[Extract from the Cor.vruy Practitioner for April, ISSO.] ' SOME REMARKS ON TDBERCDLODS LARYNGITIS. As Viewed Laryngoscopically. 1»y J. Solis Cohem, M. D., Physician to Jefferson Medical Colh-ec Hospital and to the(f•■nnan Hospital of Plr’adelphia; Lecturer on Laryngoscopy and Diseases ol the Throat and Chest in Jefferson Medical College, etc. SOME REMARKS ON TUBERCULOUS LARYNGITIS AS VIEWED LARYNGOSCOPICALLY. Physician to Jefferson Medical Colk go Hospital and to the German Hospital o!' Philadelphia; Lecturer on Laryngoscopy and Diseases ot the Throat and Chest in Jefferson Medical College, etc. J. SOUS COHEX, M. D. There are several groups of manifestations of tuberculous degeneration of the tissues of the larynx, independent of individual complications, which can hardly fail to strike those who have frequent opportunities for inspecting these lesions in consumptives. I. The most frequent, according to my own experience, is a pyriform swelling of the tissues about the supra-arytenoid cartilages, due chiefly, as determined under the microscope, to accumulation of lymphatic cells in the connective tissue. The outline of the posterior p »rtion of the fold of tissue extending from the epiglottis to the supra-aryt« noid cartilage of each side —for this form of the manifestation is most frequently bilateral though not symmetric—is rounded instead of being sharply defined, and tapers eff more or less towards the epigh ttic portion of the structure. The swelling prevents due approximation of the internal faces of the arytenoid cartilages, consequently due approximation of the posterior portions of the vocal bands which are attached to these cartilages, and thus engenders an impairment of voice, amounting to entire absence if the swelling is considerable, even though the vocal bands are ineviry way normal. This swelling rarely subsides. The local manifestation may be limited to the condition described, or it may be asso- ciated, progressively or simultaneously, with other local lesions, immediately adjacent or at a distance. 11. The next most frequent manifestation in my own experience, and one not infrequently associated with the pyriform induration first described, though often enough unassociated with any evidence of it, is a turn* faction of the connective tissue in the fold of structure uniting the two arytenoid cartilages. The inner or laryngeal face of this inter arytenoid fold or com- missure, is raised into irregular longitudinal or spindle-shaped ridges; some- times indeed, infiltrated to such a degree as to form submucous neoplasms, which intervene as wedges between the opposing surfaces of the arytenoid cartilages, and thus produce a mechanical impediment to the production of sound; and the voice may be dysplionic or aphonic as in the instances al- ready alluded to, and, like them, without any impairment of the integrity of the vocal hands themselves. This form of the affection is exceedingly apt to terminate in erosion of the mucous membrane, frequently extending to ulceration through it—a fact not surprising when it is borne in mind that this inter-arytenoid fold is con- stantly being folded up, as it were, in phonation, so that the ridges rub each other until their mutual attrition eventuates in solution of tissue. There is a partial folding and unfolding too, in quit t respiration ; and thus it is easily understood why the impossibility of in rmal complete rest to the part pre- vents repair in the majority of instances; and why the repair which occa- sionally follows absolute rc.-t to the part, abnormally secured by artificial respiration through a tracheal orifice, gives false hopes of ultimate recovery from the disease, to palliate the incessant cough and dyspnoea of which the operation of tracheotomy may have been peiformed. 111. The v ical hands are the seat of the next most frequent lesion, as I have seen it. They become infiltrated, thickened into veritable vocal cords, often rugous on their superior'surface, and are as red in color, usually, as the general lining mucous membrane. In many instances they remain of a dingy white a.-pect, occasionally redder or paler according to circumstances. This conditi >n of the vocal hands may he independent of any other appre- ciable local lesion in the larynx, hut it is frequently associated with one of the conditions previously mentioned or with both of them. When existing alone, there is no me cl ai.ii.al in \ eelin a t to the aj proximatie.n of the aryt- enoid cartilages and < f the posterior portions of the vocal hands, and hence the voice is not interfered with; but the tme of the voice is altered, with a gruff husky quality due to alteration in the tension and flexibility of the vocal hands, and consequent irregular vibrations. When associated with hsionsof the snpra-arytenoid or of the intra-arytenoid structures, there may he aphonia independently of the lesion in the phonal hands themselves. IV. The epiglottis is a frequent seat of lesion in the cases under con- sideration, often, at least at first and for a long time, without association with any other local lesion, and when so associated, most frequently with a certain amount of the pyriform infiltration of the aryteno-epiglottic fold first described. The epiglottis becomes thickened to double, triple, quadruple its normal dimensions, pale, curled together on the sides so as to resemble the shape of a crescent, a horse-shoe, or even a turban. With this is associated it.filtration of the epiglotto-pharyngcal folds, sometimes to such a degree as to complicate recognition of the structures. The result is-that due occlusion of the larynx does not take place in deglutition and dysphagia results—food readily falling into the unoccluded air passage. There is,in consequence, more absolute distress experienced in this variety of the lesion than in any other, while the interference with due nourishment exhausts the patient more rapidly, so (hat, not infrequently, he succumbs in from six (o eighteen months from the presumable onset of the hsion, while lie may subsist for four, five or more yeirs with ci I her of the lesions previously described. 'i h j epiglottis, too, in occasional cases, undergoes a partial constriction, so that one side or the other presents as an irregular globose swelling, not in- frequently mistaken for a morbid growth of the part, and sometimes actually subjected to an unnecessary and futile amputation. In some cases agr.in, the epiglottis undergoes progressive destruction, usually from the side, in cases in which it is infiltrated, and from the lower portion of its internal face, upward, in cases in which it has not undergone this peculiar infiltration, or has undergone thickening to hut a moderate ex- tent. The opinion prevalent among the profession that ulcerative destruc- tion of the epiglottis in this manner is a manifestation peculiar to syphilis is an cironcous one, to which the chances of recovery or amelioration of an unfortunate consumptive is som times undoubtedly sacrifict d. Syphilis may be a much more frequent systemic destroyer of the epiglottis, hut is bv no means the only one. V. Another distinct lesion of phthisical destruction of the tissues of the larynx, is an erosion of the mucous membrane over the vocal processes of the arytenoid cartilages. It maybe unilateral or bilateral. It may be evanescent or amenable to reined i slight as to elude detec- tion, or so indefinite as to give the patient the benefit of the doubt. I have failed by the most persistent questioning, to associate any one form of the lesion mure than another with hereditary predisposition to eon- sumption, with any other family predisposition, with hemoptysis or with special calling or vocation.