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 V/ 
 
 
ATLAS AND ABSTRACT 
 
 OF THE 
 
 Diseases of the Larynx 
 
 BY 
 
 DR. L. GRUNWALD 
 
 of Munich 
 
 AUTHORIZED TRANSLATION FROM THE GERMAN 
 
 EDITED BY 
 
 CHARLES P. GRAYSON, M. D. 
 
 Lecturer on Laryngology and Rhinology in the University of Pennsylvania- 
 
 Physician-in-Charge of the Throat and Nose Department, 
 
 Hospital of the University of Pennsylvania 
 
 With toy Colored Figures on 44 Plates 
 
 PHILADELPHIA AND LONDON 
 
 W. B. SAUNDERS Si COMPANY 
 
 1902 
 
Copyright, 1898, by W. B. Saunders. 
 
 Reprinted September, 1900, and November, 1902 
 
PREFACE. 
 
 In the preparation of this little Atlas of the Diseases 
 of the Larynx the author has adopted the same plan as 
 that pursued in his earlier Atlas of the Diseases of the 
 Nose and Throat. Its object is to help the beginner in 
 the art of observing and interpreting. As, however, a 
 knowledge of the previous history of the disease and 
 the examination of contiguous, as well as of more distant 
 organs are indispensable for diagnosis, especially in this 
 region, each picture is accompanied by the necessary data 
 in the form of a short history. 
 
 By adopting this method the author believes he has 
 also presented a valuable aid to the physician who has 
 few opportunities of seeing diseases of the larynx and 
 yet wishes to be able to recognize them. At the same 
 time a clearer mental image is obtained which may com- 
 pensate for possible imperfections in the actual picture. 
 
 The illustrations are arranged solely according to ex- 
 ternal appearances, without regard to the nature of the 
 disease; partly in order to train the eye by comparing 
 conditions similar in appearance, though differing widely 
 in their true nature, and partly to make it easier to find 
 the illustrations which most resemble the particular case 
 
 3 
 
4 PREFACE. 
 
 to be diagnosed. Many well-known pictures, as, for 
 instance, that of diphtheria, are therefore omitted. 
 
 To prepare the student for this course in the theory 
 and practice of diagnosis a short, systematic abstract has 
 been added. 
 
 In the author's opinion, a knowledge of the histology 
 of morbid processes is most essential to a proper under- 
 standing of them. Twelve plates showing the most im- 
 portant elementary alterations have accordingly been 
 devoted to this purpose. This department of pathology, 
 which has been somewhat neglected in the text-books, 
 affords the best means of arriving at clear, definite ideas. 
 
 Figure 1 is taken from Luschka's work on anatomy, 
 
 two illustrations of cadavers from the well-known atlas 
 
 by Bollinger. All the other illustrations were prepared 
 
 by the (academic) painter Mr. Keilitz, from sketches or 
 
 preparations by the author, who takes this opportunity 
 
 of expressing his thanks for the care and skill with 
 
 which they were executed. 
 
 The Author. 
 
EDITOR'S PREFACE. 
 
 If it be true that "good wine needs no bush," ^.tis 
 certainly true that so good a book as this needs no 
 preface. The American editor only ventures to add 
 a few words relative to the method of instruction adopted 
 in this book. It exemplifies a happy blending of the 
 didactic and clinical such as is scarcely to be found in 
 any other volume upon this subject with which we are 
 acquainted. It is upon the value of the clinical portion 
 of the work that the editor would dwell with particular 
 emphasis. The beginner will find here a series of patho- 
 logical conditions, illustrated with a remarkable fidelity 
 to Nature, that it would undoubtedly require him a 
 number of years to duplicate in actual practice ; while 
 the veteran, however rich his experience, will note a 
 precision, a finesse in diagnosis that cannot fail to be 
 instructive and, perhaps, even inspiring. The admirable 
 translation, which is the work of Mr. R. Max Goepp, 
 has been carefully compared with the original, and the 
 editor's comments are intended as expository of, rather 
 
 than as actual additions to, the text. 
 
 C. P. G. 
 
 5 
 
CONTENTS. 
 
 PAGE 
 
 Introductory Eemarks on the Anatomy and Physiology of 
 
 THE Larynx 9 
 
 Methods of Examination 19 
 
 1. Indirect Laryngoscopy 19 
 
 2. Direct Laryngoscopy 24 
 
 3. Inspection 25 
 
 4. Palpation 25 
 
 5. Auscultation 26 
 
 Practical Hints for the Examination 28 
 
 General Eemarks on the Causes and Treatment of Diseases 
 
 of the Larynx .31 
 
 Pathology and Treatment. 
 
 I. Acute Inflammations 36 
 
 1. Superficial 36 
 
 2. Exudative 39 
 
 3. Interstitial 44 
 
 4. Inflammations of the Muscles 48 
 
 5. Inflammations of the Joints 49 
 
 6. Inflammations of the Perichondrium 51 
 
 7. Symptomatic (complicated) forms of Acute Inflamma- 
 
 tions 54 
 
 n. Chronic Inflammations 59 
 
 1. Superficial 59 
 
 2. Submucous 62 
 
 3. Inflammations of the Muscles 63 
 
 4. Inflammations of the Joints 63 
 
 5. Inflammations of the Perichondrium and Cartilages . . 64 
 
 6. Complicated Forms 64 
 
 (a) Tertiary Syphilis 64 
 
 (&) Tuberculosis 68 
 
 (c) Leprosy 74 
 
 {d) Sclerosis 74 
 
 (e) Gout and Arthritis Deformans 75 
 
 7 
 
CONTENTS. 
 
 PAGE 
 
 III. Neoplasms 75 
 
 1. HomologQus 75 
 
 (a) Neoplasms of Individual Tissues 75 
 
 (6) Hyperplasias 77 
 
 2. Heterologous 81 
 
 IV. Disturbances of Motility 86 
 
 1. Mechanical 86 
 
 2. Neuroses 88 
 
 (a) Hyperkinetic 88 
 
 (6) Hypokinetic 90 
 
 (c) Parakiuetic 94 
 
 V. Disturbances of Sensibility 96 
 
 V*. Complicated (functional) Motor and Sensory Disturb- 
 ances 97 
 
 YI. Disturbances of the Circulation 100 
 
 VII. Solutions of Continuity • 100 
 
 VIII. Foreign Bodies 102 
 
 IX. Malformations 102 
 
LIST OF ILLUSTRATIONS. 
 
 MACROSCOPIC PLATES. 
 
 Plates 1-3. Various Laryngoscopic Images. 
 
 Plates 4-7. Alterations of the Epiglottis. 
 
 Plates 8-16. Diseases of the Vocal Cords. 
 
 Plate 17. Subcordal Alterations. 
 
 Plate 18. Disease of the Ventricular Bands. 
 
 Plates 19-26. Disease of the Posterior Wall. 
 
 Plate 27. Alterations at the Superior Aperture of the Larynx. 
 
 Plates 28-30. Diffuse Alterations. 
 
 Plate 31, 32, and Fig. 15. 
 Figs. 16-23. Paralyses. 
 
 Alterations at the Superior Aperture of the 
 Larynx. 
 
 MICROSCOPIC PLATES. 
 
 Plates 33-36. Alterations in the Epithelium. 
 
 Plate 37. Sarcoma and Carcinoma. 
 
 Plate 38. Alterations of the Lymphatic Apparatus. 
 
 Plate 39. Cysts and Angioma. 
 
 Plate 40. Disease of the Blood-vessels. 
 
 Plate 41. Syphilitic Tumors. 
 
 Plate 42. Fig. 1, Syphilitic Ulcer ; Fig. 2, Tuberculosis. 
 
 Plates 43-45. Tuberculosis. 
 
Sagittal Section of the Neck 
 
 29. Thyroid cartilage. 
 
 31. Cricoid cartilage. 
 
 32. F.piglottis. 
 
 33. Ventricular band. 
 
 34. Vocal cord. 
 
 38. Arytenoid cartilage. 
 
 39. Trachea. 
 
 40. Esoi)hagus. 
 
INTRODUCTORY REMARKS 
 
 ON THE 
 
 ANATOMY AND PHYSIOLOGY OF THE 
 
 LARYNX. 
 
 Both form and functions of the larynx are based on 
 its skeleton. This is built up mainly on two large cartil- 
 ages, the thyroid and the cricoid. Assuming that their 
 shape and smaller solid portions are sufficiently well 
 known from general anatomy, we proceed at once to a 
 description of their topographical relations. The two 
 broad alse of the thyroid embrace the lateral plates of the 
 cricoid which are narrower in front than behind, while 
 the anterior border or curvature of the cricoid is thrust 
 forward under the thyroid. Between this anterior border 
 of the cricoid and the lower part of the thyroid an inter- 
 val filled with soft structures can easily be felt in the liv- 
 ing subject. Above and at the sides, parts of the thyroid 
 only can be felt : the lateral plates (alse) and the cornua. 
 In front, the upper border of the thyroid cartilage pro- 
 jects sharply forward, and, with its notch which can be 
 plainly felt, especially in men, forms the prominence in 
 the throat known as Adam's apple ; the latter is also 
 occasionally visible in the more vigorous of the daughters 
 of Eve. The true base of the entire structure is there- 
 fore the cricoid cartilage, which also supports the smaller 
 ones : the arytenoid, Santorini's, and the cuneiform car- 
 tilages. The latter are called cartilages of motion, to dis- 
 tinguish them from the supporting cartilages. 
 
