IS LARYNGITIS SICCA AND STOERK'S BLENORRHIEA OF TILE LARYNX ONE AND THE SAME DISEASE? RY W. FREUDENTHAL, M. D., OF 5TEVT T61IK. REPRINTED .EROM ANNALS OF OPHTHALMOLOGY AND OTOLOGY, Vol HI, No. 2. April, 1894. IS LARYNGITIS SICCA AND STOERK'S BLEN- ORRHCEA OF THE LARYNX ONE AND THE SAME DISEASE?1 ♦ By W. Freudenthal, M. D., OF NEW YORK. ATTENDING LARYNGOLOGIST TO THE GERMAN POLIKLINIK ; VISITING LARYN- GOLOGIST TO THE ST. MARKS HOSPITAL AND MONTEFIORE HOME; INSTRUCTOR IN DISEASES OF THE NOSE AND THROAT, NEW YORK POST-GRADUATE MEDICAL SCHOOL AND HOSPITAL. IN the year 1874, Stoerk described a certain disease of the larynx prevailing in some parts of Austria. In 1880, in his text- book2 on laryngology, he gave an exhaustive description of it, citing the history of eleven cases. Stoerk pronounces this disease a condition in which the entire mucous membrane, extending from the nose down to the trachea, is changed into a pus secreting surface, causing the formation of crusts in the larynx and trachea. In consequence thereof, there is a tendency of the parts most affected-as the anterior portions of the vocal cords-to form adhesions, and afterwards pure hyperplasia. These parts, protected as they are by the epiglottis and the nodus epiglott. invite putre- faction. For this reason, the same goes on undisturbed and reaches its greatest intensity. Accordingly, stagnation of pus occurs in these places, ulceration and adhesion follows, and finally hyperplasia. This disease is most prevalent in Galicia, Poland, Wallachia and Bessarabia. In these countries, the endemic occurrence of this disease appears to be associated with social quite as well as with telluric and climatic conditions. The largest number of patients thus diseased are those living materially in the midst of poor and filthy conditions, which are found in these countries more than elsewhere. Since Stoerk's last publication, however, with few exceptions, this subject received but slight attention in writing or discussion. 1 Read before the Medical Society of the State of New York at its Eighty-Seventh Annual meeting, February 9, 1893. 2 Carl Stoerk, Klinik der Krankheiten des Kehlkopfes, etc., Stuttgart, 1880. 2 Having been unsuccessful in finding any American literature whatever, touching this matter, it appeared to me that this disease has remained entirely unknown in this country. For the past seven years, the material in my department of the German Poliklinik, vast in numbers of people coming from those parts of the world which Stoerk especially mentions, it is surpris- ing to say that I have not as yet met a case of Stoerk's blenorrhcea. For the first time this winter I encountered two cases, one of which answered exactly the symptoms described by Stoerk. while the other, an outspoken case of laryngitis sicca, brought to me the •conviction during treatment, that this disease was nothing but an •early stage of Stoerk's blenorrhcea. A remarkable feature of the first case was that the woman was born in New York, and that her parents had never been in Poland or Galicia. The case in brief is the following: Mrs. Annie R., aged 24, was born in the city of New York. Both her parents came from Bavaria, and arrived in America years before her birth. She always lived in the United States, and cannot remember having come in contact with people from Poland or Galicia. She is dressed plain, but neat and clean, and does not impress one as having been reared in unclean sur- roundings. She is married to a man enjoying perfect health, and has borne one healthy child. She never had any eruption on her body, and always felt well, until she became hoarse four years ago. At that time, she had no pains and no dyspnea. Three years ago, she began to be annoyed by scratching in her throat. Afterwards she began to cough and a slight dyspnea set in. These symptoms have remained permanent, with the ex- ception that they became more severe and that her voice is now entirely aphonic. Her nose felt sore as long as she can remember, and there is a secretion of a fetid and mostly purulent character. The patient is so timid that she postponed consulting a physician until a few weeks ago, and for unknown reasons she left him soon after. On my first examination, I found the mucous membrane of the nose in a very atrophic condition, with a slight hypertrophy of the middle turbi- nated body of the right side. There are stinking crusts on both sides, mixed with pus. In the pharynx, the mucous membrane was hard as leather, shining and atrophic. The larynx has the exact appearance as that described by Stoerk. The entire mucous membrane has been transformed into a gray, yellow-greenish surface. At the anterior angle of the vocal cords in particular, a mass of dried greenish pus adheres, the removal of which was not possible without some difficulty. After the larynx had been thoroughly cleansed by means of a powerful spray, in the anterior commis- sure, a narrow adhesion of the vocal cords became visible. The spray I use in these cases is an exception to my general rule, for I have entirely given up the use of such for ordinary purposes. Posterior to this, and upon the inner surface of the left vocal cord, a small ulceration came to view. The whole vocal cords are thickened. A more marked thickening presents itself below the left vocal cord, and seems to be a true hyperplasia. 