REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
larynx! 
atrophic, form of rhinitis were common affections among 
the citizens of ancient Greece and Rome. Finally, as the 
term ozaena, especially when used in the sense of a stench 
from the nostrils, serves to express a number of different 
pathological states, and in the light of our present knowl- 
edge concerning atrophic rhinitis, it is illogical to main- 
tain that the ancients were acquainted with the nasal 
form of syphilis because of the frequent allusion to ozaena 
in their medical writings. 
The foul mouth, hoarse voice, and snoring respiration 
of the cunnilingus, fellator and irrumator8 have been 
thought to indicate syphilitic affections of the throat, but, 
as I have suggested elsewhere, they were doubtless the 
symptoms of a catarrhal process acquired in the discharge 
of their filthy occupations. 
Reiskes thus describes the cimedus or sodomite : “ In 
kiaribus et in palato vitium, a qua clare non potuerint 
eloqui, sed, stertere et rhoncissare debuerint.”9 
ITlie value of this passage iu evidence, it seems to me, turns 
upon the rendering of the word vitium (and not, as Ro- 
senbaum 10 and others maintain, upon the verb peyxeiv)> 
which may mean anything from a simple inflammatory 
condition to destruction by ulceration ; and it may be with 
equal justice contended that the affection described by 
Reiskes may be referred to the advanced forms of hyper 
trophic naso-pliaryngeal catarrh. At all events, there is 
no possible reason why we should lay the affection of 
the sodomite at the doors of syphilis. 
Equally uncertain is the evidence adduced by the same 
writer11 from the disease of the armpits among the Les- 
bians, which destroyed their noses and voices, and was 
supposed by Dio Crysostom, who drew attention to it, to 
have been the angry visitation of the goddess Aphrodite. 
If now we turn to the passages which have been taken 
from the satirical writers of antiquity, the same uncer- 
tainty is found. The following are the only ones, it 
seems to me, worthy of the slightest consideration. The 
first is taken from Martial ; a certain Festus, after lie 
fouud that a dire disease had invaded his fauces, and 
crept into his countenance, committed suicide. 
“ Indignas premeret cum tabida fauces 
In quo ipsos vultus saperet atra lues.” 12 
The second is also from Martial, and refers to the de- 
bauchee and sodomite : 
“ Qui recitat lana fauces et colla revinctus 
Hie se posse loqui, posse tacere negat.” 13 
Now, it is perfectly obvious that the disease from which 
Festus was supposed to suffer may have been a cancerous 
or other malignant affection ; and in the case of the de- 
bauchee it is manifestly absurd to infer the existence of 
syphilis from what was most probably a simple sore 
throat. 
In the fifteenth century there lived an obscure poet, by 
name Pacificus Maximus, who, in spite of his apparently 
dissolute tendencies, as reflected in a volume of wanton 
poems published by him in 1489, managed to eke out 
a lascivious existence of exactly one hundred years.* 
Among his poems is the following invocation of Priapus, 
which "possesses a certain historical value : 
“ Tuque meum si non properas sanare Priapum, 
Decidet heu ! non hoc nobile robur erit. 
Ante meis oculis orbatus priver, et ante 
Abscissas foedo nasus ab ore cadat! 
» Non me respiciet, nec me vollet ulla puella, 
In me etiam mittet tristia spata puer, 
Lsetior heu ! toto me non erat alter In orbe ! 
Si cadet hie, non me tristior alter erit. 
Me miserum ! Sordes quas marcidus ore remittet! 
Ulcera quae foedo marcidus ore gerit! 
Aspioe me miserum, precor, O ! per poma, per hortos, 
Per caput hoc sacrum, per rigidamque trabem, 
Hinc ego commendo tota tibi menta, Priape, 
Fac valeat, sic sit sanus ut ante fuit.” + 
In connection with the early origin of the venereal 
complaint I wmuld like to call attention to the follow- 
ing passages, which I discovered accidentally while en- 
gaged in an historical research foreign to the subject now 
f LARYNX, TRACHEA, AND BRONCHI, SYPHILIS 
OF THE. Historical Sketch.—It is not the purpose o 
the present article to discuss the antiquity of the venerea 
complaint, but simply to briefly review the evidence o 
its ancient origin as far as it relates to affections of tin 
nose and throat. As some of the weightiest argument! 
in favor of the remote existence of syphilis rest upon then 
supposed early recognition of specific disease of the up-\ 
per respiratory apparatus, it may be interesting to ex- 
amine the reasons alleged for this assumption, which has 
been defended with so much talent and erudition. 
It has been maintained by some that certain passages 
in the ancient records of Chinese and Hindu medicine 
render it probable that syphilitic affections of the nose 
and throat have been recognized from the earliest times.1 
The evidence deducible from the researches of Dabry 
is, however, as Verneuil2 has pointed out, inconclusive 
in view of their many chronological inaccuracies, while 
there is no sufficient reason for the belief that the disease 
described in the Ayur Veda is the affection which we 
now recognize as syphilis. 
Both Hippocrates3 and Galen4 allude to falling in and 
depression of the nose from recession of the palate bones, 
and they and their followers refer to destructive ulcera- 
tion of the larynx, trachea, and nose. Aretseus,6 in his 
famous and much-discussed description of the disease 
called uva, asserts that the palate bone is sometimes laid 
bare, and that the ulcerative process spreads over to the 
fauces and even the epiglottis ; but these isolated obser- 
vations furnish obviously slender data upon which to 
base the antiquity of the venereal complaint. 
The attention paid to, and the frequency with which 
the disease called by the Greeks ozama, is encountered in 
the writings of the ancients, are at first sight naturally 
suggestive of their acquaintance with syphilitic affections 
of the nasal passages; but, if we reflect upon the sense 
in which this term was employed by the large majority 
of physicians and grammarians of those times, we shall 
be obliged to confess that it forms an uncertain element 
in the chain of evidence which links the nasal syphilis of 
to-day with the ozsena of the Greek physicians. 
By many of the ancient medical waiters ozama and 
polypus are used as convertible terms, and the cure of 
the two affections is considered under the same head. 
In this sense, too (i.e., as synonymous with polypus), 
the term is used by Pliny; and even among the later 
Latin grammarians the appellation ozeenosus was applied 
to those who suffered from nasal polypi. It is exceed- 
ingly probable, then, that the term ozaena did not carry 
with it the same significance which attaches to its use at 
the present day. The ancients have left but scanty rec- 
ord of the measures they adopted in cleansing the nasal 
passages, and indeed, if we consider their notions con- 
cerning the pathology of nasal discharges, it would not 
be surprising if they neglected that important process 
altogether. A form of instrument, the rhinencliytes, for 
injecting the nasal cavities, is mentioned by Aurelian6 
and Scribonius Largus,1 but it is highly probable that 
the important hygienic measure of systematic cleansing 
and disinfection was neglected, and that the secretion 
was allowed to accumulate and decompose within the 
nostrils—a condition which we know favors the de- 
velopment of a peculiar odor even in simple catarrhal 
inflammation of these cavities. It is, moreover, very 
probable that the hypertrophic, and consequently the 
* Born 1400, died 1500. 
t Attention was first cailed to this poem by Sanchez, in the Journal de 
Vandermonde for October, 1759, tom. ix. 
439 Larynx. 
Larynx. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
under review. The sonnet is one by Sulpicius Luper- 
cus Servastus, Junior,* and runs as follows : 
“ Atqni sunt, quod propter honestum rumpere foedus, 
Audeat inlicite pallida avaritia. 
Romani sermonis egens, ridendaque verba 
Frangit ad horrifleos tarbida lingua sonos. 
Sed tamen ex vultu adpetitur spes grata nepotum. 
Saltern istud nostri forsan honoris habent. 
Ambusti torris species, exesaque seclo 
Abduntur priscis corpora de tumulis 
Perplexi crines, frons improba, tempora pressa, 
Extantes mala deficiente genre 
Simatque jacent pando sinuamine nares. 
Territat os nudum, cresaque labra treinent. 
Defossum in ventrem propulso pondere tergum 
Frangitur, et vacuo crure tument genua. 
Discolor in manibus species, ac turpius illud, 
Quod cutis obscure pallet in invidiam.” 14 
Leaving now the question of the ancient recognition 
of the throat and nasal lesions of syphilis, and coming 
down to the close of the fifteenth century, when the af- 
fection is generally supposed to have been discovered, we 
find that the earlier writers on the lues venerea looked 
upon “softening” of the uvula, ulceration of the pha- 
rynx, tonsils, and fauces, perforation of the palate, catar- 
rhal and destructive disease of the nasal passages, and a 
hoarse and raucous character of the voice as diagnostic 
signs of the disease.15 Among them Frascatorius,16 in 
his celebrated poem on syphilis, speaks of affections of 
the voice and obstruction in the pharynx, and Alexander 
Trajanus Petronius 11 (1566) refers to liquids taken by 
the mouth returning thereby, and to chronic hoarseness 
Cvox rauca perseverans) as symptoms of syphilitic infec- 
tion. Both Maynardi18 and Fallopius mention diffi- 
cult breathing from disease of the larynx and trachea, 
and tinnitus and other symptoms referable to disease of 
the ear were observed, among others, by Botallus, Tomi- 
tanus, and Petronius. 
While these writers were doubtless thoroughly conver- 
sant with the ravages produced by syphilis in the nose 
and pharynx, and with affections of the voice and respi- 
ration, nothing definite was known concerning the patho- 
logical changes in the larynx until about the middle of 
the seventeenth century, when Marcus Aurelius Severi- 
nus 19 found in the body of a girl, dead of syphilis, the 
epiglottis completely destroyed by ulceration. This 
writer20 seems also to have been familiar with ulceration 
of the trachea, bronchi, and oesophagus.! In 1678 Gun- 
ther Christopher Sclielhammer21 adverted to dryness of 
the larynx from ulceration of the uvula, and in the early 
part of the following century Yercollonius22 gave a 
systematic account of syphilitic affections of the tonsils, 
pharynx, larynx, trachea, and oesophagus. Later on the 
subject of throat syphilis, from a clinical standpoint, was 
treated of in detail by Boerhaave,23 Astruc,24 Plenck,25 
Benjamin Bell,26 John Hunter,21 and Swediaur,28 while 
Morgagni29 directed attention to the anatomical appear- 
ances of the affection. Among the writers of the eigh- 
teenth century Raulin 30 seems to have been acquainted 
with syphilitic ulceration as it affects the larynx, trachea, 
and oesophagus.! 
At the beginning of the present century Thomann31 
drew attention to syphilis of the windpipe, and Alten- 
hofer32 announced, in a very valuable paper based on 
extensive experience, that tracheal phthisis is often the 
result of malignant or neglected syphilitic throat ulcera- 
tion. 
The impulse given to the pursuit of pathological anat- 
omy by the colossal labors of Morgagni led, among other 
things, to the study of ulceration of the upper air-pas- 
sages and to the publication of a number of special trea- 
tises on the subject,33 which culminated in the classical 
m6moire of Trousseau and Belloc.34 These observers, as 
well as those who preceded them, included syphilis, tu- 
berculosis, and other chronic laryngeal affections under 
the generic term “phthisis laryngea,” and this confusion 
practically reigned until the introduction of the laryngo- 
scope, and the pathway to differential diagnosis was 
opened by the laryngoscopic studies of Tuerek.35 
Syphilis of the Larynx.—Statistics differ widely as 
to the frequency with which syphilis attacks the larynx. 
While the elementary character of the present work pre- 
cludes a critical examination of the sources of error dis- 
coverable in the antagonistic reports of different observ- 
ers, it may be said, in general, that reconciliation of 
diverging opinions upon this subject can only be accom- 
plished by taking the life-histories of the cases upon 
which the statistical evidence is based. Were this method 
universally adopted,we believe that few syphilitics would 
be found who had not, at some period or other of the dis- 
ease, suffered from some form of laryngeal affection. 