 The arytenoid cartilages articulate with the upper bor- 
 
 9 
 
10 DISEASES OF THE LARYNX. 
 
 (ler of the cricoid by two symmetrical articular facets in 
 such a manner that, seen from above in a resting position, 
 they present a triangular cross-section, one leg looking 
 forward and inward (toward the median line), one back- 
 ward and inward, and the wide sweep of the hypotenuse 
 forward and outward. The joint itself is in the form of 
 a saddle, having one side directed forward and inward, 
 the other backward and outward. 
 
 Above, the concave surface of each arytenoid cartilage 
 presents a process on which rests the small, horn-shaped 
 cartilage of Santorini (corniculum laryngis), while at the 
 sides the cuneiform, or AVrisberg's, cartilages form another 
 link in the cartilaginous chain surrounding the upper 
 border of the cricoid. 
 
 In front, this chain finds a point of attachment in the 
 epiglottis which resists pressure in both directions, its 
 principal movement being backward and forward. 
 
 All of these solid parts are bound together by a con- 
 tinuous sheet of elastic connective tissue, which becomes 
 thi(5kened to form cords and ligaments wherever there is 
 increased active or passive strain. Of these ligaments 
 (the names and form of which we again assume to be 
 known), the cricothyroid membrane can be felt from the 
 outside. We may consider the structures known as the 
 true vocal cords and the ventricular bands, or false vocal 
 cords, to be folds of the connective tissue which respond 
 to the pull of the moveable cartilages. 
 
 The larynx is connected with the surrounding struc- 
 tures partly by ligaments and partly by muscles. It forms 
 the beginning of the air-passage, and is attached to the 
 hyoid bone by means of the thyrohyoid ligaments, the 
 middle one of which, with its overlying muscle, can be 
 felt in the living subject; posteriorly it is held in position 
 by the hiryngeal and pharyngeal muscles. The latter, 
 assisted by the thyrohyoid muscles, elevate the larynx or 
 one side of it, while the sternothyroid muscle depresses 
 it and, by virtue of its insertion in the lower back part 
 of the thyroid cartilage, tends to rotate it about the crico- 
 
ANATOMY AND PHYSIOLOGY. 11 
 
 thyroid articulation as a pivot, depressing it behind and 
 elevating it in front. 
 
 Below, the larynx is connected with the trachea by the 
 cricotrachean membrane. 
 
 The posterior surface of the larynx (formed by the 
 posterior half of the cricoid cartilage and the upper border 
 of the epiglottis) corresponds to the anterior surface of 
 the esophagus, and may therefore be regarded as belong- 
 ing either to the lowest division of the pharynx or to the 
 upper division of the esophagus. In a sense the posterior 
 and also the lateral walls of the larynx are free and pro- 
 ject into the lumen of the pharynx. Thus the larynx, 
 by pushing out a semicircular fold of the mucous mem- 
 brane of the esophagus, narrows the lumen of that tube 
 so that it almost disappears in the median line at this 
 point and is forced to find room on the sides, where the 
 soft parts offer less resistance than the rigid spinal column. 
 This results in the formation of lateral extensions known 
 as sinus pyriformes (pirus, a pear), which can be seen in 
 the living subject with the laryngoscope, although in the 
 resting position they are flattened out by the pressure of 
 the adjacent soft parts. 
 
 In front, the larynx is covered by the muscles already 
 described, and more superficially by the sternohyoid 
 muscle and the cervical fascia. 
 
 The anterior border of the cricoid cartilage also gives 
 attachment to the thyroid fascia. Occasionally a third 
 lobe of the thyroid gland, known as the pyramidal lobe, 
 extends upward in front of the cricoid cartilage, while 
 the lateral plates are partially covered by the two prin- 
 cipal lobes of the gland. 
 
 It should be remembered that of the many lymph- 
 glands in the neck one, a small one, lies in front of the 
 larynx, immediately in front of the cricothyroid mem- 
 brane. The lymph-channels of the organ empty into the 
 submaxillary and cervical lymphatic glands. 
 
 Besides the muscles already mentioned there is a series 
 of smaller ones to afford movement of the several cartil- 
 
12 DISEASES OF THE LARYNX. 
 
 ages on each other — the intrinsic muscles. It will be 
 best to consider them in connection with their individual 
 actions. 
 
 The lateral and posterior crico-arytenoid muscles are 
 inserted into tlie outer angle of the base of the arytenoid 
 cartilages ; therefore known as the muscular process. The 
 lateral portions arise by a fan-shaped origin from the 
 sides of the arytenoid cartilages externally ; the posterior, 
 on the other hand, have their broad origin on the posterior 
 surfice of the same cartilage. The posterior muscles em- 
 brace the posterior and lateral portions of the muscular 
 processes ; the lateral muscles only the lateral. As the 
 center of the arytenoid cartilage must form the pivot, the 
 action of these muscles is clear. The lateral crico-aryte- 
 noid muscles draw the muscular process forward and out- 
 ward, so that the vocal process (anterior angle of the base 
 of the arytenoid cartilage) moves inward and backward ; 
 the posterior crico-arytenoid nmscles have a directly an- 
 tagonistic action. As the true vocal cords are attached to 
 the vocal process, they necessarily follow these move- 
 ments, and the muscles are therefore known respectively 
 as the adductors and abductors of the true vocal cords. 
 
 The transverse arytenoid muscle passes transversely 
 across between the two arytenoid cartilages in the middle 
 line, and by its contraction effects mesial approximation 
 of the two cartilages. When these muscles, assisted by 
 the lateral crico-arytcMioid muscles, are put on the stretch 
 they effectually fix the arytenoid cartilages, so that the 
 latter afford a fixed origin to another muscle, the thyro- 
 arytenoid, which again consists of two fasciculi, the infe- 
 rior or internal and superior or external. The inferior 
 thyro-arytenoid muscle lies within the membranous fold 
 known as the true vocal cord (and parallel with it), the 
 suj)eri<)r within the fold known as tlie ventricular band ; 
 botli are inserted into tlie lower half of the thyroid cartil- 
 age at the line of junction of the two alae. The action of 
 the muscles is, therefore, to ])ut these folds on tlie stretch 
 whenever botii their anterior and posterior points of attach- 
 
ANATOMY AND PHYSIOLOGY. 13 
 
 ment become fixed so that they cannot approach each 
 other. In order to fix the posterior origin^ it is further 
 necessary that the arytenoid cartilage be fixed to the cri- 
 coid by means of the mechanism already described. 
 
 The thyroid and cricoid cartilages move against each 
 other by means of the cricothyroid articulation. As this 
 is placed rather far back, the upper anterior border of the 
 thyroid traverses the greater distance at each excursion. 
 (It is immaterial whether the lower border of the thyroid 
 is drawn toward the upper border of the cricoid or the 
 contrary takes place.) Approximation is effected by con- 
 traction of the cricothyroid muscle, while the action of 
 the sternothyroid, as stated above, is directly antagonistic. 
 In order to stretch the folds of membrane attached to the 
 cartilages these two muscles must act together, for, if the 
 cricothyroid muscle alone were contracted, the cricoid 
 cartilage would simply follow the pull of that muscle ; 
 while if the sternothyroid alone were contracted, the 
 same would be true of the thyroid cartilage. 
 
 It follows, therefore, that passive stretching or tension 
 of the true vocal cords can take place only 
 
 (1) When the arytenoid cartilages are fixed to the cri- 
 coid cartilage ; 
 
 (2) When the cricoid cartilage is drawn backward and 
 the thyroid forward. 
 
 To eifect this the following muscles are required : 
 
 (1) The lateral crico-arytenoid, or the transverse ary- 
 tenoid muscles, or these two groups together; 
 
 (2) The cricothyroid and the sternothyroid muscles. 
 We should observe, at the outset, that the action of the 
 
 true vocal cords consists not only in passive tension, which 
 must necessarily accompany reduction in width, but also 
 in active contraction, which results in increased vndth, both 
 actions being required to give them the elasticity necessary 
 for voice-production. The latter is accomplished by con- 
 traction of the inferior thyro-arytenoid muscles, which are 
 able to act as soon as their origin and insertion are fixed 
 in the manner just described. 
 
14 
 
 DISEASES OF THE LARYNX. 
 
 In like manner the superior thyro-arytenoid muscles 
 contract the ventricular bands within which they are en- 
 closed ; this hajipens regularly in swallowing, but only 
 exceptionally in speaking. 
 
