MCCULLOUGH, Dr. JOHN W. S., Allis- MCCULLY, Dr. S. E., Toronto, Can- MCDONALD, Dr. A. C., Warsaw, Ind. MACARTNEY, Dr. W. N., Fort Cov- ington, N. Y. MACDONALD, Dr. C F., New York. N. Y. MARTINDALE, Dr. J H., Minneapo- MATHENY, Dr. R. C., Springfield, Ill. METTLER, Dr. L. H., Chicago, Ill. MILLER, Dr. H. T., Springfield, O. MILLIKEN, Dr. SAMUEL, New York. MONELL, Dr. S. H., Brooklyn, N. Y. NAMMACK, Dr. CHAS. E, New York. ONUF, Dr. B., Brooklyn, N. Y. PACKARD, Dr. C. W., New York. Ind. PRYOR, Dr. WILLIAM R., New York. RACHFORD, Dr. B. K., Cincinnati, O. Vernon, Ind. ROBINSON, Dr. BEVERLEY, New York. SCHAVOIR, Dr. F., Stamford, Conn. La. Semeleder, Dr., Cordoba, Mexico. Ill. SHELBY, Dr. E. T., Atchison, Kar. SPRATLING, Dr. W. P., Craig Colony, WANGELIN, Dr. HUGO E., Belleville, WARD, Dr. MILO BUEL, Topeka, Kan. WEEKS, Dr. JOHN E, New York. WEISS, Dr. JULIUS, New York. WELLS, Dr. J. HUNTER, Seoul, Korea. Col. WILES, Dr. F. M., Indianapolis, Ind. WILLIAMS, Dr. E. H., Decorah, Ill. Hudson, N. Y. WILLIAMS, Dr. HERBERT UPHAM, WINTER, Dr. F. A., Fort Hancock, WITHAM, Dr. A. N., South Paris, Me. many. WYETH, Dr. JOHN A., New York. YOUNG, Dr. H. DUDLEY, Boston, SPRECHER, Dr. D. B., Sykesville, Mo. Vol. 48, No. 1. Whole No. 1287. A Weekly Journal of Medicine and Surgery NEW YORK, JULY 6, 1895. Original Articles. THE IMPORTANCE OF ADMINISTERING BY CLARENCE C. RICE, M.D., PROFESSOR OF DISEASES OF The nose and THROAT, NEW YORK POST-GRADU- THE clinical value of this paper might be largely in- Any suggestion as to the advisability of prescribing the iodide will of course be superfluous to those clinicians who are in the habit of diagnosing almost all cases of inflammation of the upper air-passages as syphilitic. We know that there are physicians of this frame of mind. On the other hand, we are satisfied that there are many who do not resort to the administration of mercury and potassium unless they are convinced that the lesion under treatment is specific. They desire conclusive evidence, and it is possible that they frequently are in error in withholding specific treatment because of lack of marked diagnostic points. Further, even expert laryngologists may easily fall into the habit of quickly classifying all laryngeal lesions in an instinctive way, and if the first impression is that the disease is other than specific it will not occur to them to use the iodide, even though the case is not progressing favorably. It has always been my habit of thought to be slow in believing a lesion was specific, unless the history strongly indicated it, or unless the lesion presented such an appearance in a clear manner. The more experience we obtain in clinical work, however, the more, I believe, we appreciate how small is the percentage of cases which closely present the characteristic appearances portrayed in the text-books. Authors are not to be blamed for describing pathological appearances as typical and constant, for, should they endeavor to mention the many great and small variations of behavior from the typical aspects, their work would not only be too voluminous, but so confusing that the beginner in laryngology would have no salient points on which to found his diagnosis. I was much impressed in listening to a discussion' on "Unusual Manifestations of Tuberculosis," by the American Laryngological Association a few years ago. One after another, men who had been active in laryngology for twenty-five years or more put themselves on record as frequently being unable to make a diagnosis of laryngeal inflammation or neoplasm, from the physical aspect of the lesion, together with the clinical history. They confessed that they were often compelled to withhold their opinion until more examinations had been made, until the microscope had aided them, or the effect of the iodide had been demonstrated. Read before the Laryngological Section of the New York Academy of Medicine, May 22, 1895. Rice: Unusual Manifestations of Tuberculosis of Larynx, Transactions of the American Laryngological Association, 1889, p. 95. $5.00 Per Annum. Single Copies, 10c. One of the most prominent laryngologists of this city remarked, in this same discussion, that there was such a thing as "diagnostic instinct;" and he meant that this had sometimes to be depended upon when all the other signs failed. It cannot be denied that, there are many cases of laryngeal disease which are difficult of diagnosis, and a number where it is impossible to state positively, for a time at least, the nature of the disease. We might commence by saying that we have a belief, founded on some experience, that there are cases of laryngeal disease non-specific, which are benefited to some degree by the administration of small doses of iodide of potassium. Perhaps the beneficial action obtained in these cases is essen:ially by reason of its socalled alterative effect, and would not be gained if the drug was administered in large doses, or if it was continued for any length of time. I have frequently ncticed this effect of the iodide. The benefit from five grains three times a day was immediate and remarkable, and that, too, after diligent treatment had been. pursued along other lines. We find a number of writers who state that they have obtained the same beneficial result from iodide when given