The delicate structure of the larynx, the irritation to 
which it is exposed in the natural discharge of function, 
or in the unnatural exercise of the same from disease of 
adjacent and communicating organs, as the nose and 
pharynx, the common invasion of its structures in other 
forms of acute and chronic blood-poisoning, and its fre- 
quent exposure to a host of other unfavorable influences 
from direct or reflected irritation, furnish, & priori, 
grounds for regarding this organ as a frequent seat of 
the manifestations of constitutional and hereditary syph- 
ilis. The impairment of nutrition induced in its struct- 
ures by the circulation within their substance of a viti- 
ated fluid, and the consequent vulnerability of its mucous 
membrane to the causes that determine catarrhal condi- 
tions, predispose, among other things, to the phases of 
so-called secondary inflammation, while its wealth in 
fibrous tissue and fibro-cartilage doubtless invites inva- 
sion by the tertiary processes of the disease. 
While it is therefore probably true that the majority 
of cases of constitutional or hereditary syphilis, if un- 
treated or neglected, will sooner or later develop some 
phase of laryngeal disorder, it is equally certain that the 
eruption of the disease in the larynx can be prevented 
or modified by early therapeutic interference. As the 
virulence of syphilitic lesions in general is modified by 
the employment of the more advanced and rational 
methods for its cure, so the destructive affections of the 
larynx are less frequently met with now than in the 
time when the therapeutics of the disease were less per- 
fectly understood, and when the exhibition of mercury to 
salivation was the catliolicon of the profession. 
Certain it is, that the proportion of the more destruc- 
tive forms of laryngeal syphilis is small, compared with 
their constancy and the terrible ravages to which they 
gave rise, as described by the writers of the fifteenth and 
sixteenth centuries. While, therefore, it is safe to affirm 
that the proportion of cases of laryngeal disease in syph- 
ilis has been notably diminished by the rational use of 
mercury, and especially by the tonic treatment of the dis- 
ease, as formulated by Iveyes,36 the injudicious use of 
that drug, on the other hand, may be looked upon as 
having, contributed in the past in no small degree to the 
determination of the disease to the throat. For when we 
recall the extensive ulceration of the pharynx and larynx 
sometimes produced by mercurials, and the free way in 
which the latter were often administered,31 it is easy to 
conceive of the disastrous influence of their incautious 
administration upon structures peculiarly obnoxious to 
the ulcerative forms of syphilis. 
The time elapsing between inoculation and invasion of 
the larynx varies greatly. Lewin,3B who has given this 
* Nothing is known concerning the age at which this member of the 
Sulpicii lived, the only trace of his literary existence being preserved in 
the above. 
t Severinus’s observations were made in the post-mortem room of a 
large hospital for venereal complaints, and must be regarded as the first 
pathological researches in the direction of syphilitic affections of the 
larynx. 
t In the sixteenth century Schenck, of Grafenberg (Observat. medicie 
de capite humano ; hoc est exempla capitis morborum, etc., obs. cccxlix. 
P; 397, Basilias, 1584) spoke of the “gula ex ulcere Gallico exesa pro- 
cidens devorata,” and also of perforation and loss of the palate (ob. 
cccxlvii., from Par6). In 1778 Andrew Duncan (Medical Cases, etc., 
p. 1 et seq., Edinburgh, 1778) called attention to dysphagia resulting 
from increased sensibility of the pharynx from pre-existing syphilitic 
sore throat; and Zeviani (quoted by Voigtel, Handbuch d. path. Anat., 
Bd. ii., Halle, 1804) placed on record a case in which a syphilitic ulcer of 
the windpipe communicated with the oesophagus. I would also call at- 
tention to the fact that Dolasus (Encyclopedia chirurgica rationalis, 
etc., ii., cap. v., p. 276, Francofurt. ad Mcenum, 1703), in his chapter on 
strictures of the oesophagus, observes, “aliquando angustia haec fieri 
solet a caruncula gulss ex ulcere venereo aborta.” These cases of oesopha- 
geal syphilis may be added to those collected from the older literature of 
the subject by Astruc, Van Swieten, and Lieutaud. 
440 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Larynx. 
Larynx. 
particular attention, asserts that the minimum period is 
from two and a half to three months, while in the well- 
known case of Turck, the laryngeal affection developed 
thirty years after infection.39 
The rarity of primary inoculation of the pharynx and 
tonsils precludes the framing of any definite conclusions 
concerning the rapidity of subsequent laryngeal invasion, 
nor has any relationship been established between the se- 
verity of the respiratory lesions and the size of the pri- 
mary sore. Reasoning by analogy, however, it might be 
said that an early invasion of the larynx may be looked 
for in primary disease of the tonsils, and that the de- 
structive tendency may vary with the character of the 
initial lesion. 
The laryngeal lesions of syphilis are superficial and 
deep. Superficial changes usually appear early during 
the secondary stage of the disease, while the deeper, de- 
structive lesions occur later, in the period of tertiary phe- 
nomena. The laryngeal inflammation is therefore, as a 
rule, associated with the corresponding external phenom- 
ena of these periods.* This relationship between the 
laryngeal and cutaneous lesions is, however, by no means 
invariable, especially as regards the superficial lesions, 
and even deep ulceration may be met with at an early 
period of the disease. 
It sometimes happens that laryngeal inflammation and 
ulceration appear many years after the constitutional 
malady has run its course, and lesions of the pliaryngo- 
laryngeal tract are occasionally encountered without an- 
tecedent cutaneous or visceral changes. In several cases 
seen by me, it was from the appearance of ulceration in 
the larynx that the patients and their attendant first be- 
came aware of the previous existence of the initial lesion. 
This remarkable tendency of syphilitic lesions to make 
their appearance in some portion of the upper respira- 
tory tract long after the affection has apparently run its 
course, or without antecedent cutaneous and visceral 
phenomena, is especially worthy of note, and also the 
fact of their isolation, under these circumstances, in the 
nose, pharynx, larynx, or trachea, without disease of adja- 
cent or communicating organs. Syphilis of the larynx 
is generally consecutive to inflammatory changes in the 
pharynx or nasal passages, but occasionally occurs as an 
independent affection. In rare instances it is the result 
of extension from the trachea. The age at which the 
disease appears will depend, of course, upon the time of 
infection, and, as men are more exposed to the exciting 
causes of inflammatory affections of the larynx, it is 
more frequently met with in the male sex. 
The experience of the writer as regards the relative 
frequency of secondary and tertiary lesions is in favor of 
the more common occurrence of the former, if the sim- 
ple catarrhal affections of that period be included under 
the head of true syphilitic phenomena. 
Varieties.—The lesions of laryngeal syphilis are patho- 
logically separable into two main groups, corresponding 
to the secondary and tertiary periods of the constitutional 
affection. In addition to these, there is a class of case 
which cannot be assigned to either extreme, and which 
belong to what Whistler40 has aptly termed the “inter- 
mediate ” period. 
I. Lesions of the Secondary Period.—In this stage the 
mucous membrane and submucous tissues are the struct- 
ures involved, and the appearances consist either in tran- 
sient or permanent liyperaemia, or in well-defined ca- 
tarrhal inflammation. The former presents nothing 
characteristic, the latter is differentiated from simple in- 
flammation by the less pronounced character of the hyper- 
aemia, and by the tendency to multiple superficial ulcera- 
tion. There is, however, nothing absolutely characteristic 
in the anatomical appearances of this form of syphilis. 
The mucous membrane is, as a rule, paler than normal, 
sometimes even almost white, and the presence of minute 
ulcers, especially in number, and associated with similar 
appearances in the pharynx, is of value in the anatomical 
diagnosis of syphilis. 
In the laryngoscopic image the existence of a brownish- 
red, mottled appearance of the vocal cords, especially if 
the condition be symmetrical, together with erosions or 
superficial ulceration of the edges of the vocal cords, on 
the free border and posterior surface of the epiglottis or 
ventricular bands, should lead to a suspicion of the spe- 
cific nature of the inflammation. 
While these appearances are strong presumptive evi- 
dence in favor of the existence of syphilis, it were more 
prudent to look for other phenomena and historical data 
before giving a decided opinion. The ulcers of this pe- 
riod are either follicular in origin or result from the 
breaking down of the more superficial portions of the 
mucous membrane. These minute losses of substance 
often coalesce to form a large ulcer with well-defined, 
elevated walls, and grayish-mottled base, which, in heal- 
ing, leaves a small, somewhat depressed cicatrix. This 
latter from a clinical standpoint offers weighty evidence 
in favor of syphilis. 
Whether ulceration of the laryngeal mucous membrane 
ever results from inoculation by the pharyngeal secre- 
tion cannot be affirmed with any degree of positiveness. 
Mucous patches and condylomata. The utmost con- 
fusion prevails concerning the occurrence and frequency 
of mucous patches in the larynx. While their exist- 
ence in this organ is strenuously denied by some who 
have specially investigated the subject, the very opposite 
opinion is entertained by equally competent observers. 
In a large number of patients with laryngeal syphilis 
that have come under the observation of the writer, he 
recalls but one case concerning the nature of which there 
could be little doubt.* The failure to detect the presence 
of mucous patches in the larynx may be due, as Morell 
Mackenzie41 observes, to their fleeting character ; while, 
on the other hand, it is highly probable that many of the 
so-called mucous patches described by writers are in 
reality nothing more than papillomatous excrescences or 
small ulcerating gummata. 
The laryngeal mucous patch, so-called, appears in the 
mirror as a grayish-red or whitish-yellow elevation, 
rounded or oval in contour, and surrounded by an in- 
flammatory areola. ' This may disappear completely or 
disintegration and ulceration may ensue. Small papil- 
lary hyperplasia} not infrequently occur in the neighbor- 
hood of existing ulcerations or on the confines of an old 
cicatrix, which should, however, not be confounded, as 
has been done, with the true condylomata. 
II. Lesions of the Intermediate Period.—These have 
been well described by Whistler. The anatomical pecu- 
liarity of this stage resides in a chronic diffuse laryngitis, 
characterized by its constant tendency to relapse, and by 
the existence of ragged ulceration of the vocal cords. 
These ulcers, in fact, represent, so to speak, a transition 
stage from the superficial destruction of the secondary to 
the deeper and more malignant ulceration of the tertiary 
period. 
The ulceration of both the secondary and intermediate 
periods occasionally extends to the fibro-cartilaginous 
structures, but the latter complication is much more fre- 
quently due to ulceration of tertiary development. 
III. Lesions of the Tertiary Period.—In this stage all 
the structures of the larynx may be involved, singly or in 
combination. The proclivity of syphilis to attack those 
cartilages only that are invested with perichondrium ap- 
plies with especial force to the cartilaginous structures 
of this organ. The characteristic lesions of this period 
are gummata, deep ulceration, and fibroid degeneration. 
1. Gummata appear as solitary or multiple tumors of 
varying size and shape, and of smooth, regular contour, 
which may proceed from any of the laryngeal structures, 
* The subject was a woman suffering from secondary syphilis. On the 
left vocal cord, about its centre, was a small, oval, yellowish-white patch, 
smooth in contour, and slightly elevated above the surface of the cord. 
Its long diameter was parallel with the free border of the cord, and its 
base surrounded by a scarlet inflammatory areola. The laryngeal mem- 
brane was slightly erythematous. Three days afterward both patch and 
areola had disappeared. 
* M. Dance has attempted to show that roseola, and even the tubercu- 
lar and papular syphilide occur in the larynx simultaneously with their 
eruption upon the external surface (Eruptions du larynx survenantes 
dans la periode secondaire de la syphilis, Paris, 1864). These observa- 
tions have never been confirmed. 