 The actions of the several muscles will be better under- 
 stood by the aid of the following diagram : 
 
 (^ 
 
 m 
 
 ct' 1 
 
 
 Id 
 
 
 J( 
 
 ^^a»**^'^*^ii«ssiii^^ 
 
 ct 
 
 St 
 
 
 Fig. 2. 
 
 A 
 
 8y thyroid cartilage, Aj cricoid cartilage, both cut in a 
 mesial sagittal plane. 6r, arytenoid cartilage, c^, direction 
 of pull of the cricothyroid muscle. Action : a})proxima- 
 tion of anterior inferior margin of thyroid, and upper 
 border of cricoid cartilages, ct', direction in which the 
 upper border of the thyroid is at the same time tilted for- 
 ward. 
 
 sf, direction of pull of the sternothyroid muscle. 
 Action : to depress tlie cricoid caTtilage. .s-^, direction in 
 which the upper border of the cricoid is at the same time 
 tilted backward. 
 
 tai, direction of ])idl of the inferior thyro-arytenoid. 
 
 Scliema (Fig. 3) of the action of muscles on the arytenoid 
 cartilage and on the true vocal cords. Both parts in hori- 
 zontal section and in respiratory position. The cords are 
 seen to consist of a ligamentous, and a cartilaginous por- 
 tion {/d and ^jc). According to their respective functions, 
 
ANATOMY AND PHYSIOLOGY. 
 
 15 
 
 the middle part of the cartilage is called the vocal process, 
 the lateral portion the muscular process (jw andpwt). 
 
 Fig. 3. 
 
 /, direction of the contraction of the inferior thyro-ary- 
 tenoid muscles. Action : tension of the edges of the true 
 vocal cords. 
 
 cl, direction of pull of the lateral crico-arytenoid muscles. 
 Action : rotation of arytenoid cartilage about the articu- 
 lation which is in the centre ; adduction of the true vocal 
 cords. 
 
 p (Fig. 3), direction of pull of the posterior crico-aryte- 
 
 noid muscles. Action : rotation in opposite directions ; 
 abduction of the true vocal cords. 
 
16 DISEASES OE THE LARYNX. 
 
 t (Fig. 3), direction of pull of the transverse arytenoid 
 muscle. Action : horizontal approximation of arytenoid 
 cartilages without rotation. 
 
 Schema of the combined action of the adductor and 
 transverse arytenoid muscles : rotation inward of aryte- 
 noid cartilages until the vocal processes come in contact 
 with each other and even the posterior portions of the 
 cartilages are approximated, resulting in closure of the 
 glottis cartilaginea. The glottis ligamentosa is still open. 
 Closure of the latter is accomplished only by the codper- 
 ation of the internal thyro-arytenoid muscles (see Fig. 7). 
 
 The inner edges of the cords still present a wavy out- 
 line ; that is, they are slack, for they cannot be stretched 
 taut until both points of attachment are fixed in opposite 
 directions. Fixation of the posterior point (arytenoid 
 cartikige) has already been effected by the action of the 
 
 Fig. 7. 
 
 above muscles ; to fix the anterior jioint (thyroid cartilage) 
 the cricothyroid muscle must be contracted. Both parts 
 of the glottis are now seen to be closed and the true vocal 
 (;ords are taut (Fig. 8). 
 
 The movements of the arytenoid cartilages in the ])er- 
 pendicular plane are not important for a study of their 
 
ANATOMY AND PHYSIOLOGY. 17 
 
 function. These movements result from the irregular 
 curve of the crico-arytenoid articulation, which is highest 
 at the center and slopes away outward and backward, and 
 inward and forward, so that the apices of the cartilages 
 are brought into higher or lower planes during motion. 
 
 The covering of the larynx consists of mucous mem- 
 brane of varying thickness, containing acinous glands, 
 found chiefly where the submucosa is thick and loosely 
 attached to the underlying tissue. They are especially 
 numerous about the upper margin of the posterior surface 
 of the larynx, in the ventricular bands, and in the ventri- 
 cles — in fact, in all those parts which are most concerned 
 in deglutition and phonation. The mucous membrane is 
 closely adherent to the free edges of the true vocal cords, 
 whereby it is enabled to take part in their vibrations. 
 Here and on the under surface the mucous membrane 
 forms thin strips, running for the most part in the sagittal 
 plane, in some places forming a network which, in vertical 
 transverse sections, appears as papillae (see Plate 36, 
 Fig. 3). It is important to know this so as to avoid mis- 
 taking these structures for pathological formations, and 
 also because they explain why papillary neoplasms are so 
 apt to form in this situation. Their similarity to the 
 papillae of the skin is very marked, and the propensity of 
 both varieties to form horny epithelial warts is therefore 
 readily understood. 
 
 In the epiglottis we also find true lymph-follicles, 
 which we must be careful not to confound with miliary 
 tubercles, if they are at all well developed. 
 
 2 
 
18 DISEASES OF THE LARYNX. 
 
 The upper layer of the mucous membrane is composed 
 of epithelium, as elsewhere. On the parts nearest the 
 fauces it consists of stratified squamous cells in layers of 
 varying thickness. Squamous epithelium, then, is found 
 on both surfaces of the epiglottis, on the upper surfaces 
 of the aryepiglottidean folds — in short, on what is known 
 as' the superior aperture of the larynx, and also extends 
 from the central portion of the arytenoid cartilages to the 
 true vocal cords. On the edges of the cords the mucous 
 membrane consists of a smooth layer which fills up the 
 interstices ; sometimes it follows the eles'ations and de- 
 pressions, so as still more to simulate the appearance of 
 papillary neoplasms. The remaining parts of the mucous 
 membrane are covered with the characteristic ciliated 
 columnar epithelium of the air-passages. 
 
 The innervation is supplied exclusively by the pneumo- 
 gastric. One branch, the superior laryngeal nerve, is 
 given off opposite the angle of the jaw, and divides above 
 the hyoid bone into two branches : the external laryngeal 
 branch, containing motor fibers, which descends along the 
 side of the thyroid cartilage to supply the thyro-epiglot- 
 tideus and cricothyroid muscles ; and the internal laryn- 
 geal branch, which pierces the thyrohyoid membrane 
 about the middle of the upper border of the thyroid car- 
 tilage and supplies the entire mucous membrane of the 
 larynx with sensory fibers. 
 
 The second branch, the inferior or recurrent laryngeal 
 nerve, follows a different course on the two sides of the 
 body. The right recurrent nerve arises at the level, and 
 in front, of the right subclavian artery, around which it 
 winds from before backward, ascends between the trachea 
 and the esophagus, enters the larynx at the lower border of 
 the cricoid cartilage and distributes its fibers to the muscles. 
 
 The left recurrent arises at the level, and in front, of 
 the arch of the aorta, winds around this structure, also 
 from before backward, and ascends a little in front of its 
 fellow — that is, rather beside than behind the trachea — to 
 enter the larynx in the same way as the right recurrent. 
 
METHODS OF EXAMINATION. 19 
 
 This condition explains why aneurysm of the aorta 
 preferably affects the left, and cancer of the esophagus 
 the right recurrent nerve. 
 
 The recurrent laryngeal nerves supply all the other 
 muscles of the larynx (in addition to those already men- 
 tioned) ; they may supply the thyro-epiglottideus muscle 
 instead of the superior laryngeal nerves, just as the latter 
 in some cases supply the transverse arytenoid muscle in- 
 stead of the recurrent laryngeal nerves. 
 
 The fibers of the recurrent laryngeal nerves present 
 some differences in their physiological action, some su2)ply- 
 ing the muscles which effect closure of the glottis and 
 stretching of the true vocal cords, while others supply 
 the dilators of the glottis, the posterior crico-arytenoid 
 muscles. In lesions of the nerve-trunk the latter fibers 
 suffer first, so that we have at first paralysis of the ab- 
 ductors and secondarily paralysis of the adductors. 
 
 The sensibility of the larynx varies in different situa- 
 tions ; it is greatest in the interarytenoid space ; hence 
 diseases of this part are so troublesome on account of the 
 intense pain and constant irritation and desire to cough ; 
 even superficial irritation in this region may give rise to 
 attacks of convulsive cough (see Plate 18, Fig. 2). 
 
 The center which presides over the movements of the 
 larynx is found, at least in animals, at the base of the 
 ascending frontal convolution. From this point the fibers 
 run through the inner capsule to the medulla oblongata. 
 Systemic diseases involving these areas must therefore 
 have an injurious effect on the action of the larynx. 
 
 METHODS OF EXAMINATION. 
 
 (1) INDIRECT LARYNGOSCOPY WITH THE MIRROR. 
 
 The laryngoscopic image, as is well known, is inverted 
 or, in reality, only half inverted, since in the mirror 
 which is held at an angle of about 45 degrees to the plane 
 
20 
 
 DISEASES OF THE LARYNX. 
 
 of the aperture of the larynx, the anterior parts appear 
 above, and the posterior parts below. It is only when 
 the image is represented on paper that it appears com- 
 pletely inverted, the front corresponding to the back, and 
 vice verna. 
 
 U.s 
 
 c.v. 
 
