenever the air tube should 
be violently distended. 
*B. Fraenkel. Archiv fur Laryngologie, Band i, Heft 1 and 2. 12 
TUBERCULOSIS OF THE UPPER AIR-PASSAGES. 
In adults these folds are less marked than in children; 
the areolar tissue hinds the epithelial layers more firmly to 
the walls. Every attack of laryngitis tends to damage this 
physiological arrangement by stiffening the subepithelial 
Fig. 1. 
structure and by hyperplasia of the epithelial cells. Much 
more must this be the case in chronic inflammations, where 
we also find some metamorphosis of the columnar into the 
squamous type of epithelium. This latter is especially TUBERCULOSIS OE THE UPPER AIR-PASSAGES. 
13 
seen in phthisis on the posterior laryngeal wall. E. Fraen- 
kel states that the base of the arytaenoid cartilages at the 
internal and opposing faces of the vocal processes, where 
rubbing occurs during phonation, is the most frequent site 
of beginning laryngeal tuberculosis. 
This may possibly be true of ulceration, but my 
clinical experience disposes me to think it is the inter- 
arytsenoid space. That situation at least is surely the 
place in which we first see that heaping up of pearly epi- 
thelium which is so significant to the experienced laryn- 
gologist. 
After this study of physiological and pathological pro- 
cesses we are prepared to admit many of the causes to 
which arc usually ascribed the supervention of laryngeal 
upon pulmonary tuberculosis—low vitality, the paroxysmal 
cough, the mechanical rasping of the sputum against the 
laryngeal walls, especially at the posterior commissure, re- 
peated attacks of acute laryngitis or the presence of the 
results of chronic laryngitis, the overuse of the voice, ex- 
posure to cold and dusty winds, etc. 
Tubercular ulceration of the pharynx is usually seen 
only in the very last stages of pulmonary and laryngeal 
phthisis, when the systemic and local vitality is at a low 
ebb, or in acute miliary tuberculosis when we have appar- 
ently some sudden weakening of the special factor which 
protects the system ordinarily from the ravages of the 
tubercle bacillus. Most of the cases of nasal tuberculosis 
which I have seen have been due to this low vitality at the 
end of pulmonary phthisis, and those cases of tubercular 
tumor which I have read of and not seen are apparently 
due to the abrasion of the finger-nail or to some other 
traumatism, as they are mostly reported as occurring ante- 
riorly on the sseptum or on the anterior ends of the turbi- 
nated bones. 14 
TUBERCULOSIS OF THE UPPER AIR-PASSAGES. 
There is no more time at my disposal to enter into a 
discussion of the question of tire spread of tuberculosis by 
means of the lymphatics and blood-vessels. While it seems 
apparent that the method of infection is usually from the 
external surface through a gap in the epithelium, it can 
not be denied that the larynx is theoretically just as apt to 
be affected (barring the scantiness of the lymphatics) by 
means of the lymph and blood vessels as are the knee and 
hip joints; and practically there are many clinical and 
morphological facts which go to sustain its actual occur- 
rence in many cases. The New York Medical Journal. 
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