in the early stages of laryngeal tuberculosis and in chronic laryngitis. I shall mention these farther on. It seems to me that the habit of administering the iodide depends largely upon the amount of dispensary work one may be engaged in. Certainly there was no need of advising its use in Charity Hospital in the 80's. I often wonder what became of the remarkable cases of syphilis of the larynx which were in the hospital at that time, cases in which the epiglottis had been entirely destroyed, others in which the entire laryngeal mucous membrane had been replaced by cicatricial tissue and the whole cavity distorted, and those in which the vocal bands were adherent to each other through the medium of webbed formations. I personally see few of such patients at the present day. I dare say this decrease in cases of such extensive lesions is due to the better and more intelligent treatment which patients now receive. The attention which is paid to the cleanliness of the nose and pharynx would diminish very much the likelihood of such severe syphilitic lesions. Patients, too, are more often seen at an earlier stage of the disease than they were fifteen years ago. There is not time here to mention the characteristic diagnostic points of each of the many diseases of the larynx. The typical lesions of each laryngeal disease we are all familiar with, and when present they furnish readily the means of diagnosis, but we often see ulcerations characteristic of no special process, but which might be the result of several, and we find enlargements or neoplasms about which no intelligent opinion can be at first formed. There are several laryngeal diseases other than syphilis which frequently present, during some part of their development, pathological conditions. which in general aspect are quite similar to syphilitic lesions, and it is in these cases we would advise the administration of iodide of potassium for a time, even though there is strong belief that the disease is not syphilis. First let us say a few words in regard to laryngeal tuberculosis. In the typical cases one would hardly be tempted to prescribe the iodides, but there are many in addition to apparently typical tubercular ulcerations. in the larynx, there was extensive loss of tissue of the epiglottis. The ulceration of the epiglottis was out of proportion to the progress of the ulceration in the larynx. The arytenoids were characteristically tubercular. The patient had advanced pulmonary involvement, but in spite of this the ulceration on the epiglottis was healed by the use of iodide of potassium, although it had no effect whatever upon the intralaryngeal tubercular ulcerations. I think it possible that the coexistence of these two diseases is more frequent than we are apt to believe. There is no doubt that patients often contract syphilis early in life and tuberculosis later. Many of the cures of laryngeal tuberculosis which we see in print are probably syphilitic. If we have any doubt as to the character of an ulceration it should have the benefit of the iodide. Is it not possible that a patient may have at the same time pulmonary tuberculosis and syphilis of the larynx ? We see cases of ulceration of the larynx in patients having pulmonary tuberculosis with tubercle bacilli in the sputa, which are healed by the iodide. Dr. Woodward, of Burlington, Vt., a laryngologist of experience, reports two cases of laryngeal ulceration in both of which tubercle bacilli were found, and the lungs showed evidences of tuberculosis. In both cases the laryngeal ulcerations were healed by iodides. He believes the cases to have been syphilitic. Dr. Jonathan Wright, in a paper, said that two cases of tracheal and one of laryngeal disease had been referred to him. They both had marked pulmonary signs. The thickening was so great that tracheotomy was performed, I believe, in both cases. An unquestioned diagnosis of tubercular laryngitis was made. They died some time after the tracheotomies. The autopsies demonstrated syphilis of the larynx. It is a good diagnostic point that tuberculosis of the 1 Transactions of the American Laryngological Association, 1889, P. 97. 2 Woodward: Tubercle Bacilli and the Diagnosis of Tuberculosis, etc., New York Medical Journal, December 5, 1893. 3 Wright: Some Remarks on Laryngeal Literature, etc., New York Medical Journal, September 22, 1894. p. 364. larynx seldom produces occlusion enough to necessitate tracheotomy. Cases which might be tubercular or syphilitic, so far as the physical aspect of the laryngeal lesions are concerned, are those in which, neither the epiglottis or arytenoids being involved, a single ulceration presents. itself on the vocal band or upon the side of the larynx, with no qualities whereby its character may easily be determined. Of course, we depend here upon the presence of lung disease and of bacilli, but even if they are both found the ulceration of the larynx may be syphilitic. Almost all the diseases of the larynx which go through an ulcerative stage are capable of producing so-called granulation tissue upon the surface of the ulceration. We have the "vegetative" form of tuberculosis, and the granular thickening of the vocal bands in trachoma. Benign neoplasms of the vocal bands may present nearly the same appearances at times as the condylomata of secondary syphilis, and the wart-like excrescences of the tertiary stage. All of these conditions look much alike, and at times it will be difficult to exclude syphilis. It will be wise to see if they are benefited by the administration of the iodide. 