 Fig. 9 shows the laryngoscopic image of a normal 
 larynx as it appears on paper, the movable parts in the 
 position which they occupy during respiration. It also 
 shows the anatomy of the parts in the living subject. 
 
 E., epiglottis ; in the middle is seen its posterior surface, 
 which is rolled from behind forward and therefore looks 
 uj)ward ; on each side the surface of the tongue is covered 
 witli blood-vessels. This is always taken as tlie starting- 
 ])()int in laryngoscopy, the directions being given accord- 
 ing to the actual relations of the parts, not the one that 
 apj)ears in the image. In front of the epiglottis the val- 
 lecula ( V.) extends to the tongue, Z., interrupted at its 
 center by the glosso-e])iglottidean ligament, Lg.e. 
 
 The posterior margin of the cavity of the larynx 
 begins at the sides witli tlie aryteno-epiglottidean folds, 
 Ld.c, wliich invest the cartilages of Wrisberg and Santo- 
 rini. The arytenoid cartilages lie hidden beneath them, 
 and between these cartilages tlie mucous membrane dips 
 down into the interarytcnoid sj)ace. For the sake of 
 brevity in describing the relations of parts, we speak only 
 
METHODS OF EXAMINATION. 21 
 
 of the arytenoid cartilages, ignoring the cuneiform, which 
 merely follow the movements of the former passively. 
 
 The external surface of the posterior wall forms the 
 anterior boundary of the entrance to the esophagus ; at 
 the sides the latter opens into the sinus pyriformes, s.p. 
 
 Within the larynx the glottis, g, extends between the 
 true vocal cords, c.v., the ligamentous portion, p.L, form- 
 ing the anterior two thirds, the cartilaginous portion, ^>.c., 
 the posterior third ; the lumen of the glottis, of course, 
 varies with the position of the vocal cords. 
 
 Above the true vocal cords (whose normal color is a 
 dull yellowish-white) lie the ventricular bands, ligamenta 
 thyroidea superiora, l.t.s., their under surface projecting 
 into the ventricle of the larynx, v. J}!, (ventricle of Mor- 
 gagni). 
 
 Marked prominence of the ventricular bands produces 
 apparent narrowing of the true vocal cords (Plate 3, 
 Fig. 1). 
 
 V.3L 
 
 Fig. 10. 
 
 If, on the contrary, they recede unduly, the interior of 
 the ventricle, v.3f., is exposed. The anterior surface of 
 the cricoid cartilage can also be seen in this image, and, 
 through the glottis, the front of the trachea and its rings. 
 If the glottis is opened exceptionally wide, the deepest 
 parts of the trachea and the bifurcation come into view 
 (Plate 1, Fig. 2) ; sometimes it is even possible to look 
 into the bronchi. On the other hand, part of the larynx 
 is sometimes hidden, especially in children, in whom the 
 epiglottis is frequently curved in the shape of an i2, so 
 that one has difficulty in seeing the true vocal cords even 
 
22 
 
 DISEASES OF THE LARYNX. 
 
 (Plate 2, Fig. 1). In some cases the larynx may be so 
 obliquely placed — either from pathological causes or as an 
 individual peculiarity — that it partly disappears under the 
 epiglottis (Plate 2, Fig. 2); in others, abnormal growths 
 may cut off part of the image above (Plate 2, Fig. 3 ; 
 Plate 16, Fig. 1) and behind (Fig. 15). 
 
 Ordinarily the light strikes the larynx from behind ; 
 but in Killian's posture, where the operator applies the 
 mirror from below, making the patient bend well forward, 
 the image is taken more from the front. Consequently 
 more is seen of the lingual surface of the epiglottis and 
 less of the anterior portions of the true vocal cords ; on 
 the other hand, their posterior attachment can be plainly 
 seen, as well as the entire front of the cricoid cartilage, 
 but no part of its posterior surface (Plate 1, Fig. 1). 
 
 p.e. 
 
 Fig. 11. 
 
 In phonation (Fig. 11) the epiglottis is raised in front, 
 so as to bring the petiolus, p.e., into view. The arytenoid 
 cartilages approach each other, so that the interarytenoid 
 space almost disappears ; the true and the false vocal 
 cords also approach the median line and lie in so-called 
 juxtaposition. The glottis is reduced to a narrow, spindle- 
 shaped chink which is barely visible, the posterior ex- 
 tremity coming in relation with the vocal processes. This 
 is the image of the so-called chest-voice. 
 
 In the production of head or falsetto notes the glottis is 
 even more tightly closed beliind, but gapes wide apart in 
 
METHODS OF EXAMINATION. 
 
 23 
 
 front (Figs. 12 and 13). This posterior closure reaches 
 its highest degree in the production of so-called abdom- 
 inal notes — ventriloquist's voice (Fig. 14), in which the 
 convulsive contraction of the adductors may even result 
 
 
 Fig. 12. 
 
 Fig. 13. 
 
 in overlapping of the true vocal cords in their posterior 
 half. At the same time the arytenoid cartilages are 
 pressed tightly together, and the true vocal cords appear 
 somewhat narrower on account of the projection of the 
 inner edges of the ventricular bands. 
 
 If for any mechanical reason the true vocal cords can- 
 not be stretched, it occasionally happens that the superior 
 thyro-arytenoid muscles contract violently and stretch the 
 
 ventricular bands to such a degree that their inner edges 
 are thrown into vibration by the air-current — resulting in 
 so-called false vocal- cord phonation ; the true vocal cords 
 are, of course, entirely concealed. 
 
24 DISEASES OF THE LARYNX. 
 
 (2) DIRECT LARYNGOSCOPY. 
 
 This method was introduced by Kirstein, and has the 
 advantage that the larynx is viewed directly. A specially 
 constructed, grooved compressor is used to press the tongue 
 forward and exclude it from the field of vision, the patient 
 holding his head as high and as far back as possible. 
 
 When the method can be used at all, it has the advan- 
 tage of showing more of the anterior surface of the pos- 
 terior wall than is the case with the mirror. It is also 
 free from the objection of having the image partly ob- 
 scured by mucus and foreign material, a factor of some 
 importance in the examination of children and uncon- 
 scious patients ; indeed, for the latter the method will 
 probably always be indispensable. For the rest, its indi- 
 cation and its application are still in the experimental stage. 
 
 Whatever method of examination be used, reflected 
 light is preferable to direct light, which is always more or 
 less cut off by the head of the operator ; we therefore use 
 a reflector which is fastened either to the operator's fore- 
 head or to a stand constructed for the purpose. 
 
 Any strong light will do for the source ; the choice will 
 therefore depend on the conveniences at hand. One dis- 
 advantage which is common to all is the color ; it is least 
 in the electric arc light or in Auer's gas-burner.^ The 
 latter was used for all the laryngeal images illustrated in 
 this work. If it is especially desirable to obtain the nat- 
 ural color in any particular case, or if, in general, sunlight 
 is easily obtainable, it will be found to be decidedly the 
 best light. In order, however, to minimize the changes 
 incident to the diflerent times of the day, and at the same 
 time to diminish the glare, it will be best to let the sun- 
 light fall first on a large reflector, after it has passed 
 through the window^, and from that by the ordinary re- 
 flector into the larynx. 
 
 ^ [The Welsbach light, the mantle being pnre white, nsed in con- 
 junction with a condensing lens, is certainly unexcelled, if not nn- 
 ecuialled, in its color and illuminating power, by any other artificial 
 source of light. — Ed.] 
 
METHODS OF EXAMINATION. 25 
 
 Laryngoscopy is, of course, the principal method of 
 examining the larynx, as it gives results which can be 
 studied directly ; still we must not entirely neglect other 
 methods whicli formerly constituted the only means of 
 arriving at a diagnosis and even now have not entirely 
 lost their value. We refer to external inspection, 'palpa- 
 tion, and auscultation of the voice and possible adventi- 
 tious sounds. 
 
 (3) INSPECTION. 
 
 By inspection we note unusual shape^ and especially 
 displacement of the larynx^ usually due to lateral pressure 
 by tumors in the neck. The cartilages are sometimes dis- 
 placed far to one side, or even close to the angle of the 
 jaw, the line connecting the upper notch of the thyroid 
 with the center of the lower border being oblique instead 
 of perpendicular. 
 
 (4) PALPATION. 
 
 Palpation informs us whether the two halves of the 
 thyroid cartilage are symmetrical. It sometimes happens 
 — as an abnormality, however — that one half is pushed 
 back under the other, with the result that, instead of a 
 well-defined line of junction in front, we feel two surfaces 
 meeting the median line of the neck at different angles, 
 one overlapping the other, so that the finger sinks into an 
 obtuse angle facing sideways. 
 