441 Larynx. 
Larynx. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
but which are usually found in the submucous tissue of 
the free border and posterior surface of the epiglottis and 
the interarvtenoid space. They are occasionally met 
with in the subglottic region, on the ventricular bands 
and vocal cords. They vary in size from that of a mus- 
tard-seed to a tumor that calls for tracheotomy. 
The color of the mucous membrane covering the 
gumma is at first intensely red, and occasionally small 
vessels are developed in its vicinity. Gradually, under 
the increased pressure of the submucous deposit, it be- 
comes pale, thin, and transparent, so that the peculiar 
yellow or whitish-yellow color of the gummatous infiltra- 
tion is distinctly visible. Necrosis of the anaemic mem- 
brane soon follows, and an ulcer results which rapidly 
. invades the submucous tissues, forming a more or less 
crater-like excavation, not infrequently involving the 
perichondrium and underlying cartilage. In small gum- 
mata absorption of the infiltration may be secured by the 
exhibition of antisyphilitic remedies, even after consider- 
able thinning of the mucous membrane has taken place. 
In histological structure the laryngeal gumma does not 
differ from similar products in other parts of the body. 
An isolated case is on record where giant cells wrere 
found in the gummatous infiltration of the larynx,42 but 
this is probably an exceptional and accidental occurrence. 
Well-defined gummatous tumors of the larynx are com- 
paratively rarely met with as compared with diffuse 
syphilitic infiltration. 
2. Fibroid Degeneration.—In the later stages of tertiary 
syphilis there is in a certain proportion of cases a decided 
tendency to the gradual development of fibroid tissue in 
the structures of the larynx, which tends to diminish the 
lumen of the organ, not only by contraction of the new- 
formed tissue, but also by the production of large, dense 
fibroid tumors, which are often mistaken for and de- 
scribed as gummy tumors, but which pathologically 
have nothing in common with them. These fibroid 
utmors appear as hard, nodular masses occupying the epi- 
glottis, ary-epiglottic folds, and other portions of the ves- 
tibule and subglottic region. Sometimes the greater por- 
tion of the organ is converted into a dense hypertrophic 
mass. Acute ulceration occurs, and is fraught with 
great danger from accompanying oedema, and each suc- 
ceeding attack of ulceration favors a greater deposit of 
fibrous tissue and increases proportionately the gravity 
of the case. In this variety of laryngeal syphilis, which 
Whistler has especially insisted upon, no retrograde meta- 
morphosis takes place ; its processes are essentially pro- 
gressive, and the calibre of the larynx becomes dimin- 
ished sooner or later by an irregular nodular mass—half 
hypertrophied tissue, half cicatricial bands—which does 
not subside under internal or local treatment, and which, 
if extensive, demands tracheotomy. 
These fibroid tumors may be differentiated from gum- 
mata by their pale grayish or whitish appearance, by the 
surrounding anaemia of the mucous membrane, and by 
the absence of the peculiar yellowish submucous discol- 
oration of the latter. The hard, dense sensation com- 
municated to the probe contrasts, too, forcibly with the 
soft elastic feel of the gummy growth. 
This class of cases is only seen in hospital or dispensary 
practice, and presents a long history of neglected laryn- 
geal trouble with gradually increasing obstruction to 
respiration. These tumors are more common than is 
generally supposed, and probably constitute a large pro- 
portion of the specimens which are labelled “ gummata ” 
in anatomical museums and collections. 
Sections of the growths show under the microscope 
thickening of the mucous membrane, a round-cell infil- 
tration of the submucous tissues, and abundant meshes 
and wavy bands of fibrous tissue, which in contracting 
obliterate more or less completely the vessels and glandu- 
lar elements of the parts. Whether this fibrous tissue 
starts from the perichondrium or submucous layer, or 
both, or what relation it bears to the fibroid hyperplasise 
which are found after the cicatrization of ulcers, has not 
as yet been made out, but it is not improbable that this 
hypertrophic syphilitic laryngitis may be due to the com- 
bined action of these different factors. 
8. Tertiary Ulceration.—Ulcers of the tertiary period 
result from atrophy of the mucous membrane, through 
the pressure of the underlying infiltration and the conse- 
quent purulent degeneration of the latter, and in this way 
excavations are formed, of more or less circular outline, 
with a deep base of grayish or lardaceous appearance and 
with elevated, clearly defined, and often bloodshot walls, 
surrounded by a scarlet zone of inflammation, and cov- 
ered with a foul, dirty yellowish secretion, which im- 
parts to the breath a peculiar and somewhat characteristic 
odor. 
Of varying sizes, the tertiary ulcer may be multiple, 
and occur in any portion of the larynx and subglottic 
space ; but it is generally solitary and occupies by pref- 
erence the lingual surface and free edge of the epiglottis. 
It may be said, in general, that ulceration of the upper 
part of the larynx is much more common than ulceration 
of the cords and subcordal region. The ulcerative pro- 
cess not infrequently extends along the ary-epiglottic fold 
to the ventricular band, or from the latter to the ven- 
tricles. The epiglottis may present a crenated appear- 
ance, like the comb of a cock, or a punched-out aspect ; 
or it may be depressed in various other ways. Occasion- 
ally it is perforated. It may be reduced to a mere rudi- 
ment, or finally be completely destroyed. 
Syphilitic ulceration of the larynx heals by peripheral 
cicatrization, as has been well described by Yircliow. 
Around the borders of the ulcer dense, callous connec- 
tive tissue makes its appearance, which is characterized 
by excessive peripheral growth, as in the cicatrix follow- 
ing a burn. The resulting scar varies in appearance, ac- 
cording to the size and situation of the original ulcer. 
On the ventricular bands and free surface of the epi- 
glottis, it is generally star-shaped, while in other situa- 
tions firm, fibrous bands are formed which connect them 
with, or bind them down upon, adjacent structures. 
As the ulcers heal, there spring up at the periphery 
of the cicatrices small papillary or fibroid hyperplasise, 
and thus, later on, small areas are found decked with 
growths, which mark the site of past ulceration. 
The deformities which result from the cicatrization of 
large ulcers are quite characteristic. The epiglottis may 
be bound down to the base of the tongue, to the lateral 
and even posterior pharyngeal wall, adhesions may form 
between its free edges and the ary-epiglottic fold, be- 
tween the latter and the ventricular bands and pyriform 
sinuses, and between the free edges of the ventricular 
bands ; or the whole interior of the larynx may be con- 
verted into a contracted cicatricial channel in which all 
trace of the original anatomy of the parts is lost. Occa- 
sionally the larynx as a whole is displaced, or individual 
parts are thrown into unnatural positions by the contrac- 
tion of the new-formed tissue. When ulceration occurs on 
surfaces that are brought in contact in the natural exer- 
cise of function, as for example, the vocal cords, mem- 
branous formations composed of cicatricial tissue are 
occasionally developed between the opposing ulcerative 
surfaces, thus forming a web between them—a condition 
which has been especially well described by Elsberg.43 
If cicatrization be not promoted, the ulcers rapidly 
descend to the perichondrium, purulent inflammation 
of that structure is established and the cartilage laid 
bare. 
Perichondritis and necrosis of the cartilages may also 
develop as a primary affection—possibly, though rarely, 
as a metastatic (septic) inflammation of the fibro-carti- 
laginous tissue. The cartilage thus becomes surrounded 
by a purulent infiltration which takes place beneath and 
in the meshes of the perichondrium, caries occurs and 
the necrotic portions are expelled as a granular detritus 
or as well-formed sequestra. Sometimes an entire carti- 
lage is expelled in the effort to expectorate. While ex- 
pulsion of necrotic cartilage usually takes place by the 
mouth, it occasionally happens that the necrosed plate 
falls into the trachea and causes death. The entire epi- 
glottis has also been found in the stomach. 
■ The presence of necrotic cartilage in the larynx, apart 
from other dangers to which it may give rise, aggravates 
the existing local disease, increases suppuration, and may 
442 Larynx. 
Larynx. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
even lead, if not artificially extracted, to metastatic ab- 
scesses in various parts of the body, to pyaemia, and death. 
If perichondritis do not result fatally, recovery takes 
place, at the expense of the functions of the larynx, with 
permanent anchylosis, with consequent paralytic affec- 
tions and diminution in the calibre of the larynx, or fis- 
tulous tracks may be established between the cartilage 
and interior of the larynx, or may connect the former 
with the external surface. 
A remote danger from tertiary laryngeal ulceration is 
death from haemorrhage, as in the classical case of 
Tiirck,44 where the laryngeal artery was opened, and in 
the one mentioned by Rokitansky,45 where sudden death 
occurred from perforation of the aorta. 
In all forms of tertiary syphilis of the larynx and in 
the deeper ulceration of the secondary and intermediate 
periods there is a tendency to acute and chronic oedema. 
The former occurs suddenly, and is sometimes the imme- 
diate cause of death ; the latter develops slowly, and, in 
some instances, without danger to life, while in others it 
causes progressive dyspnoea, which may terminate fatally 
by sudden increase of the serous infiltration. 
Symptoms and Complications.—It is manifest from 
the above that the symptoms and complications of la- 
ryngeal syphilis are of the most varying nature, and 
may consist in very slight modification of the vocal and 
respiratory functions or in their complete destruction ; 
and even, secondarily, abrogation of the process of degluti- 
tion. 
Diagnosis.—The distinctive points of difference be- 
tween the diffuse laryngitis of the secondary period and 
simple catarrhal inflammation have been already given. 
The older writers laid great stress upon a peculiar rau- 
cous character of the voice as diagnostic, and the vox 
rauca syphilitica was placed among the pathognomonic 
symptoms of the disease. This quality of the voice is, 
however, met with when the vocal cords are congested, 
thickened, or abraded from simple inflammation, and 
cannot, therefore, be looked upon as characteristic of 
syphilitic laryngitis; though it may be of value in dif- 
ferentiating the latter from tubercular inflammation. 
In the earlier laryngeal affections of tuberculosis the 
pronounced pallor of the mucous membrane of the 
pharynx, larynx, and nasal passages, the tendency to 
swelling and congestion of the posterior and inferior por- 
tions of the larynx, together with a hypenesthetic con- 
dition of the upper air-passages, and especially the phar- 
ynx, and the slow development and persistence of the 
ulcers (generally on the vocal processes) will lead to an 
examination of the lungs, where evidences of commenc- 
ing consolidation are generally to be found upon careful 
examination. In doubtful cases, where such evidence is 
wanting at the apices, the writer has repeatedly discov- 
ered signs of a localized bronchitis between the scapulae, 
and the diagnosis has been verified by the subsequent 
development of the case. 
Tertiary syphilitic ulceration of the larynx, and that 
which occurs in the intermediate period, may be con- 
founded with that of tuberculosis and carcinoma. 
From tuberculosis it may be differentiated by attention 
to the following points : Syphilitic ulcers are usually 
single, develop rapidly, and are preceded or accompa- 
nied by localized unilateral swelling of the mucous mem- 
brane or by gummatous growths. Tubercular ulcers, on 
the other hand, are generally multiple, are slow in devel- 
opment, and are preceded, as a rule, by a peculiar lustre- 
less, opaque thickening of the membrane (tubercular in- 
filtration). This may, in turn, be distinguished from 
the oedema which complicates syphilis, in that the latter 
is commonly unilateral, or confined to the parts princi- 
pally affected, is glistening, more or less translucent, and 
does not partake of the opaque, dull color of tubercular 
deposit. When the latter leads to the peculiar pyriform 
swelling of the ary-epiglottic folds or to the turban-sliaped 
epiglottis (vide article on Larynx, Phthisis of) it furnishes 
pathognomonic proof of tuberculosis. Syphilitic ulcers are 
larger, as a rule, than tubercular ulcers, and their favor- 
ite seats are the anterior surface and free edge of the 
epiglottis, while tubercular ulceration is most frequently 
encountered in the lower and posterior portions of the 
larynx and on the ventricular bands. When tuberculosis 
attacks the epiglottis it is generally the lower and poste- 
rior surface that is involved, and it may be said, in gen- 
eral, that the tendency of syphilitic ulceration is to de- 
velop from above downward, that of tuberculosis from 
below upward. Bilateral ulceration of the larynx, and 
especially of opposing surfaces, other things beiug equal, 
is in favor of tuberculosis. 
