TUBERCULOSIS 
AS 
MANIFESTED IX THE LARYNX. 
BY 
J. SOLIS COHEN, M.D., 
HONORARY PROFESSOR OF LARYNGOLOGY, AND LECTURER ON DISEASES OF THE THROAT AND 
CHEST IN JEFFERSON MEDICAL COLLEGE, PHILADELPHIA. 
The American Journal of the Medicai/Sciences,I 
EXTRACTED _ 
January, 1883. [Extracted from the American Journal of the Medical Sciences for Jan. 1883.] 
■rf 
TUBERCULOSIS AS MANIFESTED IN THE LARYNX. 
By J. SOLIS COHEN, M.D., 
HONORARY PROFESSOR OF LARYNGOLOGY, ANT) LECTURER ON DISEASES OF THE THROAT AND 
CHEST IN JEFFERSON MEDICAL COLLEGE, PHILADELPHIA. 
Tuberculosis as manifested in the larynx, includes, as discussed in 
this paper, the entire range of pathological changes which ensue in the 
larynx as a result of its infiltration by tubercle. Attention will be directed 
both to the clinical pathology of the malady as revealed by laryngoscopy, 
and to its histological pathology as revealed by microscopy. 
Following the resort to laryngoscopy as a means of objective diagnosis, 
announcements were soon made that the early presence of miliary tubercle 
could be detected in the mucous membrane of the living larynx ; and that 
the entire progress of the tuberculous process could be studied from time 
to time in the laryngoscopic image. Similar assertions, indeed, are still 
made. 
Small globular or semiglobular nodules, pin-head or thereabout in size, 
yellowish in tint, seen isolated or clustered at different portions of the 
laryngeal mucous membrane, were attributed to accumulations of miliary 
tubercle. 
The customary destructive metamorphosis of these bodies, long before 
the death of the patient, prevents verification or denial of their initial 
tuberculous character upon positive premises. By prolonged observa- 
tion, however, it has become demonstrated that these tuberculous-looking 
nodules (Figs. 1 and 2) always occupy localities normally beset with mucous 
Fig. 1. 
Fig. 2. 
Distended mucous glands. 
Distended mucous glands (of three years’ 
.*—■ 
1 A paper read before the Pathological of Sept. 28,■18(32. 2 
glands j1 whence the inference has arisen that they are not tubercles ; but are 
rather hypertrophically distended mucous glands, filled, by occlusion of 
the orifices of their ducts, with accumulated products of secretion and des- 
quamation; inflamed, perhaps, by some specially.irritative quality in the 
hyper-secretions of the coexisting chronic catarrhal laryngitis. The ulti- 
mate destruction of these glands results chiefly from necrotic inflamma- 
tory processes set up by the pressure of tuberculous infiltrations around 
them and between their individual acini. In this manner follicular ulcer- 
ations are produced whose racemose configuration so closely resembles the 
crenated margins of some tuberculous ulcerations, as to render it often 
impossible to distinguish one from the other, save under the lens of the 
microscope. 
Nodules, similar in their gross laryngoscopic aspect to those which have 
just been mentioned, sometimes remain unchanged for many months. 
Several examples have occurred in my own practice; the appearance 
depicted in the second illustration (Fig. 2) having lasted, to my knowledge, 
for more than three years, in the larynx of a practising attorney of this 
city. These certainly cannot be tubercles, except under the questionable 
hypothesis of their calcification. 
The long-mooted question of the existence of tubercle in the larynx, 
seems to have been set at rest in the affirmative; and chiefly by quite 
recent researches of Heinze2 and Eppinger.3 
Primary Tubercle Pathologists acknowledge the possibility of pri- 
mary infiltration of the larynx with tubercle ; but they await satisfactory 
confirmation of the hypothesis. No record exists, to my knowledge, oi 
detection of tubercle in the larynx of the dead subject, without abundant 
coexisting tubercle in the lungs. Clinical evidence of such primary deposit 
is presumptive rather than demonstrative. This presumptive evidence is 
based solely upon laryngoscopic inspection, which, in individuals in whom 
no physical signs of pulmonary lesion can be detected, reveals a condition 
of the larynx known to be more or less characteristic of tuberculous pro- 
cesses in that structure. 
Secondary Tubercle—Secondary infiltration of tubercle in the larynx 
is generally acknowledged to be of comparatively frequent occurrence. 
It takes place, as a rule, only in subjects of pulmonary tuberculosis; and, 
as far as my own records teach, appears much more frequently in the 
inherited than in the acquired variety. It is, furthermore, associated, as 
a rule, with secondary tuberculosis in other structures: both at a dis- 
tance, i. e., intestines, spleen, kidneys, etc.; and contiguous, i. e., trachea, 
pharynx, palate, tongue, etc. 
1 Inner surfaces of the arytenoid and supra-arytenoid cartilages, lower and inner 
surface of epiglottis, meso-arytenoid fold 
0 Die Kehlkopfswindsucht, nach Untersuchungen iin pathologischen Institute der 
Universitat. Leipzig, 1879. 
3 Pathologische Anatomie des Larynx und der Trachea. Berlin, 1880. 3 
An acute tuberculous sore throat lias been described, with considerable 
detail, by Isambert, Froenkel, and a few others. It is an acute miliary 
tuberculosis of the pharynx and larynx, which rapidly ulcerates, and ter- 
minates fatally in a few weeks, under further progress as acute tubercu- 
losis of the lungs. Abundant disseminations of confluent patches of 
miliary tubercle have been observed beneath the epithelium, which bleeds 
freely when touched. These appear first upon the palate, anterior pala- 
tine folds, the tonsils, and the pharynx ; and, at a later stage, upon the 
epiglottis and the larynx. They are exceedingly painful, so much so that 
deglutition is sometimes impracticable. Ulceration soon ensues, enucleat- 
ing a certain number of the tubercles ; and leaving empty sacs, with more 
or less deep losses of substance. Death occurs, usually, before extensive 
ravages can be produced. 
