SOME OBSERVATIONS ON THE DIAGNOSIS AND TREATMENT OF LARYNGEAL TUBERCULOSIS.

BY GEORGE B. RICE, M.D., professor OF LARYNGOLOGY, BOSTON UNIVERSITY SCHOOL OF MEDICINE.

It has long been recognized that advanced tuberculosis of the larynx is difficult to treat successfully, and that the progress of the affection is attended by great suffering. Authorities claim that between twenty-five and thirty per cent of cases of pulmonary tuberculosis are sooner or later complicated with a laryngeal infection. It has been demonstrated that early recognition and proper treatment of the pulmonary forms result in a good proportion of cures, and recent experiences have demonstrated that the same favorable showing can be made in the cure of the laryngeal involvement if only recognized early.

The following are the symptoms, both subjective and objective, in the usual order of appearance, based upon the study of a large number of cases in the author's own practice and that of others.

SUBJECTIVE.

Hoarseness: This may be constant, or temporarily relieved by clearing the throat.

Pain: Pain on swallowing with strangling and choking at times, on taking liquid food.

Hoarseness may be slight.

Marked Hoarseness or Aphonia: The voice may be high pitched and cloudy, or merely a hoarse whisper be possible.

OBJECTIVE.

The larynx may present a general mild catarrhal appearance, with marked pallor of the tissues, and slight tumefaction about the arytenoids.

Pain as an early symptom is usually caused by inflammation and infiltration of the epiglottis. Examination will show redness, tumefaction, and marked interference with the movements of the epiglottis and imperfect closure on swallowing.

Here the arytenoids may be tumefied, interfering with the adduction of the vocal bands, or one or both vocal bands may be thickened, and the movements greatly restricted.

Certain circumscribed areas may be highly reddened and swollen. while the surrounding tissues are pale, relaxed, and covered with tenacious mucus.

As the disease advances, the circumscribed areas break down and form tuberculous ulcers.

The ulceration in order of usual appearance will be seen, first, on the soft structures covering the top of the arytenoids, second the false vocal bands, third the epiglottis, fourth, the vocal bands, and fifth

Cough, unless caused by the pulmonary lesion is a late symptom of laryngeal involvement.

Noisy respiration with aphonia, pain and strangling on attempting to swallow.

on the lateral portions of the aryteno-epiglottic fold.

Ulceration of the vocal bands is usually on the glottic edge, and presents a saw-like appearance.

The lower structures of the larynx are here probably alone involved. There is mucu-purulent secretion, tumefaction, and redness.

With these symptoms a general involvement of the laryngeal structures is the rule, including the epiglottis. The parts are reddened, tumefied, covered with muco-pus, and become from time to time ædematous. During these periods respiration may become noisy, increasingly difficult, and death from suffocation may result.

The treatment of these conditions must vary with the form of involvement. Rest of the voice is always important. In the early stage of pallor and catarrhal secretion stimulating antiseptic applications of a weak formol solution should be made daily or even oftener by means of a cotton swab, together with a selection of such internal remedies as phos. ars. iod., or selenium.

When the parts become acutely inflamed from temporary conditions, soothing applications may be made, such as sabalol oil, argyrol with adrenalin, the application of these being preceded by a spray of a warm alkaline solution, and a selection from the following remedies as indicated: bell., acon., phos., kali bichrom., iodine, merc. bin., or merc. prot.

In the more advanced conditions, frequent cleaning with a warm alkaline solution, followed by applications of formol from a one to five per cent strength solution, applied as often as toleration will allow. If swallowing is painful demulcent troches, just before taking food, are helpful, of which orthoform tablets with campho-menthol are a good example. As a last resort a spray containing adrenalin, eucaine and cocaine in weak solution will give temporary relief. Internally, silica, stannum, sanguinaria, aurum iodatum will be found most likely to be of service.

The points of emphasis in this brief paper are, first, an early recognition of the disease. Second, prompt and persistent local treatment as well as internal medication. Third, a recognition of the fact that this line of treatment intelligently applied will cure a large majority of incipient cases, other conditions being favorable, and will control many of the advanced

cases.

REGENERATION IN TUBERCULOSIS OF BONE-A CASE.

BY GEORGE H. EARL, M.D.