Deformity always results when any of the laryngeal 
structures, as, for example, the epiglottis, is perforated 
from syphilitic ulceration, while the perforating ulcer of 
tuberculosis has little or no effect upon the natural shape 
and position of the cartilage. The syphilitic ulcer is 
deep, cleanly cut, with well-defined shelving walls (vide 
supra), is surrounded by an inflammatory areola, and rap- 
idly invades the submucous tissues ; the tubercular ulcer 
is surrounded by an anaemic mucous membrane, is more 
shallow, presents a characteristic worm-eaten appearance, 
and tends to spread laterally in an irregular or serpigi- 
nous manner. 
The secretion from tubercular ulceration is usually 
very profuse, accumulates with great rapidity, and gives 
to the breath a peculiar sweetish odor that is quite char- 
acteristic. Microscopic examination, moreover, will gen- 
erally detect the presence of Koch’s bacillus, which may 
be looked upon as possessing a certain crucial diagnostic 
value. In syphilis, on the other hand, the secretion is 
by no means as great, nor does it accumulate with the 
rapidity observed in tuberculosis. Syphilitic ulceration, 
especially if the pharynx be involved, gives to the breath, 
moreover, a peculiar fetid odor, which may be regarded 
as diagnostic. 
Haemorrhage from the larynx is not uncommon in tu- 
berculosis, and is rare in syphilis. Syphilitic ulceration 
tends to heal by peripheral cicatrization ; it is doubtful 
whether extensive tubercular ulceration ever heals. The 
presence of cicatrices in the larynx is prima facie evidence 
of syphilis, and when these assume their characteristic 
form there can be little doubt concerning the diagnosis. 
Small fibrous outgrowths in the neighborhood of ul- 
cers or cicatrices are additional evidence in favor of 
syphilis, while papillary hyperplasise, occurring in the 
interarytenoid fold, and especially when they appear in 
the early stages or precede well-marked changes in the 
larynx, should awaken suspicion of tuberculosis.46 While, 
moreover, small granular or papillary hyperplasias are 
sometimes found covering the base of tubercular ulcera- 
tion,* no growth ever arises from that of a syphilitic ulcer 
or from the resulting cicatrix. Papillary hyperplasia; 
are not uncommon in syphilis, but generally mark the 
seat of past ulceration, as indicated by the presence of a 
cicatrix or other evidence of pre-existing localized de- 
struction. The papillomatous excrescences of tubercu- 
losis tend in time to ulcerate and break down, those of 
syphilis rarely, if ever, ulcerate. 
Syphilitic ulceration is, as a rule, not painful, nor is the 
larynx tender to pressure, except when the deeper struct- 
ures are involved. Deglutition is also accomplished 
with ease, except in active ulceration of the epiglottis, 
when the pain is sometimes severe. In tubercular ulcer- 
ation, on the other hand, especially when the food comes 
in contact with the ulcerated surface, swallowing is in- 
tensely painful and sometimes impossible. 
In tuberculosis the respiration is always more or less 
embarrassed and the voice is enfeebled and veiled from 
insufficiency of the expiratory forces, while in syphilis, 
unless the vocal cords be involved, the phonetic quality 
of the voice is not necessarily impaired. In the differen- 
tial diagnosis between tuberculosis and syphilis, the so- 
called vox rauca may be accepted as a conclusive sign of 
the latter. 
The presence of cicatrices or active ulceration in the 
* The gummata of syphilis may possibly be confounded with tubercular 
tumors of the larynx, that rare form of tuberculosis first described by the 
writer of this article in 1882 (N. Y. Archives of Medicine, October, 1882), 
and of which other cases have been since recorded by Schnitzler (Wiener 
Med. Presse, Nos. 44 and 46, 1883), and Percy Kidd (Clin. Soc. Trans., 
London, vol. xvii., p. 164, and St. Bartholomew’s Hosp. Rep., vol. xxi.). 
443 l«aryi»x. 
Larynx. 
REFERENCE HANDBOOK OF TIIE MEDICAL SCIENCES. 
pharynx, on the palate, or in the nasal cavities carries 
with it weighty evidence in favor of syphilis, the condi- 
tion of these structures in advanced tuberculosis being 
commonly that of anaemia associated with more or less 
catarrhal disease. 
By attention to the above differential points between 
the two diseases a mistake can rarely occur. It must, 
however, be admitted that cases arise in which an appeal 
to the historical narrative of the case, the physical exam- 
ination of the lungs and other organs, and even treatment 
may be necessary before giving a positive opinion. It 
should be remembered, too, that syphilis and tuberculosis 
are occasionally combined in the larynx, and that such a 
condition can only be recognized by the eye of a skilled 
observer. 
The deformities which result from tertiary syphilis may 
be said to be practically characteristic ; but it is well to 
call attention to the fact that certain essential fevers, e.g., 
typhoid, small-pox, etc., and diphtheria, occasionally give 
rise to ulceration of the nasal passages, pharynx and lar- 
ynx, with perforation of the septum, ozoena, loss of the 
palate, epiglottis, etc., which present all the gross appear- 
ances of syphilis, and which can only be differentiated 
from the destruction of that disease by the history of the 
case. This is especially worthy of remembrance, lest, in 
the after-life of the individual, the previous existence of 
syphilis be too readily assumed from a perforation of the 
septum or the loss of the uvula or palate. 
Much more difficult is the differentiation of syphilis and 
cancerous ulceration occurring in the larynx. The chief 
points to take into consideration here are the following : 
Cancer is a disease which occurs usually after the fiftieth 
year of life, which develops less rapidly than syphilis, 
and most commonly originates from the space between the 
vocal cord and ventricular bands (except when it descends 
from the pharynx), as a more or less clearly defined nodu- 
lar growth, which subsequently ulcerates and is convert- 
ed into a deep ulcer with bloodshot walls, whose base be- 
comes covered later with fungous, bleeding granulations. 
Associated with this, or preceding its development, are 
usually evidences of oesophageal obstruction, with pain 
on swallowing, pressure, or manipulation with the bougie. 
Lancinating pain in the larynx, when at rest, radiating 
to the ear of the affected side is often present, although 
it cannot be considered characteristic, as it may occur in 
any ulcerative disease of the larynx. As the ulcerative 
process of cancer advances, extensive haemorrhages not 
infrequently take place, an uncommon occurrence even 
in extensive syphilitic ulceration. 
The secretion of cancer is profuse, ichorous, and differs 
materially in odor from the peculiar sickening stench of 
the discharge produced by syphilitic ulceration. Exam- 
ination under the microscope will occasionally determine 
the nature of the case. 
Cervical glandular enlargement is uncommon in laryn- 
geal cancer, but is not infrequently associated with ter- 
tiary syphilis of the larynx. 
While the above may serve as reliable guides to diag- 
nosis, every experienced specialist can recall cases where 
the latter could only be determined by resort to the sov- 
ereign test of treatment. Indeed in any case in which the 
slightest doubt exists, it is the part of prudence in this, 
as in other problems of diagnosis, to give the patient the 
benefit of the doubt. 
Prognosis, Complications, Sequels.—The treatment of 
syphilitic affections of the larynx is generally very satis-, 
factory, unless the cartilages and their envelopes be at- 
tacked. Even then a cure may be effected, if the necrotic 
cartilage be removed. In deep-seated destruction a cure 
can only be obtained with permanent injury to function. 
The complications and dangers to life from tertiary 
syphilis have been already alluded to in treating of the 
pathology of the disease. The possibility of the sudden 
occurrence of oedema, even in the ulcerative laryngitis of 
the intermediate period, should never be lost sight of, 
and the danger of the latter increases, in every stage, as 
the perichondrium is approached. 
It is generally possible to produce complete cicatriza- 
tion of tertiary ulceration, but when the latter is exten- 
sive, such an event is only accomplished with considera- 
ble deformity or contraction of the larynx. Ulceration 
occurring in the subglottic region and in the neighbor- 
hood of the crico-arytenoid joint is more dangerous to 
life than when the epiglottis and ventricular bands are at- 
tacked. The entire epiglottis may be destroyed without 
serious impairment of the laryngeal functions and with- 
out impediment to deglutition. 
In fibroid degeneration, when extensive hypertrophy 
has taken place, no good has as yet come from constitu- 
tional or local treatment, and the patient drifts sooner or 
later to tracheotomy. Perhaps some good could be ac- 
complished by the use of acids, electric cautery, and 
other destructive measures, with or without a preliminary 
tracheotomy in this apparently hopeless class of case. 
If properly treated, the prognosis in simple syphilitic 
catarrh, with or without ulceration, is good, and a per- 
manent cure can often be accomplished. In other cases 
relapses of the ulcerative process occur from time to 
time. In both the prognosis is influenced by the previous 
timely treatment of the constitutional disease. Finally, 
all syphilitic lesions of the larynx are rendered less 
amenable to treatment by the predisposition to or coex- 
istence of serious organic disease, as for example, tuber- 
culosis. 
Treatment.—The treatment of laryngeal syphilis is both 
constitutional and local. While there is, perhaps, no dis- 
ease of the larynx that calls for more careful local meth- 
ods of cure than syphilis, and in which the prognosis 
depends so much upon the early laryngoscopic recogni- 
tion and appropriate topical treatment of its manifesta- 
tions, the successful accomplishment of the latter is nearly 
always assisted by and often dependent upon the exhibi- 
tion of constitutional remedies. Especially is this true of 
the tertiary lesions of the disease. To neglect general 
antisyphilitic medication when an ulcer is approaching 
the perichondrium, or when the destruction of important 
parts is menaced, is, to say the least, an unsafe and in- 
judicious experiment. 
The development and permanency of secondary laryn- 
geal lesions is also influenced, in a great measure, by the 
early adoption of constitutional measures, for the latter 
not only assist in the removal of the infiltration, but, in 
some instances, act as a safeguard against true inflamma- 
tory disease. 
The different methods of administration of antisyplii- 
litic remedies will be given in the article on Syphilis. The 
writer can recommend the tonic use of mercury, as for- 
mulated by Keyes, in the treatment of syphilitic affec- 
tions of the larynx. The most direct way of producing 
both the local and general effects of the drug is by mer- 
curial fumigation or vapor-baths. 
The local treatment of the diffuse laryngitis of second- 
ary syphilis does not differ materially from that of simple 
catarrhal laryngitis (vide supra). Should ulceration occur, 
iodoform may be freely used. In the deeper form of 
ulceration this drug is of inestimable service, and is in 
the writer’s experience superior to iodine and the nitrate 
of silver. Sprays of the bichloride of mercury, or the 
local application of the yellow oxide in cosmoline, vase- 
line, or like substance are also of considerable value. 
Before applying these remedies, the ulcerated surface 
should be thoroughly cleansed by means of a detergent 
and disinfectant spray, for, otherwise, much of the good 
effect will be lost. 
Papillomatous growths may be dissipated by the local 
application of alcohol or chromic acid, or, if extensive, 
may be removed at once with the forceps. Membranous 
webs may be successfully divided with the galvano-cau- 
tery (Elsberg) or by cutting dilators, the best of which is 
that devised by Whistler, to the excellent results obtain- 
able by which the writer of the present article can testify. 
Whether any good can be accomplished by the division 
of adhesions must be determined by the peculiarities of 
the individual case. Except when function can be re- 
stored, or serious dyspnoea or dysphagia mitigated by the 
operation, it is better, as a rule, to let them severely 
alone. 