 Irregularities on the surfaces of the cartilages are 
 more significant, the surfaces being normally smooth. 
 Such irregularities may indicate a perichondritic or a 
 chondritic process, or the effects of one ; sometimes tumors, 
 especially malignant growths, betray their presence in this 
 way : here, as elsewhere, cancer often manifests itself in 
 prominent, nodular, dense infiltrations. If, however, a 
 marked condition of this kind be felt by the examiner, he 
 should not immediately pronounce the tumor a malignant 
 growth, for syphilitic perichondritis presents a very simi- 
 lar picture ; and if no signs, or, at least, no positive signs, 
 are found within the larynx, it will be advisable, as a 
 
26 DISEASES OF THE LARYNX. 
 
 matter of routine, to take that possibility into considera- 
 tion. Miraculous cures are sometimes ef!*ected by such 
 " perfunctory '^ reasoning and corresponding line of treat- 
 ment. 
 
 Under certain conditions palpation may play a promi- 
 nent part by enabling one to determine paralyses which 
 could not otherwise be recognized. In total paralysis of 
 the recurrent nerve, or at least in complete phonatory 
 paralysis, the normal vibration of the thyroid cartilage 
 may be absent on the affected side ; the value of palpa- 
 tion is obvious in such cases, especially if laryngoscopy is 
 impossible. 
 
 In paralysis of the cricothyroid muscle the normal 
 vibration of the cricothyroid membrane and the approxi- 
 mation of the lower border of the thyroid and upper 
 border of the cricoid cartilages, normally felt in phona- 
 tion, are absent. 
 
 If the posterior portion of the upper border of the 
 thyroid is compressed and the entire organ moved about 
 with the fingers, crepitation, produced by the rubbing of 
 the posterior wall against the spinal column, is felt. This 
 crepitation is distinguished from pathological crepitation 
 by its disappearing if, during the movement, the entire 
 larynx is drawn forward. The phenomenon occurs path- 
 ologically, so that it can be both felt and heard, in arthritic 
 ])rocesses affecting the crico-arytenoidean articulation. 
 (For details see below.) 
 
 It seems superfluous to say that sensitive spots must 
 always be felt for ; it is important, however, to warn 
 against pronouncing as pathological the extreme sensitive- 
 ness of the superior laryngeal nerves, which enter the 
 larynx at the center of the upper lateral border of the 
 cricoid cartilage. 
 
 (5) AUSCULTATION 
 
 nowadays is practically confined to the sounds heard by 
 the unaided ear in respiration and in phonation. Respi- 
 
METHODS OF EXAMINATION. 27 
 
 ration is normally noiseless, but respiratory sounds are 
 heard whenever the lumen of the upper air-passages be- 
 comes constricted. The term stridor is applied to these 
 sounds. Tliey are usually long drawn out, and, if there 
 is marked obstruction, quite loud ; they are heard best in 
 inspiration, especially in laryngeal stenoses, but may also 
 be audible in expiration. The reason of this phenomenon 
 probably is that air-hunger in stenosis induces more in- 
 tense inspiration, while the excessive CO^ production is 
 not so distressing, and therefore does not excite expiration 
 to the same degree. (This difference, of course, disappears 
 in severe stenoses, which tend to accelerate even the slower 
 expiratory blast.) 
 
 We must not forget that it is also possible for the mov- 
 able parts about the aperture of the larynx to be drawn 
 down into the constricted lumen during inspiration (by a 
 sort of suction) ; while, of course, expiration can only 
 blow them out into the open space beyond. 
 
 It happens not infrequently that the respiratory efforts 
 lead to perverse innervation of the larynx and consequent 
 approximation of the true vocal cords, which only aggra- 
 vates the stenosis. Pure expiratory stridor is probably 
 always due to such false innervation. 
 
 Although it may be possible to distinguish between 
 laryngeal and tracheal stenosis by direct auscultation with 
 the stethoscope, it is both easier and surer to make the 
 diagnosis by direct inspection. 
 
 In rare cases a rattling noise is heard in respiration, or 
 even in phonation, produced by some obstruction to the 
 air-current — a foreign body free to move up and down, a 
 very movable tumor, or movable secretion. 
 
 It is important to note the voice ; a practised ear can 
 make a diagnosis by the voice alone. Complete aphonia, 
 in which the patient cannot speak above a whisper, occurs 
 in paralysis of the muscles which close the glottis and 
 stretch the cords, in nervous or in muscular affections, in 
 paralysis of both recurrent nerves, in violent acute catarrh, 
 and in destruction or rigid infiltration of the muscles of 
 
28 DISEASES OF THE LARYNX. 
 
 the cords from any cause. Rough (raucous), croaking, or 
 gruntiug sounds are heard mostly in tertiary syphilis; a 
 hoarse, discordant voice, especially in the second stage of 
 the disease. In subacute and clironic catarrh the dys- 
 phonia often alternates with better, more sonorous tones. 
 There are, besides, many minor shades of difference. 
 
 The examination is by no means complete even after 
 laryngoscopy and all the other diagnostic methods of as- 
 certaining the condition of the larynx have been ex- 
 hausted. Only a few unimportant affections of the larynx 
 are independent of systemic disease or of disease of 
 neighboring organs. 
 
 Since, then, the interpretation of doubtful cases will 
 always depend largely on examination of the contiguous 
 parts of the air-passages, especially the fauces, of the ali- 
 mentary canal, and of the entire body, it is always best, 
 in the absence of a very large experience, to make a care- 
 fid general examination in order to check even such local 
 findings as seem to be perfectly clear and easy to explain ; 
 not infrequently a preconc€'ived opinion concerning the 
 primary cause of the disease is in this way shown to be 
 erroneous. The examination cannot be too thorough : in 
 no other organ of the body is disease so dependent on the 
 general condition as in the larynx, and, conversely, the 
 finding of certain conditions in the larynx often throws 
 light on latent or obscure processes in the entire organism. 
 The importance of these remarks will be better appre- 
 ciated after a careful study of the histories accompanying 
 the ])lates. 
 
 PRACTICAL HINTS FOR THE EXAMINATION. 
 
 A perfect technique in the examination of the larynx 
 in the living subject is only achieved by constant prac- 
 tice, and it is not to be sup])osed that any one would 
 exj)ect to learn it by theoretical instruction ; we therefore 
 assume that the reader has often made the examination 
 on dead and living sulyects. As the latter usually com- 
 
METHODS OF EXAMINATION. 29 
 
 prise the individuals used in clinics, who have been drilled 
 for passive laryngoscopy, and the few patients who, from 
 having been through the ordeal so often, are readily ex- 
 amined even by beginners, we need hardly say that the 
 difficulties encountered in private practice are incompara- 
 bly greater ; in most cases the physician is confronted 
 with organs which have never been examined and are ex- 
 tremely sensitive. In order to enable the beginner to 
 overcome these difficulties a few jwactical hints may not 
 be unAvelcome. 
 
 In the first place, it is always better to make the exam- 
 ination before meals ; there is less danger of vomiting 
 and, if it does occur, it will do less damage to either 
 party. 
 
 Have the patient jwotnide the tongue actively, not draw 
 it out with his fingers ; and then hold it yourself rather 
 than risk the annoyance of having the patient release it 
 at the most interesting moment. 
 
 If the tongue is so thick, or the lower incisors are so 
 sharp, that there is danger of excessive friction of, or even 
 injury to, the frenum, the soft parts should be protected 
 by placing a thick strip of cotton over the teeth. If 
 this is put in place with a forceps after the tongue is 
 drawn forward and before it is drawn down, it will not 
 slip off. 
 
 If the root of the tongue bulges upward, it will often 
 have to be pressed down with a spatula (a Tiirck's, if 
 possible) before a view of the uvula can be obtained. 
 Compress gradually, not with a sudden violent movement, 
 using, however, considerable force: firm pressure is easily 
 borne, whereas timid little dabs only tickle the organ. 
 This precaution, by the way, should also be observed in 
 laryngoscopy with the spatula after Kirstein. 
 
 The mirror is to be held gently but firmly against the 
 uvula ; not above it or to one side. If it slips past the 
 mirror, use a larger one ; in general, the largest possible 
 mirror is always advisable because the light is stronger 
 and the image larger. 
 
30 DISEASES OF THE LARYNX. 
 
 If the patient chokes before the mirror is in place, or 
 even at the first touch, make him say '* a " as in " fate '' 
 (not ^^ ah ^') very loud and long, and introduce the mirror 
 during phonation. 
 
 It is absolutely impossible to see the image if the patient 
 holds his breath convulsively : the larynx is drawn high up 
 under the root of the tongue, the pillars of the fauces 
 are stretched to the utmost, and the glottis is closed. 
 Many patients do this as soon as they open their mouths 
 and put out their tongues. In such cases, before attempt- 
 ing to introduce the mirror, have the patient take long, 
 deep breaths with the mouth in the proper position to 
 receive the mirror, until the respiration is no longer dis- 
 turbed by the introduction of the instrument. Psychical 
 irritability is sometimes diminished by dosing the eyes, but 
 they must not be shut convulsively, lest it cause the oral 
 cavity to become narrower. 
 
 Remember that the tendency to choke is constantly 
 aggravated by accumulation of saliva from excessive re- 
 flex secretion ; the patient should therefore be allowed to 
 expectorate, ivithout hawking, as that only aggravates re- 
 flex sensibility. By this means and by suitable encour- 
 agement one can also prevent constant swallowing, which 
 is so troublesome and dims the mirror every time. 
 