3 The width of the glottis is narrowed, and the voice of the patient is aphonic.. In the trachea there are still some stinking crusts, and the anterior wall of it is thickened as far down as one can see. After a very careful examina- tion, phthisis and syphilis are to be excluded. The second case, which I now cite, is Mrs. Lina P., aged 28. She and both her parents were born in Galicia, and ten months ago immigrated to the United States. She is married ten years, has two living children, and' since three months is pregnant again. Three years ago she became hoarse and was treated successfully for three weeks at Jaroslaw, (Galicia). Soon after her throat again troubled her; she felt that everything was drying in. her throat, which sensation has never left her since. After her arrival in this country, she visited a dispensary, but soon left unrelieved. Besides her old troubles, six months ago, however, she acquired dyspnea, which in the last few weeks became so alarming that she sometimes thought she would suffocate. On my first examination, I found an atrophic rhinopharyngitis, nose and pharynx coated with many inspissated crusts. The mucous membrane of the larynx was, to such a degree, atrophic and shining, as is only seen in extreme cases of pharyngitis sicca; the vocal cords throughout their length thickened. On the right arytenoid cartilage was a mass of dried stinking secretion; also below the vocal cords and in the trachea, as far as you could look down, these masses were present. The woman is aphonic and dyspnoic, gasps continually for breath. She lives in one room with her whole family, consisting of six persons, looks, and is dressed extremely- dirty. She has not had the benefit of a bath since being in this country,, and leaves her room but twice weekly to visit the clinik. When I sprayed her larynx and trachea with Dobell's solution, in order to examine the patient, she became so dyspnoic that I thought tracheotomy would be the next step. Only after having succeeded in quieting tire- woman, sufficiently to enable me to remove a piece of secretion from the trachea with a long forceps, did the dyspnea cease. This dried piece was compact, had an exquisite greenish-black color, etc., i. e., the exact appear- ance of the nasal secretion in ozena. The patient told me that during the following weeks she had several similar attacks of dyspnea. While the first case, judging from Stoerk's description, repre- sents an undoubted case of blenorrhoea of the larynx, proving at the same time that this disease may occur outside of the Austrian provinces, that it may even appear sporadically in the far away America. The other case suggested the idea that Stoerk's blen- orrhoea must be an advanced development of the much more fre- quent laryngitis sicca. The second patient's visits to the poliklinik were so irregular during the first weeks, that a course of treatment was at that time out of the question. The secretions in the larynx and trachea increasing caused, besides a permanent strong dyspnea, a very extraordinary irritating cough. In fact, the patient was constantly hawking or coughing. Under such circumstances, superficial 4 excoriations were formed, and these places already showed the gray- yellow-greenish appearance, so characteristic in blenorrhoea. The patient, after an absence of two weeks, returned, and then I found that the anterior parts of the vocal cords had grown together. It was not more than natural to suppose that if she again absented herself she would develop in a short titfie a repetition of the pic- ture I gave you of the first case. She remained, however, under my care, and I am now in such a position to be forced to declare candidly that the patient whom I demonstrated before the German Medical Society of New York as a case of laryngitis sicca, is now after five months untiring medical treatment in that state, that to- day I could demonstrate her as an exquisite case of Stoerk's blen- orrhoea, if I believed at all in a special existence of such a disease. In this time, the entire picture has so changed. The glottis is reduced to a small half-moon-shaped gap, lying before the two arytenoid cartilages. Out of the adhesion at the anterior.angle, which naturally has moved backwards, a true hyperplasia has been found, extending alongside the edges of the vocal cords throughout their entire thickness. The anterior wall of the trachea is also much thickened, which can be seen well especially by translumi- nation, which I had not utilized before. The crusts with their partly pointed, partly blunted edges, loomed upwards in the trachea, that it presented to the mind the characteristic view of stalactites in a filtering stone cavity. (Schmidhuisen). We