Of this affection I know almost nothing personally. One example pre- 
sented at the Throat Clinic of Jefferson Medical College Hospital, a few 
years ago, in the person of a lad, whom I had but the one opportunity of 
examining; and who, as I learned upon inquiry, died a few weeks after- 
wards. 
In 1868, the larynx, from what I strongly suspect to have been a case 
of this kind, was presented to this Society, by Dr. Tyson,1 who called 
attention to the fact that the ulceration began in the fauces, and that the 
patient, a man, 49 years of age, whom he had seen in consultation, suf- 
fered with painful deglutition to an extreme degree. The rapid progress 
of the disease in this instance, the intense pain on deglutition, the early 
ulceration in the throat, and the slight amount of laryngeal ulceration found 
post-mortem, tally very closely with the pathological history of the cases 
discriminated of late years as examples of acute tuberculosis of the throat. 
Presumptive Primary Tuberctilosis—My entire practice has furnished 
me with but three personal examples of even presumptive primary tuber- 
culosis of the larynx. In two instances it was impossible to detect evi- 
dences of pneumonic lesions for several weeks following recognition of the 
tuberculous larynx. The subjects were all males; aged, respectively, 29, 
27, and 21 years. 
In two cases, one a driver of an ice-wagon, and the other a sailor, the 
immediate advent of the lesion was directly attributable to severe cold ; 
probably acute laryngitis, from extreme exposure. The third patient, a 
miller, had no recollection of having caught cold. Hereditary influence 
was denied in each case. 
In the sailor, pneumonic symptoms firsl became discernible six weeks 
after the manifestation of disease in the larynx; and death occurred by 
apnoea within ten weeks thereafter. 
In the driver of the ice-wagon, pneumonic symptoms first became dis- 
cernible eighteen weeks after the manifestation of disease in the larynx; 
1 Trans. Path. Soc., Phila., vol. iii. p. 74. 4 
and death ensued eight weeks later. In the miller, the first pneumonic 
symptoms became discernible fourteen weeks (April 3, 1882) after the 
disease had begun; and at last accounts he was reported as far gone in 
pulmonary tuberculosis. 
Case I.1 (No. 17,250) The first laryngeal lesion, recognized, was a 
shallow irregular ulcer on the left side of the posterior face of the pallid 
and thickened epiglottis. Ulceration soon attacked the right side also ; 
then the central portion of the edge of the epiglottis, and subsequently its 
laryngeal face. Thus the epiglottis became encircled, as it were, with an 
ulcerating girdle, and gradually underwent destructive ulceration from 
above downward, till nothing but a hemorrhagic stump remained. At the 
autopsy it was found that the ulceration which had surrounded the epi- 
glottis had extended into the base of the tongue, and had destroyed a por- 
tion of its substance. The ulceration on the laryngeal surface of the stump 
of the epiglottis was quite extensive, as was that also on the aryteno- 
epiglottic folds and the ventricular bands. The vocal bands were intact, 
as was also the whole of the subglottic mucous membrane of the larynx 
and of the trachea, as far as it had been removed. This is distinctly 
shown in the specimen, herewith presented. 
Dr. Seiler kindly made a number of sections of this larynx, two of 
which are now under the microscope for inspection. One shows small- 
celled infiltration and caseous degeneration in the stump of the epiglottis; 
and the other exhibits infiltration with cheesy centre in the mucous mem- 
brane, and infiltration in a mucous gland. 
Tubercle was abundant in both lungs in various stages of degeneration. 
Several small cavities were seen in the upper lobe of the left lung; but 
there were none in the right lung. 
Case II. (No. 21,110)—Geo. F., aged 29, a German, blonde, unmar- 
ried, and for fourteen years a seaman, had no record of sickness prior to 
six weeks before being sent to me for laryngoscopic examination. Ex- 
posed to very cold weather in the English Channel, he acquired what was 
probably an acute laryngitis, attended by dysphonia, dysphagia, cough and 
expectoration. The dysphagia increased until swallowing had become ex- 
ceedingly difficult and exquisitely painful. His pain, indeed, was the prin- 
cipal subject of complaint. 
Nutrition seemed good. 
Lung capacity was of nor- 
mal average. There was no 
sign of dyspnoea on exertion. 
There was slight dulness on 
percussion at the apex of the 
right lung; and bilateral ex- 
aggerated vocal resonance 
on auscultation posteriorly. 
The mucous membrane of 
the gums of the upper teeth 
was studded with tubercu- 
lous-looking elevations. 
Laryngoscopy revealed 
(Fig. 3) almost complete 
ulcerative destruction of the 
Fig. 3. 
Ulcerative acute tuberculous iarnygitis. 
1 For details with illustrations, see Archives of Laryngology, vol. ii. No. 2. 5 
right half of the epiglottis. The ulcerations extended into the glosso- 
epiglottic sinuses in the one direction, and into the aryteno-epiglottic fold 
in the other; the glosso-epiglottic ligament and aryteno-epiglottic fold 
being destroyed in considerable extent. The ulceration extended into the 
base of the tongue on that side. A few red unhealthy granulations existed 
at the junction of the crest of the epiglottis with its left side; ulceration 
existing over the whole of that side of the epiglottis, also, but much less 
deeply than on the right side. The left edge of the epiglottis was several 
times the normal thickness; and a deep oval excavated ulcer occupied its 
free edge. There was immense tumefaction of both supra-arytenoid emi- 
nences. The left side of the larynx was completely hidden ; and the inte- 
rior of the right side indistinguishable. Progressive ulceration gradually 
destroyed so much of the swollen epiglottis and aryteno-epiglottic folds as 
to fully expose the interior of the 
larynx to inspection (Fig. 4), when 
it was seen that the vocal bands 
were intact; as had been inferred 
from the character of the voice. 
