GENERAL RESPIRATORY TUBERCULOSIS. Pulmonary, Laryngeal, Nasal. BY CHARLES P. GRAYSON, M.D., ASSISTANT PHYSICIAN, DEPARTMENT OR DlS'EASHli-WRTHE THROAT AND NOSB, HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA. EROM THE MEDICAL NEWS, August 13, 1892. [Reprinted from The Medical News, August 13, 1892.] GENERAL RESPIR ATOR Y TUBERCULOSIS: Pulmonary, laryngeal, Nasal. By CHARLES P. GRAYSON, M.D., ASSISTANT PHYSICIAN, DEPARTMENT OF DISEASES OF THE THROAT AND NOSE, HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA. The interest in the case herewith reported lies not only in the uncommonly wide distribution of the disease, but in certain methods of treatment adopted, and their results. The lungs were the parts primarily and most extensively involved, but it was for the consecutive laryngeal and nasal lesions that the patient came under the partial supervision of the Throat Department, and it is of these latter that I shall speak with the greater detail. To dispose as briefly as possible of the family and pre- vious personal history, I quote from the notes of the resident, Dr. Furness, who kindly permits me to do so: " George MeV., aged thirty-two years; machinist; Eng- lish. Both parents, a brother and a sister, all died of phthi- sis. Until within a year prior to his admission to hospital, a fairly healthy man. At that time a cough, which had troubled him more or less for some months, became sud- denly aggravated. Flesh and strength were rapidly lost and the voice became weak and hoarse. Six months ago, external swelling of the throat appeared; the voice was entirely lost, and swallowing became both difficult and painful." Physical examination disclosed extensive dis- ease of both lungs, further advanced in the right than in 2 GRAYSON, the left, the right upper lobe containing cavities and the lower lobes showing numerous areas of softening. The patient's first visit to the Throat Department was made December 19th. He was brought down from the ward in a wheel-chair and presented a most pitiful spec- tacle. Emaciation was extreme. Cough was frequent and painful, quite aphonic, and only slightly pro- ductive. Voice was extinct. Aside from his general appearance, the most prominent objective symptom was dyspnea. Loud inspiratory stridor was present, all the accessory respiratory muscles being in play, and the nasal alas widely dilated. Externally, the promi- nence of the larynx was increased to almost double its normal size, and seemed even larger from the advanced wasting of the neighboring cervical tissues. There were, in addition, some redness and edema of the overlying skin, with considerable tenderness on pressure. Fig. i. Laryngoscopic examination. The appearance of the epiglottis departed but slightly from the normal. There was moderate swelling, due apparently to simple edema, and a number of dilated veins coursed over the anterior surface. Below this, however, the larynx presented a picture of advanced tuberculous disease, from which death by asphyxia seemed imminent. The accompany- ing sketch may, perhaps, convey a clearer idea of its menacing condition than could a verbal description. RESPIRATORY TUBERCULOSIS. 3 It will be seen how very small an aperture remained for purposes of respiration. The whole infiltrated mass was immovable, forced inspiration, or attempted phona- tion producing no perceptible alteration in the mirrored image. As to coloring, the typical grayish pallor of tuberculous disease predominated, but it was splashed here and there by patches of catarrhal hyperemia. All of the mucous membrane in sight was still intact, but the absent voice, the agony attending deglutition, and the degree of general swelling, spoke but too plainly of active destruction going on below the parts shown in the glass. The previously mentioned redness and edema of the skin, with the marked tenderness on pressure, were sug- gestive of implication of the cartilages. Above the larynx the pharyngeal and oral mucous membranes were characteristically anemic. The nose. On both sides anterior rhinoscopy disclosed the same anemic condition of the lining mucosa as was present in the lower portions of the respiratory tract. In addition, however, on the left side, just within the margin of the vestibule, an ulcer was discovered on the septum. This lesion corresponded closely in appearance with the classical descriptions of the tuberculous ulcer in this region. There was no encircling inflammatory areola ; the edges were flush with the contiguous tissue and passed into a slightly depressed, caseating center The ulcer seemed entirely non-secreting, only a few par- ticles of necrotic tissue being found upon its surface. In shape it was irregularly oval, its longer diameter meas- uring 11 mm. The management of the case, so far as it related to the pulmonary disease and the patient's general condition, was in other hands, and will not be considered here. That portion of the treatment, however, directed speci- ally to the lesions involving the throat and nose, claims notice because of its having included the use of mercuric chloride in watery solution as an agent with which to 4 GRAYSON, check the accompanying destructive ulceration in these regions. At the time when local treatment was first instituted, the larynx presented in an eminent degree the condition termed by Gottstein "pseudo-edema"-the enormous swelling being due, not to a simple inflammatory exuda- tion into the meshes of the submucosa, but to the specific tuberculous infiltration of the tissues generally. The scattered superficial catarrh, no doubt, played a minor part in adding to the swelling, and constricting still fur- ther the already dangerously diminished space for the entrance of air, and it was to the subjugation of this that the earlier treatment was directed. This consisted of but little more than routine measures, viz., the external ap- plication of ice-water compresses, inhalations every few hours of steam medicated with compound tincture of benzoin, thorough cleansing of the larynx once daily by the use of a mild alkaline spray, followed by spraying with a 4 per cent, solution of cocaine, and this again by generous insufflations of a powder composed of iodo- form, bismuth, tannic acid, and acacia. It is scarcely necessary to add that the diet during this time was en- tirely liquid and bland. By the close of the first week there was much cause for satisfaction. The simple catarrh had subsided, and with it enough of the swelling to greatly relieve the dyspnea and to markedly facilitate expectoration. Nu- trition was improved, considerable strength regained, and the patient abandoned his wheel-chair and came for his daily treatment unassisted. At this point, an inter- vening Sunday causing the lapse of forty-eight instead of twenty-four hours without treatment, seemed to give the invading bacilli the opportunity of resuming active hostili- ties. The morning of December 28th found the laryngeal condition almost, if not quite, as grave as at the first examination. The previous treatment was renewed and continued without change, but the examination of the RESPIRATORY TUBERCULOSIS. 