PROGNOSIS OF LARYNGEAL TUBERCULOSIS ROBERT LEVY M.D. DENVER, COLO. REPRINTED FROM TEE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION SEPTEMBER 16, 1899. CHICAGO Amekican Medical Association Pkess 1899. PROGNOSIS OF L^RTNGEATJTUBERCULOSIS.* ROBERT LEVY, M.D. lii view of the many authentic cases of cures, both spontaneous and under treatment, which have of late years been reported, it is with some surprise that the vast majority of general practitioners as well as a fair num- ber of laryngologists still look with but little hope on every ease as soon as the verdict of laryngeal tubercu- losis is given. The general statement “prognosis- grave’'" is sufficient to satisfy the conscience and condemn the patient. This view is certainly to be looked on as misleading to say the least, especially as it is generally given more prominence than the modifying and qualify- ing statements which usually follow. It is quite as much to be regretted, as so well put by Schech in Heymann’s “Handbuch,” that the present “beloved joy” over the re- sults of modern treatment produces much harm both to our science and to the patient by promises which can not be fulfilled. It is with the hope of presenting the subject in a con- servative manner, with such deductions as shall be of practical value, that I offer the results of some years’ observation of carefully recorded cases. One can not as yet say that all opportunity for differences as to the prognosis of this serious affection no longer exists, and for this reason radical changes are year by year noted in ♦Presented to the Section on Laryngology and Otology, at the Fiftieth Annual Meeting of the American Medical Association, held at Columbus, Ohio, June 6-9, 1899. the views of all observers. The history of the curability of laryngeal tuberculosis is still being made, and one must not therefore expect to be too dogmatic; and still it must be conceded that certain well-defined conditions arc positive indications for reliable prognostic inferences. For these reasons the laryngologist becomes a valuable guide in early and accurate prognosis as he is in the diagnosis of this disease, and were he to examine every case of tuberculosis of the lungs or other organs his use- fulness would doubtless be increased by the detection of tubercular infiltration or other lesion in the larynx which passes unnoticed until the patient is beyond hope. The report and demonstration of spontaneous cures of tuberculous lesions in the larynx by men of undoubted veracity and authority can not be too strongly presented and reiterated—Kidd, Heryng, Rosenberg, Zendziak and others-—for it was from this that hope first sprang and that the curability of this hitherto greatly deplored con- dition wras established by the pioneers. Encouraged by nature’s lessons in repair she was assisted by our scien- tific efforts, until cures under treatment began pouring in from all sides by scores of men, such as Krause, Heryng, Bergengriin, Thost, Kewmann, Massei, Wolfen- den, Symonds, Gougenheim, Gleitzmann, Murray, Krieg, Whistler and many more equally authentic reporters. In spite of the enormous amount of optimistic litera- ture on this subject one can not ignore two important criticisms, namely, the question of diagnosis and that of the proof of cure. It would be desirable could we in all cases produce such incontrovertible evidences as in Krause’s and Heryng’s cures, in which post-mortem microscopic investigation demonstrated to the satisfac- tion of Virchow and E. Fraenkel the complete absence of tubercular lesion. Even this evidence may be questioned 3 by the hypercritical, for Sehrotter, in commenting on Heryng’s case, says that greater time must yet elapse be- fore we may accept such conclusion. For all practical purposes it would seem that Dela- van’s statement is more than sufficient, when he pro- poses “to call that case cured in which all trace of active disease has disappeared from the larynx and all active symptoms referable to that organ have passed away, par- ticularly where there is no recurrence of the local trouble during the remainder of the patient’s life.” I would go a step further and call a case cured in which all active indications of disease fail to recur after two, or in some instances after one year from their cessation. Ido not deny the necessity of waiting, but why refuse a cure to those cases which become not recurrences, but new at- tacks ? In other words, many a case may be considered cured which in later years, because of continued pulmon- ary disease cither through local infection or the lymph or blood channels, develops another and new case of laryngeal involvement. The lesson we draw from this statement is that without other exciting causes such cases would remain free from laryngeal disease. As to diagnosis, it is not necessary to await the appear- ance of typical ulcerations. Irregular spots of redness, characteristic anemia, typical infiltration and soft papil- lomatous excresences are sufficient guide to the experi- enced. Catarrhal ulcers are rare, and where they occur in phthisic patients they should be looked on as suspi- cious, to say the least. Avellis has shown that tumors not typically tubercular may yet be so, and even though Schnitzler doubts the tubercular nature of an apparently typical ulcer, because of its readiness to heal, Beale shows how easily an evident catarrhal ulcer may become tuber- cular. 