leged to observe very many cases entirely recover in the hands of my colleagues, to whom such patients were referred for local treatment. In other cases I have been forced to witness a speedy termination in a suprisingly short time after the development of the laryngeal condition. Furthermore, a few patients have been observed, in whom recovery took place spontaneously, the improvement in the laryngeal affection developing pari passu with the gain in the general condition. Heryng has reported fourteen cases in which the healing was spontaneous.

The prognosis of tuberculosis of the larynx may be assumed to vary according to the state of the general health; the extent and degree of activity of the pulmonary infection; the tendency toward tissue repair, as shown by the previous history; the location, duration, and character of the laryngeal process; the nature of the general supervisory control; the skill and experience of the laryngologist; and the personal equation of the patient as regards temperamental peculiarities. Before rendering an opinion as to the probable outcome, all the phases of the individual case should receive thoughtful consideration. The important bearing of the general health and of the condition of the lungs upon the ultimate prognosis is too obvious to warrant explanation. The situation of the tuberculous lesion is of considerable significance as regards its amenability to arrest and the degree of resulting functional disturbance. Generally speaking, a tuberculous deposit within the larynx is possessed of much less direful import than attaches to involvement of the arytenoids, and particularly of the epiglottis. Even permanent impairment of the voice, resulting from extensive destructive change involving the cords and ventricular bands, is assuredly attended by less disastrous consequences than follow the development of dysphagia. Aside, however, from the purely functional incapacity, an infection upon the exterior of the larynx is more likely to be of rapid progress than within, and is more frequently an accompaniment of a general miliary invasion. Tuberculous processes upon the ventricular bands are usually slow. Perhaps the one factor of especial prognostic moment favoring recovery is improvement in the general condition.

Treatment. The management of laryngeal tuberculosis must be primarily directed toward a restoration of the strength and powers of resistance. It is questionable if, in a very considerable number of cases, this feature of treatment should not take precedence over the employment of local applications. Any desire to reflect upon the utility of local treatment, for properly selected cases in the hands of competent laryngologists, is emphatically disclaimed. It is contended, merely, that not every case of laryngeal tuberculosis is suitable for local therapeusis. In some patients the nature of the tuberculous process is not such as to demand other than local cleanliness, which can be maintained at home under proper instructions. In others, the character and extent of the underlying pulmonary affection, with the accompanying temperature elevation and exhaustion, are sufficient to preclude attention to the larynx, unless means to conduct the treatment are improvised in the home. Even among patients whose general condition is admittedly less desperate, unfortunate results often attend the effort involved in seeking throat treatment at a point necessarily remote from one's place of temporary abode. It is probable that some patients do not secure results at all commensurate with the expenditure of energy, the nervous excitement, the interruption of the outdoor

régime, the frequent accession of fever, and acceleration of pulse consequent upon the journey to the office of the laryngologist. There can be no doubt as to the correctness of the preceding assertion, even among invalids for whom local management is actually indicated upon the merits of the laryngologic condition. Under such circumstances it necessarily becomes a choice of the lesser of two evils, the decision as to the method of procedure demanding a wise discrimination upon the part of an experienced clinician.

There can be no argument as to the propriety of local management in cases of ulcerative laryngeal involvement among individuals whose general condition does not contraindicate the effort required to secure the treatment. Nothing can be more pitiful, however, than to witness advanced and hopeless consumptives dragging themselves to a doctor's office day after day to receive a few moments of laryngologic attention, no matter how skilful or rational the treatment.

It is not within the scope of this book to enter into the details of local treatment applicable to the manifold conditions present in laryngeal tuberculosis, and, therefore, but a cursory discussion of the general principles is appropriate. The determination of the particular form of local treatment to be accorded individual cases is entirely beyond the province of the internist. The conservative judgment of the experienced laryngologist as to methods of application is of far greater value than dexterity of manipulation. In general, alkaline cleansing solutions are indicated for any variety of tuberculous lesions. Solutions of cocain and eucain are of value in case of painful deglutition, or as a preliminary to the introduction of other preparations. Levy frequently uses preparations of menthol which are antiseptic, anesthetic, and stimulant. He describes their effect "in relieving the pain, diminishing the cough, and giving the patient a feeling of general well-being.' Ulcerative processes are variously treated by applications of iodoform, aristol, lactic acid, nitrate of silver, and occasionally by the careful use of the curet. Cohen has cautioned against the use of lactic acid unless the mucous membrane is broken, but he believes it to be of especial value in case of superficial ulceration. It should not be used in excess of 80 per cent. strength, and usually in considerably weaker solutions. Its efficacy depends upon the thoroughness of its application, which involves a degree of rubbing or massage. Dr. J. M. Foster prefers a 2 to 8 per cent. aqueous solution of formaldehyd, which is to be thoroughly rubbed into the ulcers. For the technic of the several procedures, together with their special indications, the reader is referred to textbooks upon laryngology. In dismissing the subject of laryngeal tuberculosis attention is again called to the paramount importance of general management. The same principles of climatic, hygienic, and constitutional treatment apply as in tuberculosis of glands, bones, joints, genito-urinary organs, and other regions already described. It should be noted, however, that laryngeal tuberculosis, more than all other complications, is apt to be associated with considerable pulmonary involvement and a varying degree of functional derangement, systemic infection, and exhaustion. For these reasons rest, as opposed to exercise, should be emphatically enjoined. Sunshine, fresh air, and superalimentation are demanded even more rigidly than in other forms of local tuberculosis. Favorable climatic influences are of special benefit on account of the improved nutrition afforded, the increased facilities