Serious interference with respiration from any compli- 
444 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Larynx. 
Larynx. 
cation calls for tracheotomy, and the early performance 
of the latter is especially to be advised when the larynx 
has undergone the fibroid degeneration described above. 
Systematic dilatation of the larynx, as described under the 
heading Larynx, Stenosis of, is sometimes of value, but, 
as a rule, little can be expected of this line of treatment 
beyond temporary improvement, while it is much in- 
ferior to the cutting operation. 
Loosened necrotic plates of cartilage, in view of the 
dangerous complications to which they may give rise, 
should be removed, if practicable, by endo-laryngeal op- 
eration or from without, by exsection. 
Syphilis of the Trachea and Bronchi.—The in- 
dividual portions of the respiratory apparatus possess a 
decidedly varying disposition to the localization of syph- 
ilitic lesions. When the notable frequency with which 
the nose and larynx are involved during the course of 
constitutional syphilis is contrasted with the comparative 
rarity of affections of the trachea and bronchi, it may 
be with safety said that the lesions of syphilis are more 
frequently found in the upper than in the lower segments 
of the respiratory system. 
Syphilis of the trachea is of relatively rare occurrence, 
though not as uncommon as statistics would lead us to 
believe. Many cases of tracheal syphilis are doubtless 
overlooked, and especially is this true of those isolated 
inflammatory and ulcerative conditions which are found 
in the lower portion and at the bifurcation of the wind- 
pipe. In a large proportion of cases, the tracheal affec- 
tion is secondary to, and consists simply in the extension 
downward of, infiltration and ulceration of the larynx ; 
it occasionally involves the whole length of the trachea, 
and even the bronchi in its destructive action. 
Much less common is the existence of syphilis of the 
trachea without associated or pre-existent lesions of the 
larynx and pharynx, or at least, which is not the result 
of extension, but which occurs as an independent affec- 
tion. When the syphilitic disease is thus isolated, it is 
usually in the lower third of the trachea, from which it 
extends into the bronchi, or the latter may themselves be 
the seat of isolated syphilitic lesions. 
Isolated syphilis of the upper third is much less com- 
monly met with, and may occur alone or in combination 
with lesions of the lower trachea and bronchi. Usually 
both bronchi are affected. When one alone is involved, 
it is more frequently the right. Only two cases are on 
record of isolated syphilis of the windpipe in its entire 
length,41 while the isolation of the disease in the middle 
third is so rare that the possibility of its existence in this 
locality has been denied. This condition has, however, 
been found and described by the writer48 of this article, 
who, at the time of publication, could find but two simi- 
lar cases in literature (Charnal,49 Beger60), to which a 
fourth has quite recently been added by Felix Se- 
mon.61 
Pathological Anatomy.—The changes met with in the 
trachea are identical with those found in the larynx 
during the secondary and tertiary period, with certain 
differences of appearance due to peculiarity of anatomi- 
cal structure. 
Mucous patches in the trachea are liable to be over- 
looked. M. Mackenzie53 states that he has found them 
five times. Seidel54 describes as a mucous patch a pale- 
red excrescence, the size of a pea, which was associated 
with condylomata in other parts of the body, and which 
disappeared without local treatment. Diffuse superficial 
inflammation, with or without ulceration, fibroid degen- 
eration, gummatous growths, deep ulceration involving 
the perichondrium and cartilages, leading to peritracheal 
abscesses, exfoliation of necrotic tissues with subsequent 
fistulous communication with the exterior, membranous 
formations and stricture from the cicatrization of ulcers 
are all observed, either alone or combined in the course 
of constitutional syphilis. 
The ulceration generally descends from the larynx 
along the inner surface of the tube, presenting a more or 
less irregular spiral form or peculiarly forked appear- 
ance. In other cases, the long diameter of the ulcer is 
at right angles to that of the trachea, which it surrounds 
in a circular manner. Usually single, the ulcers vary in 
size, sometimes extending the whole length of the tube, 
and even to the first division of the bronchi. 
The stenosis which follows the contraction of the cica- 
tricial tissue may affect the tube as a whole, whose lu- 
men it sometimes obliterates almost completely, or the 
obstruction may be confined to its individual segments. 
The most common seat of obstruction is the lower third. 
The stricture which results from the cicatrization of a 
tracheal ulcer is of two kinds—excentric and concentric. 
The former is produced by irregularities or deformities 
of the tube from the healing of longitudinal or imperfectly 
annular ulceration, or as the result of perichondritis. In 
annular or concentric stricture there is often dilatation 
of the trachea above and below the constriction, forming, 
so to speak, an hour-glass appearance. The cicatrices do 
not differ materially from those found in the larynx. 
They either present a peculiar net-like form or resemble 
the scars found in the oesophagus from corrosions (For- 
ster). In the writer’s case the cicatrix presented a re- 
markable resemblance to a sheaf of wheat. 
Prognosis.—The prognosis of tracheal syphilis is, other 
things being equal, much less favorable than when the 
disease attacks the larynx, and it becomes graver as the 
bifurcation into the bronchi is approached. Extensive 
ulceration, especially when occurring in the lower third, 
or when it involves the bronchi, is generally fatal, while 
in obstruction in the upper third life may be prolonged by 
resort to tracheotomy or to systematic dilatation. In ad- 
dition to the usual dangers from stenosis, perichondritis, 
etc., death has been known to occur from haemorrhage, 
due to perforation of the ulcer into the aorta55 and into 
the pulmonary artery.66 In other cases the ulcer has 
perforated into the mediastinum61 and into the. oesoph- 
agus.58 
Symptoms.—Syphilis of the trachea may run its course 
without the production of any symptoms during life, or 
it may give rise to those of the most alarming and dan- 
gerous forms of stenosis. 
Congenital Syphilis op the Larynx, Trachea, 
and Bronchi.— Isolated cases of laryngeal lesions in 
congenital syphilis are to be found scattered here and 
there through medical periodicals, but systematic writers 
have either entirely ignored the subject, or referred to a 
few recorded cases as pathological curiosities. The uni- 
versal sentiment of authority has, until quite recently, 
been decidedly adverse to the frequent dangerous im- 
plication of the larynx, and the changes in the voice* 
are referred to the intervention of fortuitous catarrh. 
In the American Journal of the Medical Sciences for 
October, 1880, I called attention to the frequency with 
which the throat is involved in congenital syphilis, and 
gave a systematic description of the lesions found in 
the pharyngo-broncliial tract and oesophagus during the 
course of that disease.69 In opposition to the then gen- 
erally received doctrine, I ventured to maintain, as the 
result of careful investigation of the subject, that, so far 
from being rare, as was generally supposed, laryngeal 
affections in congenital syphilis are among the most com- 
mon and characteristic of its pathological phenomena, 
and that the invasion of the larynx may be looked for 
with the same confidence in the congenital as in the ac- 
* As early as 1837, Dr. Abraham Colles, of Dublin, called attention to 
a hoarse cry as a symptom of congenital syphilis and referred to the fact 
that when the voice became hoarse, the affection of the anus might be 
shortly expected (Pract. Observ. on the Venereal Disease, etc., Lond., 
1837, p. 269.). Rosen, a distinguished Swedish physician is cited by 
Mahon and Lamauve (Recherch. important sur l’existence, la nature et 
la communication des mal. syph., etc., p. 371, Paris, 1804), as mention- 
ing a hoarseness occurring without manifest cause, and difficult degluti- 
tion as symptomatic of congenital syphilis; but on referring to the Eng- 
lish translation of Rosen’s work, I find that the sentence relates, not to 
the inherited syphilis of the child, but to the acquired disease in the nurse 
(The Dis. of Children and their Remedies, by Nicolas Rosen von Rosen- 
stein, trans. from the Swedish edition of 1771, by Dr. Andrew Sparr- 
man, p. 332, London, 1776). Long before Colles wrote, Josef Jacob 
Plenck, in speaking of the signs of inherited syphilis, observes that not 
infrequently the fauces and labial commissures become exulcerated—a 
condition indicated by a rough voice, nocturnal cries, sleepless nights, 
etc. “Non raro fauces et commissurse labiorum simul eroduntur. In- 
dex vox rauca, clamores nocturni, noctes insomnes. deglutitio difficilis, 
tabes, mors ” (Doctrina de morbis venereis, p. 149, Vienn'as, 1779). This 
writer also refers to ulceration of the fauces in “ latent” syphilis. 
445 Larynx. 
Larynx. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
quired form of the disease. Further experience and the 
study of cures since recorded by others have only served 
to strengthen the positions taken in the paper referred to, 
for an elaborate discussion of which I must refer to the 
original, from which also the following account is taken. 
The laryngeal lesions of congenital syphilis are constant 
and characteristic and play an important role in the patho- 
logical evolution of the disease. Often among the first 
events of its clinical history, they may rapidly terminate in 
death, or stealthily advance, inducing progressive morbid 
changes, which, at first controllable and evanescent, may 
ultimately become inveterate. And thus the laryngeal in- 
flammation may outlive the series of phenomena which 
mark the progress of the malady, witnessing their incep- 
tion, course, and disappearance, itself alone rebellious to 
the approaches of the treatment by which they have been 
controlled or dissipated. 
The larynx may be involved at any, but usually at an 
early epoch. Laryngitis may even arise during intra- 
uterine life. The most common period of invasion, how- 
ever, is within the first six months after birth. Out of 
76 cases of laryngitis, 53 occurred within the first year ; 
and of these 43 within the first six months, 17 within the 
first month, and four within the first week of life. Age, 
therefore, seems to exercise a predisposing influence 
upon the eruption of the disease in the larynx. This ap- 
plies not only to the superficial changes, but also to the 
more malignant forms of laryngeal destruction. 
The laryngeal affection is met with more frequently 
in the female than in the male sex, in the proportion 
of three to two. It develops at all periods of the year, 
without regard to season, although it is naturally aggra- 
vated by those atmospheric changes that determine ca- 
tarrhal conditions. 
Imperfect nutrition and forced neglect of hygienic laws 
sufficiently explain its prevalence among the children of 
the poor. 
The classification of the laryngeal lesions of congenital 
syphilis into secondary and tertiary will not obtain as in 
the case of acquired disease. Their pathological evolu- 
tion is not governed by the same laws that regulate the 
eruption of syphilis in the adult larynx, nor can we predi- 
cate, in any given case, the order in which they will ap- 
pear. In some, not a few, the deeper destructive forms 
are the first indication of laryngeal mischief. 
In congenital syphilis we may distinguish two princi- 
pal varieties of laryngeal inflammation. In the one, the 
changes are limited to the mucous membrane, and, it 
may be the submucosa ; its march is essentially slow, and 
there is little tendency to invasion of the deeper struct- 
ures. The other is characterized by deep ulceration of 
an extremely acute nature, which, especially in early 
life, rapidly involves the cartilages and their envelopes, 
and constitutes the most frightful form of the disease. 
In addition to these, there is a third form, in which a 
gradual deposit of dense, fibrous material takes place 
within the tissues of the larynx, and leads to contraction 
of its lumen. 
These pathological facts justify a classification based 
upon the anatomical seat of inflammation. The laryngeal 
lesions may, accordingly, be classified as superficial, deep, 
and interstitial. 
Chronic superficial laryngitis is the condition most fre- 
quently met with. It is limited to the mucous mem- 
brane and submucosa ; is essentially chronic ; runs a 
definite course ; gives rise to well-defined changes in the 
larynx, and may be divided into three stages. The first, 
or stage of hyperaemia, presents nothing diagnostic ; the 
redness is generally diffuse, but sometimes is confined to 
special areas. It is commonly associated with congestion 
of the trachea, coryza, and erythema of the fauces and 
pharynx. Gradually, however, a condition of hyper- 
trophy is developed in the laryngeal membrane, which 
becomes swollen, thickened, and infiltrated, constituting 
the second stage or that of infiltration and hypertrophy. 