 Never, not even for practice, have the patient say ^^ah," 
 but always "a,'' as the epiglottis is only raised in high- 
 pitched notes, and often a mere trial-examination affords 
 a satisfactory view of the larynx. 
 
 [f, as happens in rare instances, the epiglottis even then 
 fails to rise and exj)ose the larynx, a slight pressure and 
 forward pull with a long spatula (FrankePs, for instance) 
 on the median fold of the glosso-epiglottidean ligament 
 will bring about the desired result. 
 
 Choking and vomiting are sometimes so excessive that 
 they can only be overcome by painting the parts to be 
 toucihed with cocain. A pledget of cotton the size of a 
 pea does not hold enough of the 10 per cent, solution to 
 make an application to the mucous membrane at all dan- 
 
METHODS OF EXAMINATION. 31 
 
 gerous.^ At least three minutes should be allowed for the 
 anesthetic to take effect : if it fails to act, it is usually 
 because there has not been time enough. 
 
 The choking depends more on subjective resistance 
 than on objective impossibility to overcome the irritation : 
 many patients will only become quiet after a touch Avith a 
 probe has convinced them that anesthesia is complete. 
 
 The reflector should always be held in front of the eyes, 
 not merely on the forehead, else a part of the light is sure 
 to be intercepted by the upper lip. Use both eyes, not 
 only the one behind the hole. It is not enough to examine 
 the phonatory image only ; the condition in respiration 
 should also be studied, although it is harder to see than 
 the former. 
 
 If the case is at all doubtful, do not neglect to ascertain 
 the sensibility by testing with a probe. Remember that 
 the larynx forms only a part of the air-tube, and that the 
 lungs and trachea, as well as the upper passages, the nose 
 and throat, may furnish as important data for the diagno- 
 sis as the heart, the abdomen, the nervous system, and the 
 urine. Above all, bear in mind that disease of one organ 
 is not always isolated, and that you are first a physician 
 and then a laryngologist. 
 
 As regards treatment, I would add a warning against 
 annoying tlie patient more than the whole trouble is worth. 
 Often the patient cares less about getting rid of a slight 
 annoyance than the physician, who feels himself in duty 
 bound either by ambition or the love of science. Let us 
 be kind and noble as well as helpful ! 
 
 GENERAL REMARKS ON THE CAUSES AND TREAT- 
 MENT OF DISEASES OF THE LARYNX. 
 
 Painting the throat and gargling will not cure a dis- 
 eased larynx, but suitable general treatment, even without 
 
 ^ [Putting aside the question of danger, we do not think it necessary 
 to use a sohition of such percentage. One of 4 per cent, strength will 
 produce all the anesthesia necessary to make the examination success- 
 fully.— Ed.] 
 
32 DISEASES OF THE LARYNX. 
 
 local applications, may accomplish a good deal, and it is 
 the latter that is too often neglected. A patient suffering 
 from laryngeal trouble should not be allowed to talk, any 
 more than a man with a sore foot is allowed to walk : the 
 first requisite for the cure of an inflamed or injured organ 
 is absolute rest, which incidentally removes one of the 
 commonest causes, overexertion. Loud talking should, 
 therefore, be forbidden altogetlier ; the patient should 
 converse as little as possible and always in a whisper.^ 
 The only exceptions are certain psychical or essential 
 paralyses, when it is desired to restore the functional 
 activity of the organ. 
 
 Smoking and drinking, and the eating of highly seasoned 
 food, must be restricted or prohibited entirely, at least in 
 the acute and subacute stages. 
 
 The digestion must be regulated ; this is of no small 
 importance, as constipation tends to aggravate peripheral 
 hyperemias. 
 
 Cough due to disease of higher or deeper adjoining 
 organs (nose and throat, lungs and bronchi) must be 
 checked as much as possible, for it is one of the worst 
 meclianical irritants of the larynx. 
 
 Still more injurious is the hawking so often excited by 
 disturbances of secretion in the upper air-passages (nose 
 and nasopharynx). Combined with the dri])ping of ])us 
 and mucus on the laryux from above, it is one of the 
 commonest causes of the various forms of " chronic laryn- 
 geal catarrh." The first step in the treatment of this dis- 
 ease, therefore, should be a careful examination of the 
 upper organs ; often the entire treatment may consist ex- 
 clusively in removing anomalies in those organs. 
 • Local treatment is indicated ifrst, in the comparatively 
 rare primary diseases of the larynx ; second 1 1/, whenever 
 mechanical alterations require mechanical interference. 
 
 Liquids, especially astringents, should be applied di- 
 
 ^ [If even tlie privilege of wliisperinj? is permitted, it is too often 
 apt to be abused. Besides, whispering is but little, if at all, less ob- 
 jectionable than actual phonation. — Ed.] 
 
METHODS OF EXAM I NAT f ON. 33 
 
 rectly by means of a brush or syringe ; inhalations are 
 generally useless, titrate of silver in 2-5 |)er eent. solu- 
 tion, 2-4 p(!r eent. earbolie-ae,i(l solution, and eon(;ontraterl 
 laetic aeid are used.^ lehtFiyol is an exeelient remedy in 
 secondary catarrh and in scab-formations : Jj^. Ammon. 
 sulpho-ichthyol., 10.0; glye(;rin., 40.0; ]. menth. pip., 
 gtt. V. It is best aj>plied with a pledget of cotton at the 
 end r>f an applicator; the pledget is thrown away and 
 the applicator boiled after using. Spraying is not neces- 
 sary, as a rule ; its use is more a matter of taste. 
 
 The pledget of cotton is pressed lightly against the epi- 
 glottis from behind, so that the fluid drips down ; or it is 
 introdii(;ed into the open glottis during respiration, when 
 its contents are squeezed out by the approximation of the 
 cords. Painting — that is, m(!e,}i;ini",;d rubbing in — is in- 
 jurious, and should be avoid • 1 " pt in the treatment of 
 ulcers with (iurbolic ncid or- i,!"i:" j.cid, when it should be 
 done energetically and thoroughly. 
 
 For an astringent dusting-powder use alum 1 : 10, 
 with sach. lact. or amyl trit. For disinfectants the iodin 
 preparations, iodoform and ioflol, wvc ])rine,ipa,lly used. 
 
 Dusting with these and other sitr)ilar powders is confined 
 to open ulcers ; in general, it is to be remembered that 
 deep-seated and grave diseases, esf)ecially tiibercidosis, 
 will not yield to such superficial and wliolly inaderpiat^ 
 treatment, f)ut demand more energetic destructive meas- 
 ures. The mildest form is cauterization. Lnnar canstic 
 fusfid u{)on the end of a [)robe, or trichlorar;etic acid, will 
 serve for (;auterizing su|)erficial ulcers of every kind, and 
 even for more energetic procedures against hypertrophy 
 of the e[)ithelium, so common in chronic inflafnmations. 
 
 Klf'drolyHlH is a more drastic nuiasure. The; duration 
 as well as the intc^nsity of the dose can be reguhited. A 
 current of 15-20 ma. for five minutes is the usual dose. 
 
 ' [For the less experienced reader it may be well to state that the 
 use of lactic acid liad better be begun with a oO per cent, solution and 
 the strength gradually inci-eased. For the earlier ai)plications previous 
 cocainization of the larynx will be a wise precaution. — Fd.] 
 
 3 
 
34 DISEASES OF THE LARYNX. 
 
 The requisites are an amperemeter and rheostat to measure 
 the strencrth of the current and to introduce and remove 
 it without causing pain. Ten to fifteen cells suffice for its 
 generation. It is applied with the double needle, stabbing 
 deeply after the parts have been well cocainized. It is 
 best to screw the needle directly to the conducting wires. 
 The treatment is used to remove secondary epithelial 
 liyperplasiffi (warts, '^ pachydermia "), and especially in 
 small tuberculous infiltrations ; sometimes also to melt out 
 the base of a previously extirpated ulcer. 
 
 Gahanocautery is still more heroic. The sharp-pointed 
 stabbing cautery is a powerful tissue-destroyer. It is 
 therefore properly used in nodular tuberculosis and in 
 deep ulcers. As the reaction is more severe than in elec- 
 trolysis, great care must be exercised in its application ; 
 only the diseased parts must be touched, and one must be 
 especially careful to avoid burning the surface. The loop 
 may be successfully used to remove pedunculated, hard 
 tumors or such as threaten hemorrhage. 
 
 Sharp instruments are used to separate or excise diseased 
 parts. 
 
 Operating-knives, either sharp-pointed or blunt, with a 
 cutting-edge, are employed to make incisions in edematous 
 or purulent swellings and to remove flat ulcers. 
 
 Curets, single and double, Heryng's or Krause's, are 
 used to remove diseased parts from healthy tissue, espe- 
 cially in tuberculosis, and to expose deeper infiltrations so 
 that they may be cast off more easily. 
 