Post-mortem examination re- 
vealed complete tuberculous infil- 
tration of the right lung, and almost 
equally extensive infiltration in the 
left lung; only a few cubic inches 
in the anterior portion of the lower 
lobe being free from the product. 
The lungs contained no vomicae. 
There was extensive ulceration 
of the base of the tongue, the rem- 
nant of the epiglottis, both aryteno-epiglottic folds, and both lateral laryn- 
geal walls almost to the edge of the ventricular bands. No macroscopic 
lesions were apparent on the vocal bands, or in the subglottic portion of the 
larynx, or in the entire trachea, or in so much of the primitive bronchi as 
was removed with the specimen, which is herewith presented for inspection. 
In both these cases the tuberculous lesions are limited to the supra- 
glottic portion of the larynx, as was likewise the case at the last laryngo- 
scopic examination of Case III., the pathological particulars of which, I 
shall, probably, be prepared to present to the Pathological Society at no 
distant date. 
As to the etiology of these cases, we are restricted to hypotheses. There 
is no positive evidence of hereditation. In two, there was distinct origin 
in a severe cold, most probably an acute laryngitis. 
In the third, there was no recollection of any special cold; but it is not 
improbable that the disease began as an acute or subacute laryngitis, or 
laryngo-bronchitis, milder in character than in the other cases. It is quite 
possible, further, that there may have been some slight pneumonitis ac- 
companying the laryngitis or laryngo-bronchitis in these cases, and that 
the caseous foci of some of its residual products in the lung originated the 
tuberculization. 
Fig-. 4. 
Progressive ulceration in acute tuberculous 
laryngitis. 6 
On the whole, therefore, I am inclined to the belief that cases of so- 
termed primary tuberculosis of the larynx may be relegated to the 
category of secondary tuberculosis, commencing very early and running 
an unusually acute course. 
Secondary tuberculosis of the mucous membrane of the larynx presents 
us with two stages: (1) that of infiltration; and (2) that of ulceration; 
several specimens of both of which conditions are under the microscopes 
before you. No tubercle is found in the epithelium; the infiltration always 
taking place beneath the epithelium. The infiltration is found both in 
the mucosa and the submucosa; in the latter, however, rarely as deeply as 
the situation of the mucous glands; according to some, never; but this 
negation is too absolute, as will be proved by several sections now under the 
microscope (Fig. 5). One section, through a ventricular band, exhibits 
rig. 5. 
Tuberculous ulceration; involvement of gland. Section through mucous membrane at base of 
epiglottis ; cm, gland and its duct infiltrated with granular tubercle ; 6, acinus of gland; c, 
tubercle. X 180. 
granulation tubercle extending more and more densely in the very vicinity 
of the glands, everywhere infiltrating the interacinal connective tissue, and 
in many places so profusely infiltrating the glands as to render it difficult 
to tell whether a given mass is a tubercle or an infiltrated gland. In some 
instances, as in some of the specimens before you, the infiltrate is uniformly 7 
disseminated through the entire thickness of the mucous membrane; but in 
the great majority it is found only in the upper part of the mucosa, just 
beneath the epithelium. Sometimes there is quite a free space (Heinze) 
between the epithelium and the most superficial tubercles. The overlying 
epithelium appears normal; and remains well attached unless ulceration 
has actually begun. Individual tubercles are noticed more abundantly 
in the upper portions of the mucosa, and more and more sparsely towards 
the deeper. In these portions, too, there is less granular infiltration than 
there is above. In the sections exhibited, the older tubercles occupy the 
central portion of the mucous membrane chiefly; young ones, the sub- 
epithelial portion. Giant cells are few in number. Advanced cases exhibit 
extensive caseation, both in the tubercles and in the tissue immediately 
contiguous; especially near the periphery. 
Miliary tubercle is beautifully exemplified in one of the preparations 
under the microscope, from the larynx of an infant seven months of age. 
The section, for which I am gratefully indebted to our accomplished 
curator, Dr. Seiler, includes the entire circumference of the larynx directly 
through the glottis, and the tubercles in the field of the instrument are 
located in the interarytenoid fold. 
Circular infiltration occurs partly outside the adventitia of the blood- 
vessels; but also, and to a greater extent, imbedded between its fibres. 
Fully formed tubercles are sometimes observed; occasionally with evidence 
of central caseation. The lumen of the vessels is obliterated by pressure 
in many places. Extensive infiltration has destroyed parts of the adven- 
titia; but the integrity of the remaining coats of arterial vessels is usually 
well maintained. So likewise with the capillaries; while the more deli- 
cate tunics of the veins readily undergo destruction; mere traces remain- 
ing in some localities. 
As regards the glands, to ulceration of which a tuberculous character 
has been so much attributed both by many clinicians and not a few pathol- 
gists: while they are not directly involved in the tuberculization as a rule, 
they undergo, when implicated, two processes of infiltration simultaneously. 
I. Inter-acinous; i. e., great increase of round-cells in the interacinous 
connective tissue ; or infiltration between the acini. 
II. Intra-acinous; i. <?., interstitial increase of round-cells; infiltration 
within the acini. 
The interacinous infiltrations separate the individual acini, and partially 
compress them. During this process, or somewhat later, miliary tubercles, 
likewise, collect both in the connective tissue between the individual 
glands, and between the individual acini of individual glands. The 
gland-cells lining the proper membrane become detached and undergo 
destruction; and, as the membrane is forced inward by the external pres- 
sure exerted upon it, the diameters of the acini show their compression 
from globular into irregular oval, and elliptic bodies. Many acini finally 8 
undergo partial or complete destruction, as may be, from fatty degenera- 
tion following the combined internal and external pressure. The ducts 
(Ileinze) resist the process longer than the acini. 