3 66 2 There is considerable confusion as to the identity of the pathological conditions known by some as "chorditis tuberosa;" by others as singers' nodes," and by others as "trachoma vocalis." Bosworth' and Ingals think "chorditis tuberosa" and trachoma are the same thing. F. I. Knight says they may be the same pathologically, but that they differ in clinical behavior. John Mackenzie says we should distinguish between a granular condition of the vocal bands and true "chorditis tuberosa." But the point which is most pertinent to this paper is that these processes of hypertrophy of the vocal bands often present appearances which closely simulate syphilitic lesions, and, therefore, clearly indicate the treatment. Ingals, in his text-book, gives an illustration of a thickening in a simple catarrhal laryngitis, which is formidable enough to be a syphilitic enlargement. John Mackenzie speaks of "hypertrophic laryngitis," and says that it is with difficulty diagnosed from syphilis. We frequently see changes in the vocal bands in simple catarrhal processes, in which we are tempted to use the iodide. I will cite a case in which the lesions were almost entirely confined to the vocal bands, because of its unusual behavior and because of the effect of iodide upon it. CASE.-Male, aged fifty-five. First saw him in September, 1894. Patient was hoarse, and consequently much troubled because he was a school-teacher. General condition good. No syphilitic history, and no lesion in other parts of the body to indicate that he had ever had disease of this nature. Growth the size of two large peas attached to right vocal band posterior third. Band itself slightly congested, but not markedly so. Growth was removed and examined in the laboratory of the Post-Graduate Hospital, and pronounced a simple papillomatous growth. (Fig. 2.) When next the patient was seen, a few weeks later, I found that the entire vocal band was thickened, reddened, and granular, in the sense of being very uneven. There were no ulcerations, but the band presented a very ragged appearance. Astringent applications were made. Later, growth somewhat similar to the first one, well localized, but smaller, appeared on the opposite chord, and after a few weeks that vocal band became generally thickened and congested. At one time it looked as if the inflammatory process would extend to the side of the larynx, but that was probably due to the operative work. The 1 Bosworth: Diseases of the Nose and Throat, vol. ii., p. 533. Ingals: Diseases of the Chest and Throat, p. 402. Knight: Singers' Nodes, New York Medical Journal, December Ingals: Diseases of the Chest and Throat, p. 95, Fig. 104. I, 1894. projections were removed by forceps and guillotine wherever they were large enough to be taken hold of, and several times the galvano-cautery was used. The larynx behaved very well after operation, and the subsequent inflammation was moderate. Not much im FIG. 2.-Syphilitic inflammatory growth of vocal band. provement of the voice was obtained, because of the great amount of general thickening of the vocal chords. (Fig. 3) Patient was put upon iodide of potassium in small doses and the larynx commenced to improve at once. The warty excrescences became smaller day by day and the congestion and general thickening diminished. The case at first was naturally supposed to be one of simple papilloma of the larynx, but the rapid involvement of the entire vocal bands later on pointed toward epithelioma. The appearance of the bands after they became thickened and jagged was very similar to trachoma vocalis. The effect of the iodide upon this case was so remarkable that we shall perhaps be compelled to call it a syphilitic process. The patient FIG. 3.-Syphilitic hypertrophy of the vocal bands. never took more than ten grains of the iodide three times a day. A polypus was removed from left nostril. Some of the reasons why we cannot always decide easily whether a pathological condition is syphilitic or not, are, that it is very frequently impossible to obtain. any corroborative history. The patient has had some venereal disease, but there are no evidences of syphilis elsewhere. Of course, where the scars of old inflammations are found in the nose or pharynx, the diagnosis is made. We have already mentioned that the tertiary manifestations, which are by far the most common in the larynx, are frequently obscured by a coexisting tubercular process. The primary sore of syphilis most of us will probably never see in the larynx, and very rarely shall we be called upon to diagnose mucous patches. Secondary ulcerations of the larynx are usually accompanied with a clear recent history, and syphilitic manifestations of the mouth. Congestions or erythemas due to syphilis have some distinguishing signs, and are most apt to be accompanied by the same pathological conditions of the pharynx. The tertiary lesions of syphilis, growths, gummata, and extensive ulcerations, are attended by more difficulties of diagnosis. Almost