If the larynx be examined now, its membrane will be seen 
to be deeply injected, and often slightly translucent from 
chronic inflammatory oedema. The epiglottis, ventricu- 
lar bands, and arytenoids have a swollen, rounded appear- 
ance, while the vocal cords are thickened and reddened, 
and their excursive mobility is impaired. Swelling of the 
mucous glands sometimes occurs, but the secretion is gen- 
erally scanty. These changes are occasionally limited to 
one side of the larynx. Thus, one-half of the epiglot- 
tis, its corresponding ary-epiglottic fold and ventricular 
band may be swollen and thickened, while the opposite 
side of the larynx is in a state of simple congestion. If 
the throat be neglected, minute ulcers form by the lique- 
faction of the superficial portions of the mucous mem- 
brane, which partake at first more of the nature of 
erosions, but which, in long-standing cases, involve the 
whole thickness of the membrane, and sometimes reach 
the cartilage. Arrived at this period or stage of ulcera- 
tion, the affection becomes stubbornly rebellious to treat- 
ment. Under antisyphilitic medication the ulcers heal, 
it is true, and temporary relief is afforded ; but sooner or 
later fresh ones appear in other parts, thickening and 
hypertrophy become progressive, and secondary changes 
may be induced in the lungs, either by direct extension 
through the trachea and bronchi, or as the result of a 
diminution in the calibre of the larynx itself. As cicatri- 
zation of the ulcers takes place, small papillary or poly- 
poid liyperplasiae arise around the edges of the cicatrix. 
When small, they impart (post mortem) to the finger a 
rough granular sensation. They are more common in the 
child than in the adult, and the same may be said of the 
ulcerations which precede them. 
Such is the common history of this form of laryngitis. 
Commencing in early childhood as an ordinary catarrh, 
for which it is often mistaken, it gradually, but surely 
asserts its specific nature. To it is due the characteristic 
cry and other symptoms referable to the larynx, so com- 
mon in the early stages of congenital syphilis. The 
changes which have been described require time for their 
completion, months and even years elapsing before they 
reach their full development. 
From the fact that hoarseness and other laryngeal 
symptoms sometimes coexisted with mucous patches on 
the palate and in the pharynx, it was assumed by Diday60 
that they were due to the presence of similar lesions within 
the larynx, in the neighborhood of the ary-epiglottic folds. 
Czermak61 and Tiirck62 have each reported cases where 
they were seen with the laryngoscope ; and one is referred 
to in the Gazette des Hopitaux,63 in which they were 
found in front of the arytenoids. The patches describeil 
by Czermak and Tiirck are, however, evidently exam- 
ples of true ulceration, and the account of the laryngeal 
appearances in the child from the Hopital Necker is too 
meagre to be of any value in establishing the existence of 
mucous patches in the larynx of the congenital syphilitic. 
The deep, destructive, ulcerative laryngitis corresponds 
in physical characters pretty closely to the tertiary in- 
flammation of acquired syphilis. It may follow the su- 
perficial form, but generally occurs independently of it. 
It is sometimes among the first symptoms of infection, 
and is then most destructive. 
As a rule, deep pharyngeal ulceration precedes, or co- 
exists with, this form of laryngitis, but deep ulceration 
of the larynx occurs, too, without the slightest evidence 
of pre-existing pharyngeal lesions. 
Laryngeal ulceration does not commonly follow the 
pharyngeal destruction of so-called latent syphilis. The 
palato-pharyngeal ulceration found in tardy congenital 
syphilis, has little tendency to invade the larynx ; its fu- 
ture theatre of action is the naso-pharynx and nose. 
The first stage of this form of laryngitis consists either 
in a deposit of gummatous material in, or a round-cell in- 
filtration of, the structures which subsequently become 
the seats of ulceration. The resulting ulcers have the 
same appearances as those found in the tertiary period of 
constitutional syphilis, and lead to similar deformity and 
stenosis. They are single or multiple, symmetrical, or 
confined to one side of the larynx. Tlieir most frequent 
seat is the epiglottis ; they are often situated in the ven- 
tricles ; less frequently on the upper and under surface 
of the vocal cords, ventricular bands, ary-epiglottic folds, 
and plica meso-arytenoidea. They are also observed in 
the subglottic cavity. 
446 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Larynx, 
Larynx. 
There is a remarkable tendency in the laryngeal ulcer- 
ation of congenital syphilis to destruction of the deeper 
tissues—the cartilages and their envelopes—and this pre- 
disposition is most marked in those in whom the throat 
is attacked at an early stage of the disease. There seems 
to be an inherent virulence in the process, which finds 
in the imperfectly developed laryngeal structures an ap- 
propriate field for the display of its destructive power. 
Chondritis, caries, and necrosis are found in over two- 
thirds of the recorded cases, at all ages. Of these, over 
three-fifths occurred within the first year of life. 
Chronic interstitial laryngitis is intermediate between 
the two forms of inflammation already described, and is 
rarer than either; but it is of considerable practical im- 
portance, in view of its insidious tendency to stenosis. It 
consists essentially in a gradual deposit of a fibroid ma- 
terial in the tissues of the larynx, which leads inevitably 
to serious interference with respiration. But few cases 
of this condition have been recorded ; it is possible, how- 
ever, that it may be looked for at a period when other 
interstitial changes, notably keratitis, commonly develop. 
Lesions of the Trachea and Bronchi.—The trachea is 
the seat, though much less frequently, of the three forms 
of syphilitic inflammation described as occurring in the 
larynx. Apart from superficial changes, well pronounced 
tracheitis and deep ulceration are relatively rare. The 
condition most commonly found is congestion, generally 
streaked or confined to certain areas, with moderate swell- 
ing of the mucous membrane. In two cases examined 
post mortem there were numerous small ulcers confined 
to the upper third of the trachea. Small granular hyper- 
plasiae existed in their vicinity. Ulceration and cicatrices 
have also been observed by Hiittenbrunner,64 Woron- 
chin,65 and Sturges,66 and a case of stenosis has been re- 
corded by Steiner.67 
Symptoms of Congenital Laryngeal Syphilis.— Voice and 
Cry. The cry in the infant and the voice in the older 
child exhibit all degrees of phonetic impairment, from 
slight huskiness to the toneless whisper of absolute apho- 
nia. At first the cry has a shrill, piping tone, that has 
been compared by West and Zeissl to the sound of a 
child’s toy trumpet. This sometimes degenerates into a 
peculiar squeak. Soon it assumes a characteristic vibra- 
tory twang, difficult to describe, but not unlike the vocal 
resonance which is heard just above the level of a pleu- 
ritic effusion. This is probably due to the sonorous vi- 
brations of the thickened mucous membrane, which, at a 
stage when infiltration has not advanced to consolidation, 
is loose and admits of being thrown into exaggerated 
vibration by the current of expired air. Later the voice 
becomes harsh, cracked, and finally completely lost. It 
is surprising, however, to what extent the larynx may be 
involved without impairment of the voice. 
Cough is frequently present, and is often a very dis- 
tressing symptom. It is paroxysmal, suffocative, inter- 
mittent, raucous, and often followed by vomiting. The 
impairment of phonetic quality may be of diagnostic 
value in those cases in which corresponding changes in 
the voice are absent. The paroxysms may be excited by 
crying, or attempted deglutition, but are generally worse 
at night, leading to attacks of dyspnoea, which threaten 
suffocation. There is not much expectoration, except in 
the deep ulcerative form, when it is very profuse and 
muco-purulent, filling the larynx, and interfering with 
laryngoscopic examination. The amount of secretion 
may be taken as an approximate measure of the extent 
to which the destructive process has advanced. 
Respiration is seriously embarrassed, the rhythm hur- 
ried, and often interrupted. Attacks of dyspnoea are 
brought on by coughing and suckling, and are worse at 
night, leading to orthopnoea, cyanosis, and convulsions. 
Sometimes the breathing has a bronchial sound, and is 
stridulous and stertorous, according to the amount of 
obstruction. The respiratory distress is, as a rule, com- 
mensurate with the amount of laryngeal stenosis ; but 
secondary changes in the trachea, bronchi, and lungs 
are sometimes important factors in its production. It is 
also modified by the degree of nasal obstruction from 
coryza. 
Deglutition is difficult, and sometimes painful and im- 
possible. It is caused by pharyngo-laryngeal swelling 
and ulceration ; but we may assume that, in some cases, 
it is due to lesions of the oesophagus itself. Laryngismus 
occurs quite frequently, and is sometimes the immediate 
cause of death. In a case reported by Thomas Barlow,68 
it was associated with disease of the meninges of the 
brain. 
In many cases no definite relationship seems to exist 
between the laryngeal and cutaneous lesions of congeni- 
tal syphilis. It is also an interesting fact that, while the 
external lesions yield readily to antisyphilitic medica- 
tion, the laryngeal often have a tendency to persist. The 
larynx seems to be the last organ to surrender to thera- 
peutic influence. Among the secondary complications in 
the lungs are congestion, atelectasis, emphysema, bron- 
chitis, pleurisy, and pneumonia. The latter is often the 
immediate cause of death. But the condition which 
commands most serious attention is the sudden and fatal 
laryngeal oedema, w'hich occurs without warning, and 
from which the patient dies before assistance can be ob- 
tained. 
Diagnosis.—The laryngeal affection in its first stage 
may be mistaken for simple laryngitis, and wdien asso- 
ciated wdth chronic bronchial irritation or pulmonary 
inflammation may be confounded with tubercular laryn- 
gitis. But the greatest difficulty will arise in its dis- 
crimination from laryngeal growths. Here, if laryngo- 
scopic examination be impossible, the diagnosis may be 
involved in doubt. 
Rapid cicatrization of laryngeal ulceration under the 
iodide of potassium practically settles the question of 
syphilis ; but the diagnosis can be made, in the majority 
of instances, without invoking this‘aid. When ulceration 
attacks the denser structures, the action of the iodide 
may be slow. Here, if nutrition be stimulated by tonic 
treatment, and especially by cod-liver oil, the processes 
of repair will be accelerated. But this obviously does 
not warrant the conclusion that the destruction is not 
syphilitic. The power of cod-liver oil over the phenom- 
ena of congenital syphilis is the same as that wdiich it ex- 
ercises in other wasting diseases, an influence which is 
often overlooked. The assumption, therefore, that an 
ulcer which heals under this drug, either alone or com- 
bined with the iodide of potassium, is necessarily scrofu- 
lous, diverts the mind from a rational interpretation of 
the case. 
The prognosis will be influenced greatly by the age of 
the patient; the earlier the throat is attacked, the more 
serious the results. Pharyngo-laryngeal ulceration occur- 
ring within the first year is almost invariably fatal. Deep 
ulceration of the larynx, in view of its destructive ten- 
dency, offers a grave prognosis at any period. The prog- 
nosis in chronic superficial laryngitis is more favorable 
as regards life, though the tendency to laryngeal oedema 
and spasm should not be lost sight of. Tliis form of la- 
rjmgeal syphilis is exceedingly persistent and intolerant 
of treatment. It is often the primum vivens and the ulti- 
mum moriens of the disease. As Vidus Vidius said of 
syphilis, “ it makes many truces, but never peace.” In 
all forms of laryngeal syphilis, death may take place from 
acute oedema. The prognosis will depend, furthermore, 
upon the gravity of the general infection and the second- 
ary complications in the lungs. 
Treatment.—In acute laryngeal syphilis the treatment 
should consist in mercurial inunction over the thyroid 
cartilage, the inhalation of calomel or iodate of zinc in 
the form of vapor, and the internal administration of po- 
tassium iodide. The aggregate daily dose of the latter 
should be large, and the drug pushed rapidly to the verge 
of iodism. Should the dangerous symptoms not yield 
within forty-eight hours, the question of tracheotomy 
should be considered. 