Fig. 6. 
Miliary tubercles in inter-arytenoid fold of an infant seven months old.1 a, epithelium ; 
6, right supra-arytenoid cartilage ; c, tubercles. 
Secondary tuberculosis of the larynx occurs, according to my own 
clinical observations, both in an acute and in a chronic form. The acute 
form occurs chiefly in cases of rapidly caseating pulmonary tuberculosis, 
is liable to occur quite early in the disease, and has an average life of from 
six to eighteen months. The several varieties of the more chronic forms 
occur chiefly in the more languid cases commencing as localized pneumo- 
nitis, occur at a comparatively advanced stage of the disease, and last 
from tw7o to four years, or even longer. 
The earliest recognizable stage of the acute form is almost always mani- 
fested by marked congestion of the mucous membrane. The earliest 
recognizable stage of the chronic and much more frequent form, is almost, 
always manifested by marked pallor of the mucous membrane. 
In the acute form—The period of the pulmonary disease at which the 
secondary tuberculosis takes place is not uniform. In most instances, 
1 This specimen shows, too, the layer of squamous epithelium at the posterior wall 
of the larynx. 9 
evidences of softening are indubitable when the laryngeal disease comes 
first under observation; but in many they are absent, or escape detection. 
The intense catarrhal laryngitis of the acuter form usually subsides, in 
the course of from two to three weeks, into a severe chronic catarrhal laryn- 
gitis, indistinguishable, laryngoscopically, for a considerable period (per- 
haps as many as two to six weeks) as a malady due to specific constitu- 
tional disorder. In the course of from three to six weeks, a number of 
superficial ulcerations become noticeable upon the surface of the mucous 
membrane; most frequently upon the upper portion of the posterior sur- 
face of the epiglottis, frequently upon the inter-arytenoid fold, less fre- 
quently upon the inner face of the arytenoid or supra-arytenoid cartilages, 
upon the vocal bands, or upon the ven- 
tricular bands, and other portions of the 
interior of the larynx (Fig. 7). These 
initial multiple superficial ulcerations of 
quasi-tubei’culous origin may not be fol- 
lowed or succeeded by any other local 
manifestations characteristic of tubercu- 
losis. 
They present at first the closest phys- 
ical similitude to the catarrhal epithelial erosions or aphthous ulcera- 
tions of a chronic laryngitis with especially irritating secretory products. 
Suspicion as to their dependence upon tuberculosis is excited by their 
multiple manifestation; purely catarrhal erosions being solitary, or very 
few in number. 
The shape presented by these superficial ulcerations differs with the 
locality they occupy. They are roundish or ovoidal on the epiglottis, and 
upon the pharyngeal surface of the supra-arytenoids; elliptic or linear on 
the vocal bands and on the inter-arytenoid fold. This difference in con- 
figuration, being unusual in mere catarrhal erosions, is indicative of a differ- 
ence in character. Catarrhal laryngitis coexists with the condition under 
consideration, as in several other varieties of intra-laryngeal disease; but 
the multiple ulcerations seem specifically due to the underlying dyscrasia, 
and not to the attendant catarrh. 
Erosions purely catarrhal in origin may also exist, but they are not 
essentially part and parcel of the tuberculous malady. 
These individual ulcerations gradually extend in depth and in peri- 
phery, and often coalesce. Thus they can rarely be submitted, in their 
initial state, to the observation of the pathological anatomist. 
Erosions similar to these, however, sometimes take place from time to 
time as fresh manifestations in the more chronic form of the affection ; 
and these latter forms often come under post-mortem observation; as in the 
specimen herewith presented. 
Fig. 7. 
Multiple initial superficial ulcerations. 10 
Inferentially it may be presumed that the early erosions in the acuter 
forms of laryngeal tuberculosis are similar to these in their histologic 
pathology. 
The fresh superficial ulcerations last alluded to, exhibit under the micro- 
scope a loss of substance, confined to the epithelial layer in many examples, 
while extending in others to the immediately subepithelial portion of the 
mucosa also. Portions of epithelium implicated, but not yet exfoliated, 
are turbid; and, at some points, partially detached. 
Ulcerations extending somewhat deeper into the mucosa show different 
stages of cell infiltration, erosion of vessels, accumulations of detritus and 
fatty degeneration. But no miliary tubercle can be detected either in the 
beds and edges of the ulcers, or in the tissues in their immediate vicinity. 
The broken down debris of tubercle presenting nothing characteristic, 
the tuberculous nature of these initial superficial ulcerations is inferred, 
therefore, from the fact that they are rarely observed apart from subse- 
quent undoubted tuberculous manifestations in different portions of the 
laryngeal mucous membrane. If this inference be justifiable, it should be 
admitted that tuberculous ulceration may occur independently of direct 
tuberculous infiltration in situ; in which case they might probably be ac- 
counted for by so great a constitutional proclivity to tuberculous degene- 
ration as to favour ulceration as a result of local irritation of almost any 
kind. Should this view of the subject be unsatisfactory, we would be 
obliged to regard these ulcerations as non-tuberculous in character; or to 
acknowledge the probability of an actual infiltration with tubercle, and its 
rapid destruction and discharge. Later in the disease, when these ulcera- 
tions have extended in depth and in periphery, or by coalescence, their 
positive tuberculous character becomes manifest ; as is evident, after death, 
by the detection of secondary miliary tuberculosis in parts immediately 
contiguous. 
As previously intimated, it is both a matter of doubt and of dispute, 
whether these shallow ulcerations are preceded by miliary tubercle. 