for outdoor exercise, and the psychic effect of changed environment. A tendency has been observed to decry the advantages of climate for invalids suffering from any form of laryngeal tuberculosis. As a matter of fact, however, if the general condition and the pulmonary infection are such as to suggest the propriety of climatic change, the existence of a laryngeal tuberculous deposit only intensifies the necessity of prompt action. Any therapeutic agent known to exert a favorable influence upon the course of the pulmonary disease may be expected to exercise a corresponding effect upon the local condition. The existence, therefore, of vulnerable tissues within the larynx, in association with pulmonary tuberculosis, in the absence of special contraindications, accentuates the wisdom of early climatic change.

CHAPTER LXXVIII

TUBERCULOSIS OF THE EAR AND NOSE

THE frequency of purulent otitis media among pulmonary invalids is a matter of common clinical observation. The tuberculous nature of the affection is demonstrated by the presence of bacilli in the secretion and by the results of autopsy, the latter having disclosed tubercle deposit in the membrana tympanum, the middle ear, and even the inner ear. According to James, Wingrave found true tubercle bacilli in the purulent discharge of 17 patients with middle-ear disease out of a total of 100, and pseudotubercle bacilli in 7 cases.

There appears to be no fixed relation between the activity or extent of the pulmonary process and the development of tuberculous disease in the ear. It is generally believed, however, that the otitis is more prone to occur among advanced consumptives, and to be relatively infrequent during early stages of pulmonary disease. As a matter of fact, tuberculosis of the ear is comparatively rare as a clinical manifestation among rapidly progressive cases of pulmonary tuberculosis, but, upon the contrary, develops somewhat more frequently among chronic invalids in whom the pulmonary process is more or less stationary. It should not be assumed that the aural affection rarely supervenes during periods of general or pulmonary improvement, nor that a previous otitis media invariably undergoes a corresponding change for the better at such a time, after the manner of laryngeal tuberculosis. It is not uncommon, even among consumptives who have attained a moderate degree of improvement in the general condition, with an apparent quiescence of the tuberculous infection. I have had occasion to note its occurrence not infrequently among cases of the fibroid type, and it has appeared in some cases after a complete arrest of the pulmonary infection has been secured. Several patients have presented the history of a purulent discharge of a demonstrably tuberculous nature as the first manifestation of tubercle deposit.

In view of the preceding observations, it is reasonable to question to what extent the disease of the ear is dependent upon the pulmonary infection per se. Unusual facilities are presented among consumptives

for the extension of the tuberculous infection to the middle ear, the Eustachian tubes constituting the medium of bacillary transmission. The orifices of the tubes are subject to almost continuous exposure to infection, on account of the frequent passage of sputum to the pharynx, and the forced distribution of bacilli to neighboring regions by violent expulsive cough. Masses of infected sputum frequently become adherent to the posterior wall of the pharynx, and remain for prolonged periods. This is also true of the nasopharynx, particularly with the patient in the recumbent posture during sleep. Cornet has referred to the statement of Dmochowski concerning the difficult detachment of bacilli after their deposit upon the projectile lips of the Eustachian orifices, and to the opinion of Haberman that the tubes are wider in consumptives, by reason of the greater absorption of fat and tissues. There also exist among pulmonary invalids certain other exciting and aggravating causes of bacillary extension to the middle ear. The acts of coughing and sneezing, vomiting and retching, so common among this class of patients, provide a means of ready communication to the ear through a patulous tube. In this connection the thought is suggested that the violent paroxysmal cough, frequently observed among cases of the fibroid or bronchitic types, is at least a partial explanation of the surprising development of ear tuberculosis in patients otherwise maintaining a degree of improvement.