always the gummatous enlargements have undergone ulceration by the time they reach us, so that we have to deal with ulcerations of most varied appearances in the larynx. If such ulcerations occur, as they very frequently do, in patients much debilitated and generally anæmic, they present conditions which are but slightly, if at all, different from those of tuberculosis. If we cannot obtain a syphilitic history, or find specific lesions in the pharynx, or other parts of the body, then it will be necessary to exclude tuberculosis, Now, in regard to perichondrial inflammation of the laryngeal cartilages. We know that as a primary disease it exists very rarely, but is on the other hand an indication of tuberculosis or syphilis. In 33 cases tabulated by Bosworth,' 9 were syphilitic and about the same number followed typhoid fever. The tubercular cases were not included in this list. Several authors agree that when the arytenoids are attacked by perichondrial inflammation the strong inference is that the process is tubercular, because the other inflammatory diseases seem to prefer the cricoid and thyroid. Bilateral enlargements of the arytenoids present no special interest, and may usually be put down at once as being tubercular, and we occasionally see marked erlargement of one arytenoid with anchylosis at the joint, in which all the phases of tubercular laryngitis rapidly follow. I cite the following case: First, because it was supposed to be tubercular; second, because there were reasons why an acquired syphilitic condition was not supposed possible; and third, to note the effect of iodide upon it. CASE.-Male, about forty years of age, works in an office. Very small, weighing, I should think, about ninety pounds. Heredity good. Chronic conjunctivitis, granular lids, decided scrofulous appearance. Slight cough for a year. Husky voice. Rough and high-pitched breathing at apices. Tubercle bacilli, very few found in expectoration. Laryngeal appearance as follows: Left vocal band immovable, markedly congested throughout its entire length and thickened. Marked enlargement of left arytenoid cartilage. Positively asserted that there was no specific history. Patient asserted that he had never had intercourse with women, and his statement seemed probable as his genital organs were very much undeveloped; his penis was no larger than a child's five years of age. Diagnosis at first thought to be tubercular perichondritis, although the uniform redness of the vocal band without ulceration did not seem like a tubercular lesion. (Fig. 4.) I need not enlarge upon this case, except to say that the patient was not improved by ordinary laryngeal medications, nor by cod-liver oil and tonics. Iodide was commenced in small doses and the benefit was immediate, and after three weeks of its administration, in of the arytenoid was so great that there was some dyspnoea and he was unable to swallow solid food. I have never seen the effect of the iodide more marked than in this case. Bosworth says that the iodide is useful in perichondritis, whether it is syphilitic or not. We have spoke of the ulcerative lesions of the larynx, and of the confusion which may attend their diagnosis, and also of the tissue hypertrophies which are caused by a number of different inflammatory processes. It remains to allude briefly to the growths or neoplasms of the larynx, benign and malignant, and to note their similarity to syphilitic lesions, and the difficulty oftentimes in their earlier stages of diagnosing them, and consequently the advisability of administering iodide until the diagnosis is confirmed by microscopical examination. In our first case we referred to a supposed simple papilloma of the vocal band, the base of which was absorbed by the action of iodide. pa Before speaking in detail of growths in the larynx of whatever nature, I cannot help alluding to a review, by Dr. Jonathan Wright,' of a paper by Chiari on "The Structure of the So-called Fibromata of the Vocal Bands." The ground taken by the author of the per was that these growths are inflammatory and not neoplastic, as they often show such inflammatory phenomena as œdema and hemorrhagic extravasations. This view seems to me to be thoroughly in accord with clinical observation. Dr. Wright says that "it is a superficial, misleading, and dangerous proceeding to calmly describe growths as fibromata, myxomata, etc., when they are, in the vast majority of instances, nothing but different manifestations of chronic inflammation.' If such a pathology is correct, our views must be changed as to the relation of so called neoplasms to all inflammatory processes, not only to that of a simple catarrh, but to the processes of syphilis and tuberculosis. In other words, what we have considered typical papilloma or fibromata of the larynx, accidents existing without apparent cause, may be rather manifestations of a simple catarrhal process, or a syphilitic condition, or perhaps the result of a tubercular germ. This is most interesting pathologically, and important clinically, because it is quite possible that some of the cases which we have been in the habit of diagnosing as forms of benign or malignant neoplasms are rather the manifestation of syphilis, and so may be benefited by the iodides. We do not believe