They come to the notice of the laryngoscopist, as a rule, only after the 
disease has made such progress as to have rendered an examination almost 
a matter of necessity; and he misses the pre-existent lesion. 
In this connection it will be useful to mention an instance in which 
Prof. Sclmitzler of the Vienna University claims to have had an oppor- 
tunity, and the only one he has had, to watch the development of shallow 
ulcerations from miliary tubercles.1 It is the most useful instance that I 
have come across in my reading; although fully as authoritative assertions 
have been made by others as to having encountered cases in which they could 
detect the miliary tubercles laryngoscopically. These opportunities ai'e so 
1 Zur Kenntniss der Miliartuberkulose des Kelilkopfes und des Racliens, Wien, 1881. 11 
rare, however, that Tuerck never reported more than one in his famous 
clinical collection ; and Stoerck, of Vienna, now the oldest living laryn- 
gologist, has reported but one from his extensive experience. 
As for myself, I have never been able to detect tubercle laryngoscopically; 
not even in the case of the preparation which I present, in which ample 
evidence of tuberculous infiltration was visible macroscopically in the well 
washed specimen (Fig. 8). 
Fig. 8. 
Tuberculous infiltration of larynx. 
To resume the clinical pathology of laryngeal tuberculosis, it is to be 
remarked that subsequent laryngeal manifestations of local tuberculosis 
may be moderate or severe. As a rule, some characteristic circumscribed 
tumefactions attract notice not many days after the advent of these shal- 
low ulcerations, and while they are increasing in depth and in periphery 
and by coalescence. Similar characteristic changes are manifested in some 
instances previously to any ulceration of the mucous membrane whatever. 
They take place at almost any stage of the malady; and they may remain 
the sole visible manifestation of the tuberculosis. These circumscribed 
tumefactions are chiefly thickenings of tissue, and are observed at various 
points of the structures. 12 
The intumescence occurs chiefly in the mucous membrane of the epi- 
glottis, ventricular bands and vocal bands; and less often in the inter-ary- 
tenoid fold and aryteno-epiglottic folds; in the last named structures, 
perhaps, less frequently than in any others; presenting, in this respect, a 
marked contrast to the more chronic form of laryngeal tuberculosis, in 
which these selfsame aryteno-epiglottic folds are much more frequently 
involved than any of the other tissues. 
The epiglottis undergoes tumefaction on its posterior aspect, to several 
times its normal thickness; its functions as an obturator to the larynx in 
deglutition being thereby impeded. 
The ventricular bands thicken so as to overlap the vocal bands to a con- 
siderable extent ; and even to conceal them from view in some instances. 
The vocal bands become thickened into veritable vocal cords indeed; 
and their inferior aspect becomes tumefied; sometimes to such an extent, 
that, as in a specimen exhibited by me before the society,1 some years 
ago, for the purpose of demonstrating the fact, they are transformed into 
thick, bulky, tumour-like folds, absolutely larger than the ventricular 
bands themselves. 
When these tumefactions are multiple or bilateral, as often occurs, their 
encroachment upon the calibre of the larynx is in some instances so great 
as to produce a veritable stenosis, threatening asphyxia, and sometimes 
requiring tracheotomy. 
Not only do these tumefactions occur with the ulcerations just discussed; 
but they also accompany other intra-laryngeal tuberculous processes. They 
may also take place without previous ulcerations or other visible manifes- 
tations of tuberculous disease. 
The swollen mucous membrane becomes irregularly tumid, acquires a 
pallid yellowish-gray or gray colour, as is observed in the early stage of the 
more chronic form, looks sodden and corrugated, and often supports a dingy 
yellowish pultaceous deposit. 
Under the microscope, these swellings are found to be due to copious 
infiltration of small (lymphoid) cells from immediately beneath the epi- 
thelium inwards, both in the mucosa and in the sub-mucous connective 
tissue; massed here and there into tubercle nodules or groups of miliary 
tubercle, some of them undergoing central caseation. They extend from 
the epithelial layer as far as the glandular structure ; the older tubercles 
being usually the deeper-seated ones. The glands, as a while ago stated, 
are not often themselves infiltrated, but the infiltration is usually massed 
around them and between their individual acini, which are thus com. 
pressed out of shape and subjected to fatty degeneration from pressure. 
When the epithelium becomes detached, hemorrhagic ulcerations are 
thus exposed, of undoubted tuberculous character. These ulcers rapidly 
1 Trans. Path. Society, Phila., vol. v. p. 83. 13 
extend in the most irregular manner; so that large portions of tissue are 
soon included in their ravages. Their edges are well defined and often 
slightly hemorrhagic or injected; their beds are rough and irregularly 
mamellonated, and usually covered with caseous detritus. The ulcers 
deepen and deepen in convergent outlines; or undermine the surrounding 
tissue at different points of their periphery. They extend to the ultimate 
limits of the cell infiltration, and may thus lay bare the very perichon- 
drium—the first structure that seems fashioned to resist actual tubercu- 
lization. 
Submitted to the microscope these ulcerations usually present one of 
three conditions:— 
I. No evidence of tubercle in either bed or edge of the ulcer, but 
infiltration of granular tubercle in immediate contiguity to the ulcer, or 
but a short distance from it; 
II. Either infiltration of granular tubercle, or nodular tubercle in edges 
or bed, or both, without either contiguous or distant infiltration; and, 
III. and most frequently, tubercle in the edges and bed of the ulcer, 
associated with granular tubercle-infiltration, whether contiguous only, or 
copiously disseminated throughout the mucous membrane. 