therefore see, to voice the sentiments of Virchow, that a chronic, fibrous, retracting inflammation has set in. The woman is aphonic, at times hoarse, and suffers from a strong dyspnea which, of course, is augmented by her pregnancy. The principal danger threatening the patient arises from the dried crusts in the trachea, and this alone might necessitate a tracheo- tomy on this woman. The stenosis in the larynx being ever so small, is nevertheless sufficient to enable the patient to breathe tolerably well. For this reason, intubation would be out of the question. I have to add that in most of my examinations, the- dried secretions were found in the anterior angle of the vocal cords, the place of prediliction. Very frequently, however, they were seen on all other places of the larynx on the border of the vocal cords, on their lower surface and on the arytenoids. After having become familiar with the history of these two cases, the next question arising is: How is it that we come in contact daily with cases of rhinitis and pharyngitis sicca, seldom meeting examples of laryngitis sicca, and very rarely outspoken 5 Stoerk's blenorrhoea ? Is it true, that laryngitis sicca is nothing but an extension of pharyngitis sicca ? In answering the latter question, first, there is one point re- markable. The phlegm of the retro-nasal catarrh, of pharyngitis granulosa and sicca goes downwards in accordance with the law of gravity, mostly attacking the esophagus and the stomach, a fact to which attention has been drawn repeatedly by laryngologists. Why does it reach the larynx in so few cases, and how is it that the most tenacious phlegm, the removal of which gave me so much trouble, should be found not only in the pharynx, but also and especially so in the larynx and down in the trachea,-whilst the more fluid phlegm usually attacks the entrance of the larynx only? Lublinski3 believes that laryngitis sicca is merely a continuance of pharyngitis sicca, and Felix Semon's4 remarks seem to coincide with him. I differ from them, as I think that laryngitis sicca must be classed alone as an independent disease. The facts given to you would be quite sufficient to substantiate my statements, but allow me to mention another case as proof positive which in itself is of more than ordinary interest for our present subject. The case was published by Benno Baginsky5 under the name of ozena laryngo-trachealis. This case, that otherwise resembled the blen- orrhoea described by Stoerk, differed in that the larynx alone of the year old patient, was affected by the disease, and not the nasal chambers, the retro-pharynx and the posterior wall of the pharynx. This was, therefore, a genuine disease of the larynx and trachea, making it clear that such a disease is possible, though rare. As a further proof in addition to this, I state that the crusts in many cases of laryngitis sicca choose with preference just that place, which is the least accessible from above, i. e., the anterior angle of the vocal cords. This, too, is opposed to the theory that the disease originates in the pharynx. But I desire no misunderstanding, and by no means create the impression that it is my idea that out of every slight atrophic laryngitis now, Stoerk's blenorrhoea must develop. Of one thing, however, I am convinced that Stoerk's blenorrhoea is nothing more than the result of some cases of laryngitis sicca or ozena laryngo-trachealis, especially those which are serious or much neglected. But I will now quote others. 3W. Lublinski: " Ueber Laryngitis sicca sive atrophica." Deutsche Medic. Ztg., p. 99, 1886. 4Internal. Centralbl. f. Laryngologic., p. 251, Vol. 1. 5 Benno Baginsky: " Ein Fall von Ozaena laryngo-trachealis." Deut- sche Med. p. 296, 1876. 6 It is most peculiar, that with the exception of Stoerk and his school, only few firmly believe in a special form of the disease. Even other laryngologists of Vienna, who also see a great many patients from Galicia and Poland, deny the existence of such a sickness; as for example, Schrotter, to whom we will refer later on. A case of Stoerk's blenorrhoea, presented by Grabower be- fore the Berlin Laryngol. Society, January io, 1S90, was generally doubted as such, even by the former assistant of Stoerk, Dr. P. Heymann. The other authors I make mention of are Max Bresgen6 and Krakauer, * both also former assistants of Stoerk. While Bresgen still upholds Stoerk's opinions, Krakauer differs in that he says: "The process in the larynx has great similarity to the so-called laryngitis sicca, while in the nose it reminds one of the common ozena, and I hold the name which Mr. B. Baginsky substituted for that of blenorrhoea, the name of ozena laryngo-trachealis as a happily selected one." B. Frankel8 years ago pronounced Stoerk's creation of a new disease to be without sufficient reason, as secretions dried into scabs with or without smell are to be found idiopathically, though less often than in the nose, in the pharynx and trachea, whenever these organs are attacked by an atrophic catarrh. P. Heymann9 and I. Schmidhuisen10 both plead for a special form of the disease. Gordon Holmes11 and David New- man12 mention a special form of atrophic laryngitis, without touch- ing the question of Stoerk's blenorrhoea at all. Schrotter also having drawn attention to the fact that there exists a form of catarrh in the larynx and trachea, characterized by dry- ness of the membrane, loss of epithelium, excoriations and the like, now adds, as I have lately read in his textbook.13 that it could 8 Max Bresgen : " Einige interessante Faile aus dem Ambulatorium des Herrn Professor Stoerk in Wien." Deutsche Med. Woch., Nos. 26 and 27, 1876. 