5 next day showed that the progress of the disease was not again to be arrested without the aid of some power- ful ally. Small superficial erosions on the left ary- epiglottic fold heralded the commencement of general disintegration of the infiltrated tissues. Additional erosions soon appeared on the right fold also, and on both sides these rapidly coalesced, deepened, and passed into active ulceration. In the face of this exhi- bition of weakness upon the part of iodoform, it was de- termined to substitute for it a solution of mercuric chloride. The strength first employed was i : 500. As a sort of control-experiment this was applied for the first two days to one side only, the right, while the iodoform was continued upon the left. This period, brief as it was, proved quite long enough to exhibit a marked difference in the behavior of the two ulcerating folds under the two methods of treatment. The right had undergone easily-perceptible improvement by the end of the second day, while the ulceration on the left side seemed to have been quite unaffected in its progress by the daily coating of iodoform. Subsequently, therefore, the bichloride solution was applied to both sides. The cotton-wool tufts used for this purpose were made to carry a just sufficient quantity of the medicament and no more. Thus the action of the solution was carefully limited to the cocainized ulcerations, and no excess was allowed to jeopardize the integrity of still intact membrane or to expose the patient to the risk of the toxic effects of the drug. For almost two weeks the condition of the larynx underwent steady improvement. Destruction was checked, vigorous granulations made their appear- ance, and as these underwent transformation into cica- tricial tissue, considerable contraction of the swollen folds occurred, with coincident widening of the respira- tory aperture and proportionately diminished dyspnea. At this time the disease-process seeming so well under control, another Sunday was allowed to pass without treatment. Before the day was over, however, the pa- 6 GRAYSON, tient, through some carelessness of his own, became chilled, the weakened throat felt the effects of the shock most keenly, and the ensuing morning found us con- Fig. 2. fronted by a second relapse. Appearances were again so menacing that, rather than risk having all that had been accomplished quickly undone, the strength of the bichloride solution was doubled, making it i : 250. Once more it proved wholly efficient, the threatened recommencement of disintegration was averted, and from this time until the patient's death the larynx was kept entirely neutral so far as its exerting any influence in hastening that result was concerned. On February 4th, three days previously to death, this second sketch was made. Comparison with Fig. 1 will demonstrate with sufficient clearness, it is hoped, what the treatment had accomplished. Autopsy. The larynx being removed, examination revealed the following condition : In spite of post-mor- tem shrinkage, it was, as a whole, much larger than normal. But little remained of the vocal bands-these, together with the lower thirds of the ventricular bands, having been almost completely destroyed. The upper portions of the ventricular bands were merged above into the thickened ary-epiglottic folds, and these latter bore upon their upper surfaces smooth, well-organized cicatrices, free from vegetative proliferations, and show- RESPIRATORY TUBERCULOSIS. 7 ing but slight traces of the recent active ulceration. Death was due to asthenia, the advanced destruction of the lungs found fully confirming the results of physical examination. A few words in conclusion as to the nasal lesion. The reported cases of genuine tuberculous ulceration of the nasal cavities are comparatively few (under thirty) in number. I much regret that, no microscopic examina- tion of the contents of this ulcer having been made, the diagnosis may be fairly questioned. If, however, in connection with the characteristic local appearances present, the case be considered in its entirety, together with the fact that all of the other probable or possible causes of such ulceration could be definitely excluded, I think that but little doubt can reasonably be entertained as to its tuberculous nature. Regarding its treatment: Its location made it so easy of access that the galvano-cautery promptly suggested itself as the speediest means for its eradication. This is a measure that has been successfully adopted and warmly advocated by several Continental authorities. During the first week, however, the patient's general condition forbade an immediate resort to this measure, and the same local applications were made here as to the larynx. The result was largely negative. The ulcer became cleaner and, in so far, improved in appearance, but at the end of ten days it had not undergone the least contraction, and no disposition to the formation of healthy granulations was manifest. Simultaneously with the first use of mercuric chloride to the larynx, it was applied here. The ulcer being first thoroughly curetted, the I : 500 solution was pressed firmly into the resulting excavation. Healing was much more prompt than in the more inferiorly situated disease, the comparatively sheltered position of this lesion and its freedom from the constant disturbance to which the larynx was sub- jected, enabling it to outstrip the latter in their common course toward cure. The Medical News. Established in 1843. A WEEKL YMEDICAL NEWSPAPER. Subscription, $4.00 per Annum. The American Journal ' OF THE Medical Sciences. Established in 1820. A MONTHLY MEDICAL MAGAZINE. Subscription, $4.00 per Annum. COMMUTATION RATE, $7 50 PER ANNUM. LEA BROTHERS & CO. PHILADELPHIA.