As the disease progresses, nearly the whole interior of the larynx 
becomes involved. The tissues, generally, become so swollen that all the 
sharp outlines (edges of ary-epiglottic folds, vocal bands) become lost in 
thick welts. Later, as the ulceration extends, the whole structure be- 
comes transformed into an irregular, excoriated, ulcerating, almost fun- 
goid mass. Especially is this marked in the epiglottis and vocal bands; 
the latter, by fissure-like longitudinal ulcerations, becoming converted into 
a series of bands. 
In many instances, local suppurative centres of inflammation become 
established in the immediate contiguity of these ulcerations, and, as they 
reach the perichondrium, involve that structure also, so that the cartilage 
becomes exposed. 
The cartilage, too, becomes attacked, and undergoes destruction, in 
debris, as is most usual with the epiglottis (Fig. 9), or in fragments and 
in mass, as with the vocal processes, arytenoids and supra-arytenoids, and 
even the cricoid; or in large plates, as with the cricoid and thyroid car- 
tilages. These fragments are often discharged by expectoration ; the 
posterior vocal processes, and even the entire arytenoid cartilages, being, 
at times, exfoliated in mass. In the dead body, such fragments, or de- 
tached cartilages, are often seen loose in the abscess which surrounds them. 
The epiglottis is sometimes destroyed in its entire free portion, by pro- 
gressive ulceration from above downward, so that a mere deformed stump 
remains; occasionally the destruction is by progressive ulceration from the 
side. 
The similitude of the laryngeal pictures of this variety of laryngeal 14 
tuberculosis, to those presented in presumptive primary laryngeal tuber- 
culosis, indicate to my mind such similitude in character that the latter 
may be regarded as acuter examples of the former. Both occur in cases 
Fig. 9. 
Tip of epiglottis, showing tuberculous ulceration and necrosis of cartilage, X 60. Section cut 
by Dr. Forinad. 
of rapid pulmonary tuberculosis; both become associated with secondary 
tuberculosis of the trachea, pharynx, palate, tongue, lips, and other 
structures ; both progress without interruptions. 
The chronic form of tuberculosis of the larynx is not ushered in by 
congestion following distinct history of exposure, as in the acuter form 
just described ; but it is characterized by well-marked pallor of the mucous 
membrane; a pallor participated in, in many instances, by the mucous 
membrane of the pharynx and mouth. This anmmia is often apparent 
long in advance of similar evidence of impairment of nutrition elsewhere. 
Although somewhat characteristic, and strongly suggestive of consti- 
tutional tuberculosis, this appearance is not peculiar to the tuberculous 
larynx only. In many cases, congestion ensues at a later period of the 
disease; as a result of the irritation produced by the tuberculous process; 
—but in many, the pallid hue continues to the very last. 
Accompanying this local anmmia, there is an irregular vascularity of 
portions of the mucous membrane, which, in localities where its connec- 
tions are loose (inter-arytenoid fold, ventricular bands), is elevated here 15 
and there in irregular wrinkled ridges or welts, red or gray in colour, 
often of a distinctly villous aspect. 
Some instances present spots of ecchymoses, or little irregular varices, 
irregularly located on the laryngeal surface of the epiglottis, or on points 
in the interior of the larynx proper. There is often a general tumid con- 
dition of the mucous membrane; but this is by far a less frequent condi- 
tion than circumscribed tumefactions of a peculiar character. 
I. The most frequent locality of tumefaction is in the tissue inclosing the 
supra-arytenoid cartilages and the apices of the arytenoid cartilages; the 
least frequent point of intumescence in the acute variety. These tissues, 
for the intumescence is most frequently bilateral, undergo gradual trans- 
formation into pale, tumid, club-shaped, and finally distinctly pyriform 
or irregularly globose tumours, gradually tapering off, stem-like, toward 
the epiglottic extremity of the aryteno-epiglottic fold ; with obliteration 
of all evidences of demarcation between the edge of the fold and the 
peculiar outline of the cartilages of Wrisberg and Santorini (Figs. 10, 
11), and the intervening tissue. 
Fig. 10. 
Fig. 11. 
Supra-arytenoid pyriform intumescence, at 
an early stage. 
Supra-arytenoid pyriform intumescence at a 
later stage; with thickening in the epi- 
gottis likewise. . 
Although most frequently pale in colour, these pyriform tumefactions 
sometimes become very much injected ; sometimes intensely so ; in excep- 
tional cases, to actual lividity at the points where they press against each 
other in the movements of phonation and deglutition. 
The tumefaction, if unilateral, or the greater of the two, if bilateral, is, 
according to my own experience, almost always situated on that side of 
the body corresponding to the lung more advanced in disease. This 
peculiar pyriform, aspect of the aryteno-epiglottic fold is sufficiently char- 
acteristic of coexistent pulmonary phthisis to establish the diagnosis. It 
occurs chiefly in slow cases, commencing with a localized pneumonitis; 
and is noticeable at a comparatively advanced period of the first stage 
of the disease. 
It is a hyperplasia due to extensive proliferation of lymphoid cells in 
the adenoid tissue normally very abundant in this structure.1 The 
1 Wagner, Das tuberkelahnliche Lymphadenom. Leipzig, 1870-1. 16 
increase of thickness of the mucous membrane is often three- or fourfold ; 
so that it not infrequently measures fully one centimetre. Later in the 
disease, both granular and miliary tubercle are found. These swellings, 
as I have seen them, never subside, except in such partial measure as 
they may have been due to effusion of serum or other products, as a result 
of the inflammatoi’y process, set up mechanically by pressure, or by irri- 
tation. They are distinct from the slight serous oedema which sometimes 
accompanies protracted subacute laryngitis, with which they are occa- 
sionally confounded. 
II. In another group of cases the epiglottis undergoes great thickening 
of its free surface, from tuberculous infiltration, into a tumid ridge of 
turban-shape (Fig. 12); its edge often presenting as a thick crescentic 
Fig. 12. 
Fig. 13. 