The conveyance of tuberculous infection to the ear through the tympanum by the introduction of contaminated fingers and a multitude. of miscellaneous articles, as claimed by various authors, although accepted as a most remote possibility, is of but slight practical interest. There are, however, other sources of infection of undoubted importance exclusive of the existence of pulmonary tuberculosis. Purulent otitis. media is a not infrequent sequel or accompaniment of cervical adenitis in children. In the discussion of glandular tuberculosis it was pointed out that involvement of the cervical glands was often due to an infection traceable to the nose, mouth, pharynx, or tonsils. The development, therefore, of tuberculosis of the glands of the neck simultaneously with that of the middle ear, in the absence of pulmonary disease, suggests the probability of their common origin. Attention has been called to instances of tuberculous infection of the tonsils and adenoid structures, which serve both as receiving reservoirs for bacilli and as points of departure for further dissemination. The reports of various observers as to the frequency of involvement of these tissues have been cited. The faucial tonsils and the lymphoid tissues in the nasopharynx are unusually receptive to wandering bacilli, by virtue of their exposed position and the anatomic peculiarity of their construction. The evidence is apparently conclusive that infection of these parts, even in the absence of pulmonary tuberculosis, occurs considerably oftener than has been supposed, and that a ready transmission may be effected to the ear through the Eustachian tube. Jonathan Wright has repeatedly called attention to the fact that various forms of bacteria are retained upon the surface of the epithelial lining of the tonsillar crypts, while carmin granules and oily particles traverse the tissues without obstruction. He regards the tonsillar crypts as pits especially suited for the lodgment and retention of tubercle bacilli. The cavities are unprotected by cilia, which serve to sweep away the bacteria in upper portions of the respiratory tract. It is evident that the tonsils and contiguous

areas are regions of essential importance as regards the occasional transmission of tuberculous infection to various parts of the body.

The origin of middle-ear tuberculosis is sometimes referable to a distribution of the infective microorganisms through the circulatory channels, but this is, to say the least, quite exceptional, save in cases of general miliary infection. The development of mastoid involvement without middle-ear disease is perhaps suggestive of hematogenous infection. The extension of the tuberculous process to the mastoid following middle-ear infection is fairly common, though by no means so frequent as the secondary involvement of the mastoid after nontuberculous otitis media. Personally, I have observed but very few instances of mastoid disease complicating middle-ear tuberculosis among pulmonary invalids. Dr. W. C. Bane reports that not over 3 per cent. of all the cases of mastoiditis operated by him were of tuberculous origin. Dr. J. M. Foster, after a careful review of his cases submitting to mastoid operation during three years, reports no single instance of tuberculous infection. As the result of a wide experience, he is inclined to regard the tubercle bacillus in the production of mastoiditis requiring operation as a negligible quantity. It is hard to subscribe to a statement, recently made, that the common channel of tuberculous infection to the meninges of the brain is by way of the ear.

The onset of otitis media among pulmonary invalids is less often abrupt or attended by acute inflammatory symptoms than among cases of a non-tuberculous nature. An early premonitory symptom is a sensation of slight fulness in one ear, and a beginning impairment of the hearing. At times complaint is made of pain, though this is rarely extreme, and is much less acute than in cases of non-tuberculous otitis media. The pain, though localized in the ear, frequently radiates from this point to the entire side of the head, and there is often present a distinct throbbing sensation. In the beginning there is usually but slight, if any, elevation of temperature, thus differing from the early fever almost invariably present in ordinary acute suppurative inflammations of the middle ear. With increasing distention of the drum, these symptoms, as a rule, become correspondingly more severe, while dizziness and tinnitus aurium are often distressing manifestations. After perforation has taken place a varying amount of purulent secretion is discharged. In addition to tubercle bacilli there is usually present a secondary infection consisting of streptococci, staphylococci, or pneumococci. The pain in most cases disappears with the appearance of the discharge, which, as a rule, is non-odorous, finally becoming scanty and of a thick, tenacious consistency. This often evinces a tendency to dry upon the edges of the perforation, which in some instances is completely covered, producing an underlying maceration of tissue. There is usually a dulling and reddening of the ear-drum as a result of the inflammatory change, and the membrane is thickened to a considerable extent. The perforation varies in size and shape, sometimes an extensive area of the membrane having been destroyed. Necrotic changes in the middle ear occasionally supervene, and the process continues to extend to the destruction of the inner ear, involving the labyrinth, or spreading posteriorly to the mastoid. Fever is common, as is also a fetid discharge. The involvement of the mastoid may be either chronic or acute, neither condition, however, being especially frequent in tuberculous disease of the middle ear, though possible of