that it has been the habit of laryngologists to prescribe iodides in cases of laryngeal growths. They have only been. regarded and treated surgically. This pathology of laryngeal neoplasms, if true, will aid very much in the diagnosis of many growths which have been very difficult to classify; growths not typical, and which always have seemed to bear an intimate relation to some constitutional disease. If these growths are inflammatory, we shall be encouraged to ascertain what kind of inflammatory process is behind them. A benign growth may therefore be an earlier manifestation of tuberculosis than we have hitherto recognized. A causative relation of some of them to syphilis may be established, and the remedy will then be apparent. All laryngologists admit the difficulty of always being able to diagnose growths in the larynx. Dr. Delavan, in a carefully written article on the "Early Diagnosis of Malignant Disease of the Larynx," said: "We are taught that cancer, syphilis, tuberculosis, and lupus all present characteristics which distinguish them to the eye, but unfortunately this is not true." And further he said that "a large number of cases in which the microscope has revealed tubercular disease have proved 1 Wright: Remarks on Laryngology Literature, New York Medical Journal, March 16, 1895 2 Chiari: Fraenkel's Archiv, vol. ii., No. 1. Delavan: Transactions of the American Laryngological Association, 1890, p. 87. to be malignant when more carefully examined microscopically later on." We know that malignant disease in its early stage may easily be mistaken for some phase of syphilis or tuberculosis. Dr. Mulhall, of St. Louis, in the "Transactions of the American Laryngological Association " (1890, p. 96), said that he had had two cases of cancer of the larynx which had been greatly improved by the iodide of potassium. The late Dr. Hooper,1 of Boston, in examining 7,500 patients having laryngeal disease, found only 21 benign. neoplasms. Papilloma occurs more frequently than all the other forms combined. A good diagnostic point about benign growths is that they are rarely subglottic. Sarcoma exists still more infrequently. Butlin 2 found only 23 cases recorded. In 848 cases of sarcoma Gurlt found only one of the larynx. Sarcoma seems to involve the lymphatics much less frequently than does the more common form of cancer-epithelioma. Gurlt, in reviewing the literature, found that epithelioma involved the larynx but sixty-three times out of 11,131 cases of epithelioma occurring everywhere. The terms carcinoma and epithelioma seem to be used synonymously. Of 24 cases of carcinoma, 23 were epithelioma and I was of medullary character. I cannot enlarge here upon the diagnostic points of malignant disease. It is easy sometimes to mistake it for syphilis and tuberculosis. A discussion on the diagnosis of malignant disease brought out such salient diagnostic points, as greater general thickening and infiltration of the larynx than in other diseases, and an inflammatory areola surrounding the base of the growth; and with this infiltration there generally follows loss of motion of the side of the larynx involved, and this often without involvement of the crico-arytenoid articulation, the immobility being caused by infiltration of the muscular tissue. Pain in the ear is considered a significant symptom. But, after all, the microscope must be the final court of appeal. But it is often necessary to wait for some months before a satisfactory portion of the growth can be obtained for microscopical examination. It would be unwise to dig into a deeply situated enlargement of the larynx beneath unbroken mucous membrane, just for the purpose of obtaining a microscopical specimen, so that it is wise to ascertain the effect of the iodide while we are waiting. There is difficulty, too, in securing enough of the growth to positively acquaint us with its histological character. Wright says that "small, round celled sarcoma, granulation tissue (syphilitic or tubercular), and lymphoid hypertrophy, are frequently indistinguishable under the microscope. But even in cases which have every appearance of malignant disease, I believe the conservative physician will always give the patient the benefit of the iodide and mercury. It is my belief that extirpations of half the larynx have been performed by surgeons at an early stage, in undoubted cases of syphilis, where anti-syphilitic treatment would probably have effected a cure. Dunn, of Richmond, reports a case of laryngeal growth, which had every appearance of malignancy, which disappeared after the application of compound tincture of iodine. We might continue to cite cases of most varied pathological appearances-ulcerations which seemed to be tubercular, small growths which were apparently benign, large swellings with every appearance of malignancy-which were afterward proven to be specific, or which disappeared, at least, through the effect of iodide of potash. This drug and the microscope cannot be ignored in searching for a truthful diagnosis. Hooper: Case of Tumor of the Larynx, MEDICAL REcord, March 7, 1891. 2 Butlin Malignant Disease of the Larynx. London, 1883. 3 Gurlt: Arch. für klin. Chir., 1880, vol. xxv., p. 436. 4 Ibid., p. 426. & Dunn: New York Medical Journal, December 17, 1892. |