Turban-like thickening of the epiglottis, 
Crescentically swollen epiglottis over- 
hanging the orifice of the larynx. 
cushion or pad, in some instances overhanging the laryngeal orifice so as 
to conceal all the tissues from view, save, perhaps, the pyramidal intu- 
mescence of the supra-arytenoid cartilages (Fig. 13). 
This may be associated with previously existing pyriform tumefaction 
of the supra-arytenoid and aryteno-epiglottic structures; or it may exist 
independently of any such manifestation at the time or at any subsequent 
period. 
Ulceration usually begins superficially upon the laryngeal face near the 
edges, and gradually extends in depth and periphery. In most instances, 
progressive destruction takes place from above, until nothing but an irreg- 
ular stump remains; but sometimes it proceeds from the side inwards, as 
admirably shown in the drawings exhibited. 
As ulceration reaches the petiolus, it spreads along the commissure of 
the vocal bands into the ventricles, and along the ventricular bands. 
Ulceration limited to the epiglottis is exceedingly infrequent, and is 
seen chiefly, if not only, in subjects who succumb rather early to the 
general malady. Ulceration of the anterior or lingual face of the epi- 
glottis is unusual, and is almost always an extension of ulceration from 
the posterior face along the free edge. In one of the specimens under the 
microscope, however, the lingual face of the epiglottis is equally with the 
laryngeal face beset with tubercle infiltration. 17 
III. Still another group of cases may be classified in which the epi- 
glottis is flaccid instead of rigid; and in which the peculiar manifestations 
begin on the posterior portion of the larynx, and chiefly on the inner sur- 
faces of the meso-arytenoid fold—a point of tissue which almost invariably 
suffers likewise in cases which have begun with other manifestations. 
This fold of tissue becomes red, its normal surface interrupted, irregu- 
larly tumid in projections which often increase in size until they simulate 
polypoid excrescences, condylomatous (Fig. 14) or accuminated (Fig. 
15). Under the microscope, granular and nodular tubercles are found 
Fig. 14. 
Fig. 15. 
Condylomatous inter-arytenoid infiltration; 
colour normal; softening right apex. 
Accuminated inter-arytenoid infiltration; 
condensation right apex ; red right vocal 
band ; thick and irregular vocal bands. 
beneath the epithelium. Small superficial ulcerations soon appear in this 
fold, or upon these projections of the mucous membrane. These ulcerations 
increase in periphery, coalesce, and become covered with yellowish, gray- 
ish detritus, which, when wiped off with a brush or sponge, or subjected 
to a douche or spray, reveal an irregular and slightly hemorrhagic surface ; 
the ulcer having bled freely, though slightly, on contact with the cleansing 
substance. The surface is almost constantly covered with a thin layer of 
the products of secretion and disintegration. 
In all these varieties of secondary tuberculosis of the larynx the normal 
colour of the vocal bands is retained in most cases. In some they are 
injected, sometimes deeply, and in occasional instances are hemorrhagic 
on some points of their surface. But in almost every case the peculiar 
polish of the surface, which presents such a remarkable appearance in 
health, is lost, and their aspect is dull. 
In other cases, while the general surface of the vocal bands is congested, 
there are opalescent patches, dingy white in aspect, and more or less irreg- 
ularly parallelogramic in configuration; probably groups of turbid pave- 
ment epithelia. Sometimes the smooth surface is interrupted by projec- 
tions resembling excessive granulations. Ulceration takes place at the 
outer margins or edges of the vocal bands usually, and they become irreg- 
ular in outline (Fig. 16) ; sometimes by small losses of substance, looking 
as though removed by a punch; sometimes in a jagged or more or less ser- 
rated edge. 18 
The breadth of the band is thus actually dimin- 
ished at the points where ulceration exists, and 
often looks still more attenuated in consequence 
of the overhanging of the ventricular band. These 
ulcerations are most frequently seen at or towards 
the posterior extremities of the structures. Should 
the vocal band give way in great extent, as occa- 
sionally happens, retraction occurs in the frag- 
ments ; and the shape of the glottis becomes, in 
consequence, very irregular. Should it give way 
at the posterior vocal process, that structure will be apt to project across 
the glottis. 
Fungous vegetations are sometimes developed upon the ulcerated edges 
of the vocal bands ; and these sometimes produce adhesions at the anterior 
portion of the bands. 
Collections of tubercle within diffuse tuberculous infiltration is rarely 
observed in the mucous membrane of the vocal bands. It is infrequent 
also in the elastic fibrous tissue, in the muscular substance, or between the 
muscular fibres (Heinze). 
IV. Still a series of cases may be differentiated in which the principal 
lesions are located in the vocal bands themselves. 
The posterior surfaces of the vocal bands undergo great intumescence, 
so that they project beyond the vibrating edge of the band, and encroach 
seriously upon the calibre of the larynx. The dyspnoea from this stenotic 
condition is often sufficiently intense to threaten asphyxia, and only to be 
alleviated by tracheotomy. 
Ulceration usually takes place in the longitudinal direction of the bands 
and the irregular appearance is quite suggestive of laryngeal neoplasms. 
Tubercle is infrequent either in the muscular substance of the vocal 
band or between the muscular fibres. 
Pyriform intumescence of the posterior portions of the aryteno-epi- 
glottic folds has, in my practice, been far more frequent in young adults 
than in those in middle life; but I have seen the condition in patients 
as old as fifty-six. 
Patients above fifty years of age are much more apt to exhibit, in my 
experience, torpid ulceration, with imperfect granulations, on the inner 
aspect of the mucous membrane over the supra-arytenoid and arytenoid 
cartilages; and most of the cases I have seen have exhibited both the 
ulceration and the pulmonary softening on the left side. 