7Krakauer: " Fall von Stoerkscher Blenorrhoe." Bert. Klin. Woch- enschr., p. 973, 1887. 8B. Frankel's article in von Ziemssens Handbuch IV., 1, 2, Aufl., p. 154. 9 Berl. Klin. Wochenschr., 1887. 10 L Schmidhuisen: " Zur Casuistik der chronischen Blenorrhoe der Nasen-Kehlkopf & Luftrohrenschleimhaut." Berl. Klin. Wochenschr., p. 150, 1878. 11 Gordon Holmes: "Chronic Catarrhal Laryngitis." The Lancet, November 8, 1884. 12David Newman: "Two lectures on Chronic Laryngitis." The Brit. Med. your., July 4, 1885. 13 L. Schrotter: " Vorlesungen ueber die Krankheiten des Kehlkopfes, etc." Wien and Leipzig, 1892. 7 easily be imagined that the same process, consisting of an atrophy of the mucous membrane, degeneration of the glands and of a copious production of quickly drying secretions could even also originate first from the laryngo-tracheal mucous membrane or could be limited to it. When Schrotter, and with him, other authors speak of a degeneration of glands and increased secretion, it is a combination which I cannot understand, because the glands must be either degenerated and then they secrete less or not at all, or they secrete more and cannot be degenerated. I believe that in reality the glands secrete less than normally, that in addition the chemical combination of the secretion is so abnormally changed that it dries with exceptional readiness. Schrotter expresses his views explicitly, i. e., if the conditions called laryngitis sicca or ozena laryngo-trachealis (Baginsky), are not already identical with Stoerk's blenorrhoea, they could very well correspond to the initial stage of that disease. I had read this last view of Schrotter long after having watched my two cases; at that time I had already formed my own opinion, and his views served to strengthen my belief, which belief was corroborated in an almost experimental way in the second case. That in some of these cases there is a process similar or identical with the rhinoscleroma, I think I am justified in believing, after a case that came under my notice at the Montefoire Home. The patient, a man 27 years of age, born in Russia, came to the Mon- tefoire Home with the outspoken symptoms of rhinoscleroma. He died suddenly a few hours after admission. The autopsy of the upper air passages was made by the house physicians, Drs. Bloch and Frankel. I saw the specimens a few days later-the patient himself I had never seen. In the larynx there were extensive cicatricial adhesions of the mucosa and submucosa. This process affected especially the ventricles of Morgagni. But the whole appearance of the larynx differed materially from that of Stoerk's blenorrhoea. The whole surface was covered with a whitish layer, which could be easily removed. There were no crusts in the larynx. Signs of syphilis were not to be found on the cadaver. This case will be published hereafter by one of the house physicians in extenso. However, it was interesting to us to see these -specimens of a disease belonging to this category. That my second case shows at present a typical picture of Stoerk's blenorrhoea, and that Stoerk himself would not contradict the diagnosis of this case, there is hardly a doubt in my mind. The woman, coming as she does, from Galicia, completes the chain 8 of evidence demanded by Stoerk. But this demand of Stoerk is unnecessary and unjustly exacting, as my conviction compels me to believe that this is merely an accident. As you have heard, my first case was a native of the United States, whose parents even had never been in Austria. That furthermore, people in better circumstances can acquire this disease, Stoerk afterwards himself mentions. Of his eleven cases, one was a priest, the second a student of philosophy, and the third, a lady of " extraordinary in- telligence." The case of Krakauer was a woman of Berlin. He does not mention whether she fulfilled the requirement of an un- cleanly condition. The same can be said of the case of Grabower. Both of these cases make positive that Stoerk's blenorrhoea may occur in any country and under any condition, though not so frequent. If we, in conclusion, review the most salient points in the history of our two patients, we see No. i, whose disease reached such a high development simply because she did not seek medical advice out of fear; for had she been treated, the progress of the disease might have been checked, although not eradicated, as there are no small