In the more chronic forms, mercury in tonic doses, 
combined with iodide of potassium, should be exhibited, 
the local treatment consisting in the use of topical appli- 
cations and inhalations. As a topical application to the 
ulcers, great reliance may be placed upon iodoform, or 
the vapor of the iodate of zinc may be used. 
447 Larynx, 
Larynx. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
The Effect of Certain Acute Morbid Processes 
upon the Throat Affections of Syphilis, Congeni- 
tal and Acquired.—In a paper read before the Ameri- 
can Laryngological Association in 1884,69 I contributed 
some observations on the manifestations of congenital 
syphilis in the throat and their behavior under the influ- 
ence of certain acute diseases, from which the following 
extract is taken: 
In the paper on congenital throat syphilis to which ref- 
erence has already been made in the preceding article,10 
the following conclusions were reached in regard to deep 
destructive ulceration of the oro-pharyngeal cavities : 
1. That deep ulceration may invade the palate, phar- 
ynx, and naso-pharynx at any period of life from the first 
week up to the age of pubertjr. Thus, of thirty cases 
analyzed with reference to the period of invasion, four- 
teen occurred within the first year, and ten within the 
first six months of life, the remainder occurring at peri- 
ods more or less advanced toward puberty. 2. When the 
eruption of inherited syphilis is apparently delayed until 
the latter period, that lesions of the palate and pharynx 
are found with a peculiar constancy, and often first at- 
tract attention to the existence of a diathesis of which 
they are the sole pathological expression. 3. That fe- 
males are attacked more frequently than males. Thus, 
out of 69 cases of pharyngeal ulceration, 41 occurred in 
the former sex. 4. That ulceration may occur in any 
situation ; but its most frequent seat is the palate, for 
which it exhibits the closest elective affinity. 5. That, 
when situated at the posterior portion of the hard palate, 
the tendency is to involve the soft palate and velum, and 
thence to invade the naso-pharynx and nose; while, situ- 
ated more anteriorly, it seeks a more direct pathway to 
the latter, which is established by perforation of the bone. 
6. That the next most common seats of ulceration in or- 
der of frequency are the fauces, naso-pharynx, posterior 
pharyngeal wall, nasal fossa and septum, tongue, and 
gums. 7. That ulceration, especially that of the palate, 
shows a disposition to centrality of position, together 
with a special tendency to caries and necrosis of the bone, 
a fact probably explicable by the great vascularity of the 
periosteum and medullary membrane in youth. 8. That 
the tendency to necrosis exists at all periods of life, but 
especially in early youth, when it is more destructive and 
less amenable to treatment. 9. That while deep pharyn- 
geal ulceration generally precedes or co-exists with simi- 
lar affections of the larynx, the latter occurs, too, without 
evidence of pre-existing pharyngeal lesions. 10. That 
simultaneous or consecutive ulceration of the palate, 
pharynx, and nose seems to be characteristic of syphilis, 
or at least occurs more frequently in this than in any 
other disease. 
I bring these facts again into prominence because they 
differ from commonly accepted views, and because they 
possess at least a certain value by reason of the method 
by which they were obtained. 1 desire also to reiterate 
what was said in connection with the confusion of these 
lesions with so-called “scrofulous” ulceration. With- 
out entering into a discussion of the subject, suffice it to 
say that there is no just ground for belief in an ulcera- 
tive scrofulide of the throat. It needs only the most su- 
perficial review of the writings of those who maintain its 
separate existence to show the utter confusion which pre- 
vails, as the result of erroneous views handed down 
among the traditions of an obsolete pathology. 
It is obviously a point of great practical importance that 
this fact should be recognized, and especially in view of 
the rapidly destructive tendency of inherited syphilitic 
ulceration in the oro-pharyngeal cavities and larynx. 
The throat ulceration of congenital syphilis not only 
exhibits a special tendency to rapid invasion of the deeper 
tissues ; it often possesses an inherent virulence which 
places it apparently beyond the reach of therapeutic con- 
trol. This is markedly true of the ulceration which oc- 
curs in the earlier years of life. Cases are now and then 
encountered in which the ulcers stubbornly refuse to cica- 
trize, or do so sluggishly and imperfectly, healing at one 
point and becoming simultaneously active at others. 
Under such circumstances, 'when remedial measures are ap- 
parently of little or no avail, they sometimes cicatrize, as if by 
magic, on the accession of an acute disease. It is to this that 
I wish to direct particular attention. 
The clinical study of the cases upon the analysis of 
which the report referred to was based disclosed certain 
striking facts in connection with the influence of some of 
the ordinary infectious diseases of childhood upon the 
progress of the inherited syphilitic affection. From the 
historical narrative furnished by this particular group of 
cases, it would appear (1) that, while congenital syphilis 
affords no absolute protection against certain -acute infectious 
diseases, its existence in the individual seems often, other 
things being equal, to mitigate their severity and exert a fa- 
vorable influence on their course; (2) that certain acute dis- 
eases, accompanied by an exanthem, favor the dissipation, at 
least temporarily, of the throat and other manifestations of 
the disease ; (3) that ivhile at no period of the disease is the 
child exempt from these affections, they are more liable to be 
contracted during the period of latency—that curious inter- 
val of apparent health in congenital syphilis-which Cazenave 
has poetically called the sleep of the virus. 
These remarks are limited to scarlet fever, measles, and 
chicken-pox, but they coidd doubtless be extended to 
embrace others of the exanthemata. 
They do not apply, for obvious reasons, in the case of 
excessive virulence of the syphilitic cachexia or malig- 
nant epidemic influence of the intercurrent disease. 
Of special interest is the effect produced by acute fe- 
brile disease upon the throat lesions of congenital syphi- 
lis. Chronic inflammatory conditions and ulceration of the 
larynx, pharynx, and nasal passages, are often influenced 
in a remarkable manner through the presence in the individ- 
ual of an intercurrent febrile affection. This is, moreover, 
eminently true of those acute blood diseases with special ten- 
dency to local manifestations in the throat, such as scarlet 
fever, measles, diphtheria, etc. According to personal ex- 
perience, scarlet fever and measles exert, as a rule, a favor- 
able influence on the course of the throat affection, their su- 
pervention being of itself sufficient to cause its complete 
disappearance. The poisons of the two diseases in their cir- 
culation in these regions appear to be mutually destructive, 
and the throat escapes by virtue of such reciprocal antago- 
nism. * The cure here may be permanent, or relapses of the 
inflammatory or ulcerative process may follow the removal of 
the antagonistic influence of the intercurrent disease. 
These remarks do not apply to diphtheria. When this 
affection supervenes during the existence of lesions in the 
throat, the patients rapidly succumb to the disease. The 
existence of syphilis in the child apparently increases the 
tendency to membranous formation ; indeed, in some in- 
stances, apart from the presence of the diphtheritic proc- 
ess, there seems to be a special tendency to fibrinous for- 
mation in the nose and retro-nasal space. 
The influence of acute disease upon the manifestations 
of constitutional syphilis is a subject which has received 
some attention at the hands of syphilographers, especially 
certain of the French school ; but very little is known as 
yet beyond the empirical fact that the lesions of that dis- 
ease, and especially the cutaneous syphilides, are often 
modified by the introduction into the blood of the virus 
of an intercurrent febrile affection. This modification 
may consist either in the permanent or temporary dissi- 
pation of existing syphilitic lesions, or in the exaggera-- 
tion or intensification of the morbid process. Thus, for 
example, various syphilitic affections, such as skin erup- 
tions, exostoses, etc., have been observed to disappear 
during the course of erysipelas,11 acute rheumatism,12 
cholerine,13 variola,14 febrile furunculosis,15 etc. La- 
segue 16 has recorded a case of ulceration of the pharynx 
and tonsils which disappeared during an attack of ery- 
sipelas, while in a similar one observed by Martelliere 11 
a fatal result ensued from that disease. The dissipation 
of syphilitic eruptions has also occurred during preg- 
nancy,78 and as the result of vaccination,19 and there is a 
case on record where the latter apparently exerted a cura- 
tive influence in caries of the pharyngeal vault.80 
* It is quite possible that this may also be true of other mucous surfaces 
of the body. 
448 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
Larynx. 
Larynx. 
The remarkable power of erysipelas over the cutaneous 
syphilides has suggested its artificial production as a 
therapeutic agent in these affections,81 while their behav- 
ior under the operation of the vaccine virus led to the 
now almost forgotten practice of Lukonski.82 It has, 
finally, even been proposed by an enthusiastic pupil of 
M. Hardy to inoculate the poison of small-pox in cases of 
syphilis which have resisted all other methods of treat- 
ment.83 
It is sufficiently evident, then, that a reciprocal antago- 
nism exists between the poison of syphilis and that of a 
number of acute diseases. By what pathological law this 
is brought about is, in the present state of our knowledge 
of the mutual relations of disease, a matfer of pure specu- 
lation. 
This remarkable influence of the febrile state upon 
syphilitic inflammation and ulceration of the nasal pas- 
sages and throat is also, in a measure, true of simple in- 
flammatory conditions of these cavities. It were foreign 
to the purpose of the present article to elaborate this lat- 
ter and cognate subject, and I shall, therefore, simply 
offer for consideration the fact that simple catarrhal 
inflammation of these regions occasionally disappears com- 
pletely, and is permanently cured during the course of an 
acute febrile disease. Whether this occur as a phenome- 
non of so-called “substitution,” or as the result of a pro- 
found impression made upon the nutrition of the parts by 
virtue of which abnormal secretion is arrested and the in- 
flamed tract placed in a condition favorable to resolution, 
can only be determined by the accumulation of more ex- 
act scientific data concerning the reciprocal antagonism 
of pathological processes. 
Without, then, attempting any special explanation or 
generalization, I present the foregoing observations from 
my clinical experience as a contribution to the study of 
an interesting but imperfectly understood subject. 
John Noland Mackenzie. 
25 Joseph Jacob Plenck : Doctrina de morbis venereis, pp. 93, 94, 97, 
99, 100, 143, 147, and 149-151. Vienna;, 1779. This writer seems to have 
been personally familiar with syphilitic affections of the oesophagus and 
cicatricial stricture of the pharynx. 
26 A Treatise on Gonorrhoea Virulenta and Lues Venerea, vol. ii., pp. 
37 and 43. Dublin, 1793. 
27 Treatise on the Ven. Dis., pt. vi., chap, ii., p. 262, et seq. (in Works, 
with notes by Babington, Phila., 1839). See also Babington's excellent 
observations, pp. 266 to 268. 
28 Complete Treatise on the Symptoms, Effects, etc., of Syphilis, 
Phila. ed., 1815, p. 293. Swediaur also alludes to affections of the ear 
(tinnitus) from compression and corrosion of the Eustachian tubes, p. 
294. 
20De sedibus et causis morborum, Epist. xliv., cap. xv., Bond, ed., 
1769. 
3° Traite de la phthisie pulmonaire, par M. Raulin, pp. 13 and 79. 
Paris, 1784. 
31 J. N. Thomann’s Annalen der klinischen Anstalt in dem Julius 
Hospitale zu Wurzburg f. das Jahr 1800, p. 242, Wiirzb., 1803 ; see 
also case in Hufeland’s Bibliothek der prakt. Heilkunde, Bd. ii., St. ii., 
S. 143. 
32 Beobachtungen iiber die Natur u. Heilung der Syphilis. Russische 
Sammlung f. Naturwissenschaft u. Heilknnst, I. Bd., St. ii., 2ter Ab- 
schnitt, S. 36. Riga u. Leipzig, 1816. 