 If curettage is resorted to at all, it must be done thor- 
 oughly, down to the healthy tissue ; it is, therefore, indi- 
 cated only when there is reasonable hope of success. 
 Furthermore, the operation should be exhaustive, and 
 completed at one sitting, not split up into innumerable 
 little pickings. Many failures are attributable to such 
 senseless and ineffectual methods. 
 
 The use of the numerous instruments devised for ex- 
 tirpating tumors (loops, tonsillotomes, forceps, annular 
 knives, etc.) can only be learnt by practice. 
 
METHODS OF EXAMINATION. 35 
 
 In all kinds of instruments the shaft should be bent to 
 the riglit near the handle, so tliat the operator's hand does 
 not encroach on the field oF vision. The handles them- 
 selves should be flexible. Frequently it is impossible to 
 reach the deeper and more remote parts of the larynx 
 with certainty, unless the handle of the instrument has 
 been previously bent in the proper direction according to 
 measurements obtained by means of a sound, because the 
 oral cavity limits the play of the instrument. 
 
 Muscular and nervous paralyses occasionally require 
 electrical treatment to prevent the occurrence of atrophy ; 
 peripheral nerve-lesions, if amenable to treatment at all, 
 also appear to be favorably influenced by electricity. 
 Whether the electricity is applied to the larynx internally 
 or externally is a matter of taste. A faradic current, 
 strong enough to produce poAverful, but not painful, con- 
 tractions in the tongue, is applied for from one-half to one 
 minute once daily ; or a galvanic current of 5 ma. in- 
 ternally and 10-15 ma. externally, from one to three 
 minutes, with change of poles and interruption. Great 
 care is necessary to avoid burning the delicate mucous 
 membrane ; therefore use broad electrodes. 
 
 To remove transient or chronic stenoses we employ in- 
 tubation after O'Dwyer, dilatation with bougies or tin 
 bolts after Schrotter (the latter only after tracheotomy), 
 and finally the insertion of chimney-sha])ed cannulse after 
 Mikulicz in thyreotomized larynges. But good results 
 are often obtained without these complicated appliances in 
 less marked stenoses and membranes, by forcing successive 
 tampons of increasing thickness through them, especially 
 if the treatment can be assisted by bloody dilatation. 
 
PATHOLOGY AND TREATMENT. 
 
 I. ACUTE INFLAMMATIONS. 
 
 1. SUPERFICIAL INFLAMMATIONS. 
 (a) Idiopathic. 
 
 This division includes all inflammations which directly 
 attack the larynx in consequence of unfavorable external 
 influences, tliough they may be synchronous with disease 
 in other parts of tlie body. 
 
 First in order is simple catarrh, a frequent accompani- 
 ment of coryza. 
 
 ;^tiology. — Catching cold, especially if the patient 
 forces his voice in defiance of noticeable impairment, or 
 persists in the use of tobacco and alcoliol. Inhaling irri- 
 tant gases or dust (street-dust in w^indy weather, brick- 
 dust, dust of clu'omic acid, spices, and similar materials 
 in factories and warehouses). 
 
 Symptoms. — Dryness of the throat, slight difficulty in 
 swallowing and in speaking, hoarseness (rough, deep v(^ice) 
 or complete aphonia. At first there is slight cough, which 
 soon becomes more severe ; it is dry and irritating, and 
 secretion is still scanty ; later, when the secretion has be- 
 come looser and more copious, it is brought up more easily 
 and with less irritation, at the same time slight rales may 
 be heard. The breathing is shallow, as deep inspiration 
 excites cough. The subjective symptoms vary a good 
 deal according to the principal seat of the disease. 
 
 lyaryngeal Image. — Inflammation and slight swell- 
 ing of the entire mucous membrane or of single areas. Later 
 a glairy secretion is seen, and, rarely, toward the close, a 
 
 36 
 
ACUTE INFLAMMATIONS. 37 
 
 yellowish secretion. Depending upon the seat of the in- 
 flammation, the epiglottis and, perhaps, the aryteno-epi- 
 glottidean folds as well, are seen to be inflamed (especially 
 after thermal irritation, when dysphagia is the principal 
 symptom), or the ventricular bands (see Plate 8, Fig. 2), 
 or the true vocal cords, either in their whole extent (Plate 
 9, Fig. 1) or only in part (Plate 8, Fig. 1), in wdiich case 
 dysphonia is the principal symptom. In very rare cases 
 the appearances are confined to the interarytenoid space 
 (Pkite 1 9, Fig. 2), when the voice may be perfectly clear ; 
 while, on the other hand, cough is incessant and uncon- 
 trollal)le, causing great discomfort to the patient. Occa- 
 sionally the mucous membrane of the under surface of the 
 true vocal cords becomes swollen, especially in children, a 
 condition which is aptly designated as laryngitis hypo- 
 glottica (pseudocroup). 
 
 In some cases the hoarseness is caused by impaired vi- 
 bration of the thickened true vocal cords, in others by 
 insufficiency of the muscles concerned in phonation, either 
 from inflammatory infiltration or from neuritis. We there- 
 fore meet with the picture of paralysis of the internal 
 thyro-arytenoid muscle (Plate 9, Fig. 1), or of the trans- 
 verse arytenoid (Plate 8, Fig. 1), or of both together 
 (Plate 8, Fig. 2) ; quite frequently also that of the lateral 
 crico-arytenoid muscle (Fig. 6). 
 
 The inflammation, whatever may be its seat, sometimes 
 goes on to exudation within the mucous membrane, re- 
 sulting in slight edema ; the true vocal cords then appear 
 round like sausages. The integrity of the blood-vessels 
 may be impaired by the inflammatory process, so as to 
 give rise to small hemorrhages, especially during a parox- 
 ysm of coughing ; these hemorrhages appear as blood-red, 
 and later as black spots in or upon the mucous membrane. 
 The delicate organs of singers are particularly liable to 
 suffer in this way after functional abuse. In other cases, 
 especially in cases of long duration, the epithelium may 
 be softened by the inflammatory infiltration and cast off. 
 If this process is confined to the surface, dull whitish 
 
38 PATHOLOGY AND TREATMENT. 
 
 specks appear ; but if the desquamation reaches the mu- 
 cosa, shallow yellowish depressions, so-called erosions (see 
 Plate 11, Fig. 1), result, which may become at times quite 
 extensive. 
 
 Prognosis. — Spontaneous cure if the voice is allowed 
 to rest ; if it is overexerted, and no care is taken to avoid 
 fresh exposure, chronic inflammation develops. 
 
 Treatment. — At first only general, no local treatment: 
 sweating, regulation of the bowels, Priessnitz bandage 
 al)out the throat ; talking and smoking to be forbidden ; 
 lukewarm, non-irritating food and drink. Later — after 
 ten to fourteen days — perhaps painting Avith a 2-4 per 
 cent, solution of nitrate of silver ; in the hemorrhagic 
 form or in erosions dusting with aluminis crudi 20.0, sach. 
 lact. 30.0, dose 1-2 gr. In the last two conditions the 
 use of the voice must be strictly prohibited. 
 
 If the erosions persist a long time, they may be cauter- 
 ized once with solid nitrate of silver, but on no account 
 are they to be painted. Violent cough may demand 
 morphin (0.1 : 15.0 aq. dest., 10-15 drops three times a 
 day). 
 
 Acute catarrh in children presents some peculiarities. The secretion 
 is scanty and there is constant, dry, barking cough. Swellings in the 
 ventricles, causing actual stenosis, combined with the extreme reflex 
 sensibility characteristic of childhood, bring on disturbances of respira- 
 tion in the form of choking fits ; they are also caused by perverse inner- 
 vation of the adductors of the glottis. The similarity of these symptoms 
 to those of diphtheria suggested the term pscudocroup, but the term 
 catarrh is anatomically more correct. The attacks of stenosis are best 
 controlled by a cold douche in a warm bath. The bowels must be care- 
 fully regulated, better a little diarrhea than constipation. Give 2-3 
 knife-points daily of pulv. glycyrrh. comp, 
 
 (b) Symptomatic catarrh is met with in all the acute in- 
 fectious diseases. As it is associated both in time and in 
 situation with other anatomical altcration.s, partly specific 
 in character, it will be treated witli these separately. 
 
ACUTE INFLAMMATIONS. 39 
 
 2. EXUDATIVE INFLAMMATIONS. 
 
 (a) Diphtheria. 
 
 Htiology. — The Loffler bacillus is now UDiversally ac- 
 knowleclo:ed to be the cause of this inflammation. Its 
 action, however, undoubtedly depends on individual dis- 
 position and usually on predisposing external causes. 
 Though the latter may not be absolutely essential, they 
 furnish the only explanation for the cases being most 
 numerous in winter, in regions characterized by sudden 
 changes in temperature and under unfavorable hygienic 
 conditions. The latter must not be understood to mean 
 only poverty ; poor children in the country are often 
 better off hygienically than rich children in the city, and 
 the want of cleanliness among the latter may be as great 
 as in poorer families. 
 