number of dispensaries open to the poor of New York where they can find the most skillful aid. As a proof, the patient found relief after regular treatment. Her aphonia gave way to hoarse- ness in a short time. Whether the improvement would have been further advanced is, of course, questionable. She left the clinic long ago. Circumstances are different in the second case. She has really been reared amidst poverty and filth, and has been influenced so little by the social atmosphere of New York that she continues her former habits and mode of living. This still suffices to assist the disease in its progress. Notwithstanding, even in her case, there was a subjective improvement, and the hoarseness substituted aphonia, whenever she made several successive visits to the clinic. We see, therefore, that this patient at first showed the objective symptoms of laryngitis sicca, a fact which in the discussion follow- ing my demonstration before the German Medical Society was not doubted by any of the speakers. After a few weeks, a superficial exulceration set in; later on an adhesion of the vocal cords at their anterior angle, an hvperplasia, etc., followed and the picture of the disease formerly called Stoerk's blenorrhoea was slowly formed and completed under our eyes. This case, therefore, is positive evidence that laryngitis sicca and Stoerk's blenorrhoea are one and the same disease, merely in different stages. And if you question 9 me why it is one so often sees laryngitis sicca and so seldom the so-called Stork's blenorrhoea, I answer that most of the patients are not as indifferent as the poor population of Galicia, Poland, etc., and that they usually consult a physician sooner, and give us occasion to change their mode of living, and through direct local treatment, check the disease. I have adopted the name of laryngitis sicca for this disease, fol- lowing B. Frankel's suggestion, as it covers a broader field, and I leave the name ozena laryngo-trachealis for those cases where ozena really exists, as in the nose. And now, but a few words on the treatment of this disease, which in its latter stages becomes so hopeless. I proceeded with both patients in the following manner: First, I sprayed with a powerful spray larynx and trachea, during deep inspiration. This usually produced a coughing spell, by which some scabs were ex- pelled. Whether I used for the spray Dobell's or a weak solution of chloride of or of tannic acid, or nitrate of silver, I confess made very little difference. The effect was the same. Following this, I put tampons dipped in Lugol's solution in both nostrils, leaving them in ten to thirty minutes. Thereafter, I sprayed again the larynx and wiped away all visible phlegm from the naso- pharynx and pharynx. Internally, I gave K. I. and pilocarpine without a perceptible effect. The fol. jaborandi and the fl. extr. jaborandi seemed to act with better effect than pilocarpine. As a final and most efficacious treatment, after cleansing the upper air passages in the above manner, I applied the massage of the throat. Over a year, I am working at this, and hope in a short time to publish elsewhere the experiences I have thus far gathered. To mention it as a part of my treatment was doing but justice to the good effect it gives. 943 Madison Avenue. ANNALS OF OPHTHALMOLOGY AND OTOLOGY. A QUARTERLY JOURNAL OF PRACTICAL OPHTHALMOLOGY, OTOLOGY, RHINOLOGY AND LARYNGOLOGY. Price per annum, in advance, $4.00. Single Copies, - - 1.25. The Annals of Ophthalmology and Otology continues to afford Specialists, with well-earned reputations, a medium for communicating the results of their observation and research, and to disseminate meritorious contributions to the literature of Ophthalmology, Otology, Rhinology and Laryngology, giving especial attention to Practical Articles devoted to Medical Ophthalmology, Ophthalmoscopy, and the Pathological relations between the Eye, Ear, Nose or Throat, and the general system. And to furnish brief condensed Reports on Progress in the four important departments of Medical Science mentioned, in which are recorded the most recent advances of real and permanent value, and practical interest, from the current special medical literature of the world. It is the aim of the Editors and Collaborators to keep the Annals up to a high standard of excellence. Each Quarterly number contains one hundred and twenty-eight pages, fully indexed, and handsomely printed on the finest quality of book-paper. In price, the Annals is the cheapest special journal published, consider- ing the practical value of its contents. Neither labor nor expense are spared in making the Annals the best, the most practical, and the most scientifically useful special journal on either side of the Atlantic. The cost of producing such a publication precludes the sending out of sample copies free, but a copy will be sent to any physician on receipt of one dollar. Address subscriptions and all communications to the Editor. DR. JAMES PLEASANT PARKER, 701 Olive Street, SAINT LOUIS. MISSOURI.