33 The principal of these are the following: Before the era of patho- 
logical anatomy, Richard Morton, Phthisiologia, seu exercitationes de 
Phthisi, Londini, 1689; after the time of Morgagni, Petit (M. A.), Diss. 
de Phthisi Laryngea, Monspelii, 1790, October 25th (copies of both 
these rare tracts may be found in the library of the Surgeon-General’s 
Office); Sauvee, Recherches sur la phthisie laryngee, Paris, 1802 ; 
Schiinbach, De phthisi laryngea, Wilmse, '1808 ; Jos. Sigaud, Recher- 
ches sur la phthisie laryngee, Strasburg, 1819 ; Wm. Sachse, Beitrage zur 
genaueren Kenntniss u. Unterscheidung der Kehlkopfs- u. Luftrohren- 
Schwindsucht, Hannover, 1821 ; Barth, Mem. sur les ulcerations des 
voies adriennes, Arch. gen. de Med., 1839, p. 137, et folg. 
34 A Practical Treatise on Laryngeal Phthisis, Chronic Laryngitis, and 
Diseases of the Voice, trans. fr. the French. Philadelphia, 1839. 
35 Allg. Wiener med. Zeitung, No. 48, 1861 ; No. 43, 1866 ; also Klinik 
der Krankheiten des Kehlkopfes, etc. Wien, 1866. 
36 American Jour, of Med. Sc., January, 1876, also Tonic Treatment of 
Syphilis, New York, >876. 
37 See Colson, Journal Hebdom., 1831, p. 36; also Crampton (Trans. 
Dublin Coll, of Phys., vol. iv., p. 91), where two grains of calomel caused 
ulceration of the throat and death, and Devergio (Archives gen de rrnkl., 
tom. ix., p. 468), gangrene of the throat and death ; also a case (Broad- 
bent, Mem. of Lond. Med. Soc., vol. v., p. 112) where globules of mer- 
cury were found upon the laryngeal cartilages after death. 
38 Die Behandlung der Syphilis mit Sublimat-Injectionen, Berlin, 1869 ; 
Ziemssen’s Encyclop., Am. ed., vol. vii., p. 862, New York, 1876. 
30 Op. cit., p. 377. 
40 Lectures on Syphilis of the Larynx. London, 1879. 
41 Diseases of Throat and Nose, vol. i., p. 356. London, 1880. 
42 Browicz: Centralblatt f. die Med. Wissensehaft, 1877, s. 346. 
43 Syphilitic Membranoid Occlusion of the Rima Glottidis, New York, 
1874. 44 Klinik der Krankheiten des Kehlkopfes, 1866, S. 413. 
45 Path. Anat., Bd. iii., p. 22. 
40 Stoerck: Klinik der Krankheiten des Kehlkopfes, etc., Stuttgart, 
1880, s. 282. Major; Trans. Am. Laryng. Assoc., 1883, p. 163. 
47 Zurhelle : Berliner klin. Woch., 1872, No. 35. Wilks: Guy’s Hosp. 
Rep., ix., 1863. 48 Wiener med. Jahrbiicher, 1881, I. Heft, p. 75, et seq. 
49 L’Union Medicale, 1859, No. 21. 
60 Deutsch. Arch. f. klin. Med., 1879, S. 608. 
61 London Lancet, vol. i., pp. 905-906, 1882. 
62 Reference omitted after electrotype plate had been made.—Editor. 
83 Diseases of the Throat and Nose, vol. i., p. 531. London, 1880. 
64 Seidel: Jenaer Zeitschr. f. Med., 1866, S. 489. Canstatt, 1866, S. 497. 
66 Rokitansky; Patholog. Anatomie, Bd. iii., p. 22. Wilks: Trans. 
Path. Soc., vol. xvi., p. 52. 
56 Gerhardt: Arch. f. klin. Med., vol. ii., p. 541. Kelly: Trans. Path. 
Soc., vol. xxiii., p. 45. 
57 Wallmann: Virchow's Archiv, Bd. xiv., p. 201. 
58 Beger, loc. cit., and Axel Key and Oscar Sandhal, cit. in Schmidt’s 
Jahrbuch., 1870, 147, p. 48. 
89 Congenital Syphilis of the Throat; based on the Study of One Hun- 
dred and Fifty Cases. 
60 Syphilis des Nouveaux-nes. New Syd. Trans., p. 64-65. 
61 Der Kehlkopfspiegel. New Syd. Trans., 1861, p. 53. 
62 Klinik, etc., Wien, 1867, 161 Fall, and Atlas, xxii., 4. 
83 Gaz. des Hop., 1860, No. 51, p. 202. 
84 Jahrbuch fur Kinderheilkunde, Bd. v., 1872, p. 338. 
68 Ibid., Bd. viii., 1875, p. 108. 
66 Vide Lond. Lancet, April 10, 1880, p. 566. 
87 Jahrb. f. Kinderheilkunde, Bd. vii., 1865, ii., § 64. 
68 Trans. Path. Soc., London, vol. xxviii., 1876-1877, p. 287. 
69 A Contribution to the Study of Congenital Syphilis, Trans. Am. 
Laryng. Assoc., 1884, and N. Y. Medical Journal, May 31, 1884. 
70 See article on Congenital Syphilis of the Larynx. 
71 Vide Cazenave and Schedel, Practical Synopsis of Cutan. Dis., etc., 
p. 353, Phila., 1829; Rayer, Traite des mal. de la peau, Paris, 1835 ; La- 
marche, De 1’drysipMe salutaire, These de Paris, 1856, and the excellent 
articles of Mauriac, clinique sur l’influence d’erysipelas dans la 
syphilis, Paris, 1873 ; published also in the Gaz. des Ilopitaux. Nouv. 
ser., 1873, pp. 305, 321, 346, 385, 410, 443, 466, 506, 546, 569, 594, 601. 
See also Bidenkap’s case (cited by Baumler, von Ziemssen’s Cyclopaedia, 
Am. ed., vol. iii., p. 98, 1875). 
72Rayer, op. cit., p. 546 (Mauriac); see also Jourjon, Infl. des mal. 
aiguSs sur quelques manifestations cutan. de la syph., Thdse de Paris, 
1870. 73 Cazenave : Traite des syphilides, p. 593 (Mauriac). 
74 Gore : Lancet, September 2, 1858. 
75 Diday (quoted by Mauriac, 1. c.). 
78 Traite des angines, pp. 110-112. 
77 Sur l’angine syphilitique (cited by Mauriac). 
78 Gilbert: Bull, de l’acad. de mod., 1851, tom. xvii., p. 156. 
1 For a full statement of this argument, see Lancereaux’s'treatise on 
Syphilis. New Syd. Soc. Trans., 1868, vol. i., pp. 8 to 10. Quotations 
taken from Captain Dabry’s book, La Medecine chez les Chinois, Paris, 
1863, and from Hessler’s translation of the Ayur Veda. 
2 See Lancereaux. 3 Epid. 6, sec. 1. 4 Isag., cap. 20. 
8 De causis acut. morborum, lib. i., cap. viii. 
8 De Chron. Morb., lib. ii., cap. 4 ; lib. iii., cap. 2. 
7 De Compositionibus Medicamentorum, comp. vii. 
8 See especially Martial, I., 66, 79 ; VI., 41 ; IV., 41 ; XI., 30 ; VI., 55 ; 
XI.. 92, 61 ; VII., 33, etc. 9 Observ. Miscellan., Leid., 1745. def. p. 28. 
10 Die Geschichte der Lustseuche im Alterthume, Halle, 1845. 
11 Orationes ex recensione. Lipsiae, 1784, vol. ii., orat. 33. See also 
Rosenbaum, op. cit., p. 158. 12 Lib. I., 78. 13 Lib. IV., 41. 
14 Sulpicius Lupercus Servastus, Junior, in Authologia veterum latin- 
orum Epigrammatorum et poetarum, Lib. I., p. 515, et seq., Ed. Bur- 
mann, Amstelodami, 1759. 
18 See Nic. Leonicini, De Epidemia, etc., in Aphrodisiac, sive de lue 
venerea, ab Aloysio Luisino, Lugd. Bat., 1728; Nic. Massa, De morbo 
gallico, cap. vii., et quarti tract., cap. iv. (Aphr., pp. 46 and 96- 
07) ; Jacob. Cataneus, De morb. gall., cap. iv. (Aphr., p. 148); Pet. 
Maynardi, De morb. gall, tract., i., c. 4, Fernelius, De lue venerea caput 
(Aphr., pp. 613-614) ; Victorius, de morb. gall., liber, cap. iii., alludes 
to flattening of nose and caries of nasal bones, ozcena, polypus (hyper- 
trophic catarrh), etc. ; Marchelli, De morb. gall, tract. (Aphr., p. 732) ; 
Fallopius, De morb. gall, tract., cap. xxiii. (Aphr., p. 781), and cap. xciii. 
(p. 824); Botallus, Luis venerea: curandse ratio, cap. iv.; Tomitanus (B.), 
De morb. gall., lib. i„ cap. xxviii. (p. 1047), also lib. ii., cap. i. (p, 1053); 
Sylvius, De morb. gall, tract, (p. 1109) ; Paschal, De morb. gall, tract, 
(p. 1113) ; Borgarutius, De morb. gall, methodus. cap. vii. p. 1129), 
et at. See also Benevenius (Antonius), De morb. gall, tractatus, in 
his work De abditis nonnullis ac mirandis morborum et sanationum 
causis, Florent., 1507 ; this work is the first essay on pathological anat- 
omy (Library Surgeon-General’s Office, Washington). 
18Hieronymi Frascatorii, Veronensis, Syphilis, sive Morbi gallici, lib. 
111., lib. i. (Aphr., p. 187), B. and lib. ii. (Aphr., pp. 191-192), C. (a.d. 
1555); see also Frascator, De Syphilide, seu Morb. gall, lucubratio, cap. 
i. (Aphr., p. 199). 
17 De morbo gallico, lib. ii., cap. xxii. (Aph., pp. 1222 and 1223), and 
lib. vii., cap. viii. and cap. xix. 18 Loc. cit. 
19 This case is recorded in the Collegium Anatomicum of Severinus, 
from which it is taken by Bonetus (Sepulchrctum, Ludg., 1700, tom. 
1., p. 766). 
20 See Astruc., De lue venerea, tom. ii., p. 921 ; Van Swieten, Comm, 
in Aphor.; Boerhaave, § 1445; and Lieutaud, Hist. Med., tom. ii., lib. 
iv., obs. 105, Parisiis, 1777 ; also Lieutaud, Synopsis of Pract. of Med., 
ed. Atlee, Phila., 1816, p. 97. 
21 Diss. inaug. de voce, ejusque afEectibus, cap. ii., p. 52, Jen®, 1678. 
22 De pudendorum morbis. sec. 2, 12, p. 182; 9, 10, 13, p. 183, and 
14, p. 184, Lugd. Bat., 1722. 
23 Aphorism, de cognos., et. curand. morbis., § 1445, Lugd. Bat., 1728; 
also Tract, de lue venerea, Lugd. Bat., 1751. 
24 De morb. ven. libri sex, etc., II., cap. ii., cap. vii., IV., cap. iv. and 
cap. viii. and xi., § xii. Parisiis, 1736, 1738, and 1755. See also Lond. 
ed. of 1754, pp. 124 to 159 of Bk, ii., and pp. 9-14, 15, 89-90 of Bk. iv. 
Vol. IV.—39 
449 Larynx, 
Lateral Curvature. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
79 Vide Revue med., 1861, tom. i., p. 167, Jeltzinzld. 
90 Jeltzinzki, 1. c. : Sur la cure radicale de la syphilis par la vaccination. 
81 Sabatier: Propositions sur Fdrysipele considdre principalement 
comme moyen curatif dans les mal. cutanees, etc., Th6se de Paris, 1831. 
82 Jeltzinzki, 1. c. 
83 Garrigue : De l’influence des mal. aig. sur les diatheses, Th6se de 
Paris, 1870. 
450