Perichondritis and chondritis, which usually attend the later stages of 
the malady in prolonged cases, are to be regarded as inflammatory processes 
of septic origin due to the tuberculosis ; and not as tuberculous processes 
proper. Tubercle is rarely found close to the perichondrium ; the infiltra- 
tion, as has been stated, being chiefly in the upper part of the mucosa. 
These processes may be limited in extent, be confined to one surface ; or 
Ffg. 16. 
Ulcerated vocal bands and 
ventricular bands, cavity left 
apex; solidification of right 
apex. 19 
they may be extensive and involve the entire surface, leading to propor- 
tionate destruction of tissue. But the processes themselves are by no 
means always proportionate to the intensity of the tuberculous process 
which has excited them. 
Abscesses often result from the perichondritis, and usually point inwards 
towards the free surface of the larynx. They are liable to be productive 
of suffocative phenomena. Their incision and discharge, when practicable, 
usually relieves the threatening asphyxia, which, under other circumstances, 
may compel resort to tracheotomy. 
After intra-laryngeal discharge of the abscess, spontaneous or artificial, 
fragments of cartilage are sometimes seen projecting into the free lumen 
of the larynx. This takes place most frequently with the posterior vocal 
processes, the arytenoid and supra-ai’ytenoid cartilages, and much less 
frequently with the cricoid cartilage. 
Tuberculous ulcers rarely heal. Exceptional cases of cure are occasion- 
ally noticed, but it becomes questionable whether those instances have been 
examples of actual tuberculous ulceration ; and the conservation of the pa- 
tient’s life prevents an accurate answer to the query, for verification is 
possible only under microscopic inspection. 
A disposition to heal is sometimes manifested by the appearance of 
healthy looking granulations upon the bed of the ulcer; but ere long the 
tuberculous infiltration occurs in the new-formed tissue which speedily 
succumbs to the invasion. Exuberant granulations are often developed in 
these ulcers, and even proliferate at times into veritable tumours or 
vegetations, which sometimes require removal to clear the air-passage 
from obstruction to respiration. 
In cases of pulmonary tuberculosis following as a sequel to caseous pneu- 
monitis, the general vitality of the tissues is impaired to such a degree 
that even follicular ulcerations of the larynx are insusceptible of cure. 
The percentage of cases of pulmonary tuberculosis in which the larynx 
undergoes tuberculization has not been approximatively estimated; but it 
is probably not very large, and is much greater in hospital than in private 
practice. Heinze’s personal pathological investigations yielded a percent- 
age of 6.5. Men are more liable than women, in the proportion of nearly 
three to one; probably as the result of their greater exposure to inclement 
weather. 
As mentioned earlier, the disease appears to be more frequently en- 
countered in inherited than in acquired pulmonary tuberculosis. 
The period at which tuberculization of the larynx occurs is variable, 
but as a rule the disease in the lungs is more advanced than in the larynx. 
If tuberculous ulceration has taken place in the larynx, cavities are almost 
always to be found in the lungs. 
Inherited or acquired tendency to catarrhal inflammations of mucous 
membranes, especially to inflammations of the mucous membranes of the 
aerial tract, seems to be a causal factor in the development of tuberculosis 20 
of the larnyx. Inheritance, in my experience, has seemed to be an import- 
ant factor. 
The tuberculous process itself seems to be an inflammatory process 
attended with profuse cell-proliferation, in tissues abundantly supplied 
with blood and lymph channels ; the proliferation being too profuse for 
absorption, and undergoing maceration or decay. 
Some acute observations of Dr. Formad appear to indicate an anatomi- 
cal reason for the development of tubercle in certain subjects, and I trust 
that he will present these views to us this evening. Suffice it now to say, 
that he finds the lymph spaces extremely small in those animals most 
readily tuberculized, and likewise in the tuberculized subjects of the human 
species, and in tuberculous subjects only. 
During the last three years I have, as opportunity permitted, examined 
the blood of many of my cases of tuberculosis of lungs and larynx. While 
often failing to encounter any appearance at all peculiar, I have so fre- 
quently observed a condition which has not been noticed in my examina- 
tions of blood in connection with other disease, that it seems to me to 
have some very close relation with tuberculosis. In all the cases with a 
temperature exceeding 100° F., this condition was almost sure to be 
found., and was rarely encountered at a lower body temperature. 
In the first place, the proportionate number of white corpuscles is much 
diminished; secondly, the red corpuscles have a great tendency to become 
massed; and, thirdly and chiefly, plugs of granular matter become caught 
here and there between the individual members of certain groups of red 
corpuscles. 
These granules look like granules which may have escaped from the 
white corpuscles, perhaps by dissolution of the protoplasm; and this of 
course would account for the paucity of the white corpuscles. 
Clinicians have been too much inclined to regard the morbid manifes- 
tations which have been under consideration, as pathological processes 
remotely due to tuberculosis, but not in themselves tuberculous nor con- 
fined to tuberculosis. 
Pathologists, with but few notable exceptions, view them as specific 
results of tubercle, the direct outcome of tuberculization, and not the mere 
result of irritation occurring in tuberculosis. The tenor of these remarks 
would indicate the greater confidence in the latter opinion. 
Note.—Every point touched upon in the foregoing paper was amply illustrated 
by specimens, microscopic sections, and drawings. The various sections under 
the microscope were prepared by Drs. Longstreth, Seiler, and Formad, from three 
of the specimens exhibited ; and they represented tubercle infiltration in the vari- 
ous component tissues of the larynx. The camera-lucida drawings, which are as 
beautiful as the preparations themselves, were made by Dr. Blackburn, under the 
immediate supervision of Dr. Formad. Without the assistance of the gentlemen 
named, it would have been impossible for the writer to have made his demonstra- 
tions so satisfactorily. AYlf/ 
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