(Orthopedic Surgeon, Massachusetts Homoeopathic Hospital.)

Gertrude M., ten years old, entered the Massachusetts Homœopathic Hospital Sept. 13, 1904. She was wearing a plaster spica on the left hip, and came with the hope of being fitted with a splint,, which would enable her to walk.

Family history, poor. The father died of "consumption" five years before, and an aunt had also died with the same trouble.

FIG. I.

necessary to resume extension in bed.

The patient's health had been good up to August, 1902, when she failed in health. Her physicians suspected "lung trouble," and kept her much in the open air. Shortly after this she was thrown from a wagon,striking on the left hip. From that time on she exhibited the usual symptoms of hip joint disease. The treatment was by extension in bed; a part of the time living in a tent. A trial was made of ambulatory treatment, but was unsuccessful, the pain making it

On admission to the hospital there was complete eversion of the foot, a fluctuating swelling about the joint, and a sinus, discharging very slightly. Slight passive motion was not painful.

Operation was advised, it being deemed that the joint was wholly destroyed, and further so-called conservation treat

ment constituting a great menace. This was declined, but after nearly two months in the hospital, consented to.

On making the incision, several ounces of characteristic broken-down tubercular material escaped. Then the head of the bone, bits of the neck, and the complete shell of the trochanter were removed with the finger.

The upper end of the femur remaining jagged and seemingly split, pieces were removed. The bone resembled to the touch a piece of bamboo, which had been pounded. Taking hold of this with a piece of dry gauze, and twisting, the entire shaft of the bone separated and came out, exactly as a bone would be extracted from a piece of cooked meat.

There was great shock to the patient and to the operator. The convalescence was stormy, and for the first week it seemed as though she would not survive.

She was put to bed with extension, the extremity elevated and support

ed, and the wound

FIG. 2.

thoroughly drained. Many details of the after treatment would be of interest, but the reason for making this report is the fact that during the fifteen months since the operation the patient has practically grown a new and serviceable femur.

This is explained by the fact that while the disease had destroyed so much of the bone, it had been confined to the bone, and had not destroyed the periosteum.

The specimen of bone shows that five inches of the shaft

was removed, and the upper end of this fragment began below the trochanter. The plates show two radiographs: one made April 8, 1905, six months after operation, and the other Feb. 4, 1906, fifteen months after operation. At first glance these plates look much alike, but it will be noticed that in No. 1, the whole leg is much smaller, and so should show comparatively a cleaner shadow of the bone, while in fact it is less distinct than in No. 2, indicating that the remaining bone was not healthy.

In No. 1 the length of the thigh is 84 inches, while in No. 2 it is 11 inches, an increase in length of 34 inches.

The child has been walking for a year, on an ordinary Thomas knee splint, which is practically a perineal crutch. She has not used ordinary crutches since the first two weeks of walking on the splint.

She is strong and well, growing rapidly, and has gained twenty pounds since going to her home last Autumn. She has the power of lifting the leg, controlling its movements, including both outward and inward rotation.

In cases of tuberculosis of the ankle or tarsus, nature does wonders in the way of preserving a member, and restoring function.

By persistence and refracted operation, extensive tuberculosis of the foot may be overcome, much bone removed, and nature's substitute, fibrous tissue, made to serve very well.

There are cases of regeneration of bone after other infections, but so far as known this case is unique in showing an actual regeneration after removal of bone for tubercular infection.

POQUE, in the Medical Record, December, 1905, quotes Bernheim of Paris in regard to the rest treatment of tuberculosis:

1. In the treatment of phthisical patients the rest cure is the indispensable complement of a sojourn in a salubrious climate and of forced alimentation.

2. Since the lungs participate in all excessive activity, the effect produced is an active congestion in the region of the tubercular focus, and new tears in old adhesions.

3. Forced feeding and life in the open air are of profit to a tuberculous patient only when he is placed under conditions of absolute repose.

4. Furthermore, repose plays another important rôle; it prevents the general localization of the bacillus of Koch.

5. One should therefore prescribe the rest cure for every phthisical patient who has fever and in whom one observes clinical symptoms of tubercular activity.

6. This rest cure may be practised in all cases, provided it is applied in a disciplinary manner and with intelligent supervision.