4 The presence of tubercle bacilli in the sputum will often clear up a doubtful ease, but where they are absent or of doubtful origin, an examination of the scrapings from a suspicious lesion will almost invariably give posi- tive results. Having thus briefly considered such general topics as would seem essential to a clear judgment of the prognosis of laryngeal tuberculosis, what special questions may as- sist us in arriving at practical conclusions? In studying my cases I am particularly impressed with the influence on the progress and termination of the cases by: 1, the nature of the lesion; 2, the position of the lesion; 3, the combination of lesions; 4, the pulmon- ary complication; 5, the coexistence of syphilis; and 6, the treatment. The Nature of the Lesion.—Tubercular infiltration is frequently seen alone, but in the majority of cases only early in the disease. It is often ■ associated with new formations of papillomatous appearance, and alone or in this combination continues indefinitely. It is not my purpose to prove, beyond question, a position by offering statistics; these can be perverted to suit any occasion; but one may obtain at least a glimpse of the truth by a study of numbers of cases. My records cover several hundred cases, but many are incomplete as to result. I find, however, 144 complete accounts of cases, of which 84 were of the infiltrative and papillomatous variety, and of these 26 have gotten worse or died; only 8 of the 26, however, were materially in- fluenced in their downward march by the laryngeal com- plication, making a percentage of 9 plus. The re- mainder were either cured or improved,. Cases of the ulcerative variety numbered 60, and of these 37 got worse or died, of which 29 were hurried to an unfavorable end- 5 ing by the laryngeal disease, making a percentage of 48 plus, the remainder being improved or cured at last re- ports. It is thus shown that a favorable view may be accorded the infiltrative and papillomatous variety over the ulcerative by 39 per cent. The Position of the Lesion.—No portion of the larynx is exempt from tubercular attack, and it would indeed be tiresome and but slightly profitable to classify in minute detail and separately each site on which a lesion has been found. In a general and practical classification one may be content to divide the lesions into: 1, those which have not yet attacked the epiglottis and aryepiglottic folds; and 2, those in which the epiglottis or aryepiglot- tic folds or both have been also involved. My records show 103 cases of the former, of which 11 got worse or died, and 41 of the latter, of which 29 died. The relaT tive percentage shows that of Class 1, 10 per cent, plus, and of Class 2, 70 per cent, plus succumbed, thus mak- ing the class in which the epiglottis or aryepig- lottic folds were involved 00 per cent, more fatal. I am frank to admit that these figures may be subject to criticism, for so many elements must enter into an analysis of cases; still they present the rel- ative gravity of various lesions in laryngeal tuberculosis on a more definite basis than has been heretofore at- tempted. In a general way many authors have shown results which are in accord with those above given. 1 refer principally to Krieg, Heryng, Bosworth, Wolfen- den, Symonds, Gougenheim, Schech. While therefore admitting the great gravity of cases in which the epiglottis and adjacent structures are in- volved, one must recall not a few eases in which even here a cure resulted. Cohen, Symonds, Castex, Heryng, tis, Newmann, Whistler, Gleitzmann, the author and others, have placed such eases on record. I have records of 13 such cases cured or improved. Of these, 4 were possibly mixed with syphilis, the remaining 8 being purely tubercular, of which 4 are improving rapidly and 4 are known to be cured. The Combination of Lesions.—By this I refer to cases which are mixtures of two or more of the forms already outlined or the association with edema, acute tuber- culosis or pharyngeal tuberculosis. When complicated by the last named, the prognosis is most grave. The Pulmonary Complication.—Krause has shown that it is possible for laryngeal cures to result even while* the lungs continued to fail, while Browne has shown that improving the larynx may bring about pulmonary im- provement. Still the rapidity* extent, length of time, stage and nature of the lung disease must have a very close bearing on the course of the laryngeal complication. Thus also, as Heryng points out, age, constitution, sur- roundings, the number of bacilli and, according to Thost, whether the disease be hereditary or acquired, play a part in determining the denouement. The Coexistence of Syphilis.—That syphilis may mod- ify the course of laryngeal tuberculosis is well estab- lished. The question of diagnosis, however, becomes here a most important one, for doubtless many an atypical syphilitic lesion has been mistaken for a tuberculous one. The presence of tubercle bacilli in scrapings from such a lesion throws much light on the case. The weight of opinion seems to favor the mollifying influence of syphilis, but as Eice has said, “the prognosis will depend on which one of these two diseases is the more active,” or, as Schech puts it, the prognosis becomes more un- favorable as the tuberculosis gets the upper hand. In four otherwise unfavorable cases which I saw cured, syphilis was a decidedly possible complication and great- ly influenced the favorable termination. Well-Selected and Skilful Treatment.—That properly chosen surgical or medical treatment may greatly in- fluence the prognosis of this disease must be acknowl- edged. The many remedies which have been followed by individual success and the many rules which have been laid down for .surgical and other interference are evidence of rather chaotic conditions in the matter of in- dications for treatment. Above all should great care and consummate skill be exercised in the application of heroic measures. 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