 Morbid Anatomy. — The first manifestation of the 
 morbid process is an exudation of lymphatic elements from 
 the blood-vessels. These migrating cells soon undergo 
 coagulative necrosis and lose their structure, so that 
 nothing remains but a reticulated infiltration, consisting 
 chiefly of fibrin from the broken-down cells. According 
 to the gravity of the case and the point of entrance of 
 the poison, this network of fibrin penetrates only the epi- 
 thelium and superficial, or even deeper, layers of the mu- 
 cosa. At first there is a line of demarcation between the 
 necrosed and the living parts, and then the former are 
 cast off. As the infiltration spreads out over the surface 
 it comes away in the form of a membrane. If the de- 
 marcation has been insufficient, the membranes can only 
 be removed with difficultv and bv sacrificino^ some of the 
 living tissue ; in the contrary case they are easily removed. 
 That demarcation occurs more easily in superficial infil- 
 trations is self-evident and explains why the latter sepa- 
 rate more easily ; hence there is no fundamental difference 
 between removable and non-removable membranes. 
 
 If the blood-vessels are affected by the violence of the 
 morbid process to such an extent that the nutrition of the 
 
40 PATHOLOGY AND TREATMENT. 
 
 parts suffers, either from injury to the walls and conse- 
 quent impaired metabolism, or from thrombosis, ex- 
 tensive areas of the mucous membrane die off, and Ave 
 have the so-called gangrenous form. In the milder forms 
 the membranes often present a sliining white, or occasion- 
 ally a cloudy, yellowish appearance ; the dreaded green 
 and black discolorations, on the other hand, are due to 
 admixture of necrotic blood-corpuscles by the above- 
 mentioned process. The appearance of tlie diseased parts, 
 therefore, varies. In the beginning the mucous membrane 
 is only slightly inflamed, soon it becomes covered witli 
 single, opaque, whitish streaks or circular spots, or even 
 with a broader ring of a delicate bluish-white. Later tlie 
 spots run together to form larger opaque areas, white or 
 yellowish-white in color. They may appear in any part 
 of the larynx ; sometimes the entire organ is covered, 
 especially in complications with disease of the trachea 
 and bronchi. After the adhesions become loosened they 
 se})arate in tlie form of shreds or membranes, or even 
 regular tracheal casts. 
 
 General Symptoms. — During the onset the symp- 
 toms are general : a feeling of discomfort, lassitude, loss of 
 appetite, constipation, slight difficulty in swallowing, and 
 hoarseness. If the true nature of the disease is not 
 already apparent from the ap])earance of the throat, it is 
 often revealed by a dry, barking cough acconq^anying the 
 first indications of laryngeal disease. Laryngoscopy, if 
 it be j)ossible, will even at this stage show the beginning 
 of membrane-formation . 
 
 The tenq)erature is like that in continued fever, with 
 .^light morning remissions; sometimes with greater fluctu- 
 ations, according to the progress or abeyance of the morbid 
 process. In the most severe cases, the septic ones, the 
 temperature may be normal or subnormal. 
 
 The voice is affected in the mildest cases ; usually it 
 becomes quite toneless — after the membranes come away, 
 sometimes rough and dec)), or shrill, in rapid alternation. 
 The respiration is always distui-bed even to the point of 
 
ACUTE INFLAMMATIONS. 41 
 
 extreme dyspnea, if there is active membrane-formation. 
 The dyspnea shows itself in long drawn-out, sighing in- 
 spirations ; the head is retracted, and all the accessory 
 respiratory muscles are contracted to the utmost ; the skin 
 is both cyanosed and pale, and cold to the touch from 
 cardiac weakness. 
 
 The pulse is not characteristic ; it merely serves as a 
 manometer to register the general reaction of the body. 
 Partial loosening of the membranes sometimes betrays 
 itself by a rattling noise during inspiration ; complete 
 separation is followed by discharge. The latter may 
 occur as the final stage of the process ; that is, during 
 convalescence, or in the course of the disease, so that we 
 may have new membranes forming after the discharge of 
 the first. 
 
 In addition to the laryngeal symptoms, the throat, and 
 especially the trachea, bronchi, and the parenchyma of the 
 lungs, demand attention. It goes without saying that 
 the general condition, as shown by consciousness or un- 
 consciousness, pulse, reaction to irritants, state of the 
 bowels, must be carefully watched. 
 
 The duration is usually a week, although sudden death 
 or more speedy recovery is not rare. 
 
 Death results either from heart-failure or from COg 
 poisoning, or from both together, since, in the cases with 
 stenosis, the heart-failure is to be attributed as much to 
 interference with the circulation through insufficient ven- 
 tilation of the lungs and inadequate supply of oxygen, as 
 to the absorption of toxins. 
 
 Recovery may be complete or may be followed by se- 
 quelae, particularly in the nervous system : paralysis of 
 the ciliary muscle and loss of accommodation ; paralysis 
 of the muscles of the pharynx and esophagus, so that par- 
 ticles of food and liquids regurgitate through the nose 
 and cannot be swallowed ; of the sensory laryngeal nerves, 
 causing the patient to swallow into the respiratory tract ; 
 and finally of the motor laryngeal nerves which may re- 
 sult in prolonged paralysis of the true vocal cords (see 
 
42 PATHOLOGY AND TREATMENT. 
 
 Plate 13, Fig. 2). The life of the patient may even be 
 threatened by paralysis of the plirenic or of the pneumo- 
 gastric nerve, resulting in respiratory insufficiency and 
 impaired heart-action ; even pareses and paralyses of the 
 extremities are among the possible sequelae. 
 
 Fortunately, however, these nervous disturbances are 
 rare compared with sequeke in the lymphatic system and in 
 the ear. The latter frequently follow complications of 
 the nose and throat, and are sufficiently important to merit 
 a passing mention ; they are — permanent enlargements of 
 the palatine and pharyngeal tonsils and purulent disease 
 of the middle ear. 
 
 The treatment must be more general than local. The 
 remedy of prime importance is antitoxin. Although it 
 may be years before we can judge of its true value, its 
 evident harmlessness and very successful clinical career 
 justify and even compel its use. Other therapeutic 
 measures must, however, not be neglected, especially such 
 as are indicated by local alterations. 
 
 We cannot here go into the treatment required in com- 
 plications or in primary formations of foci in the throat. 
 
 Very little can be done in the larynx itself. In a few 
 cases the membranes may be loosened and wiped away 
 with tampons dipped in lime-water, but this is not often 
 successful, and half-way measures only produce dangerous 
 irritation. CcmMics are absolutely oontra-indicated. The 
 loosening process may be assisted by constant inhalations 
 of moist air, vapor of lime-water being the best ; the 
 value of all other remedies, even of the vaunted emetics, 
 is very questionable. Deep breathing and vigorous ex- 
 pectoration may be successfully induced by cold douches. 
 If the temperature is high, the douches may be given in 
 an empty tub ; if moderate, in a tepid bath (50° C.) with 
 watorat 12°-15° C. 
 
 The bowels are to be regulated. Nutrition must be 
 encouraged by giving small doses of stimulating foods 
 and condiments at fre(iuent intervals : beef-tea, chaudcau, 
 egg-nogg, warm beer Avith the yolk of an egg, biscuits. 
 
ACUTE INFLAMMATIONS. 43 
 
 boiled chopped meatj plenty of milk, and occasionally, 
 but only when the strength begins to fail, alcohol in the 
 form of somewhat diluted Cognac or good Bordeaux. 
 
 If disturbances of the respiration manifest themselves 
 in the form of frequent choking tits or even lasting dysp- 
 nea, it is better to interfere too soon than too late. If 
 the bronchi are still open, simple intubation may be sufft- 
 cient ; but if they, as well as the trachea, are already in- 
 volved and the tubes are in imminent danger of becoming 
 clogged, or if the external conditions (lack of necessary 
 attendants) preclude such measures, tracheotomy is to be 
 preferred. The operation should not be delayed till the 
 stage of asphyxia has set in (cold, cyanosis, deep traction 
 of the diaphragm on the thorax), but even then it should 
 not be omitted. 
 
 The author prefers high tracheotomy, because it avoids 
 the thyroid gland, which can be safely separated from the 
 upper margin of the cricoid cartilage by means of Rose's 
 transverse incision. Care must be taken not to injure or 
 divide the cricoid cartilage, as cricotomy is frequently fol- 
 lowed by the dreaded granulation which interferes so 
 much with removal of the tubes. 
 
 During convalescence disturbances of accommodation 
 must be looked out for as precursors of other paralyses. 
 If paralysis of the esophageal muscles or of the sensory 
 nerves of the larynx supervenes (cough in swallowing), 
 the patient should immediately be fed through a sound or 
 per rectum exclusively ; the former method is to be pre- 
 ferred. Paralysis of the vagus is combated with complete 
 rest and digitalis. Strychnin-injections are futile, the 
 paralysis progressing serenely in spite of them. 
 
 Symptomatic diphtheria may be due to other delete- 
 rious causes, whenever a necrotic process in the epithe- 
 lium is accompanied by inflammatory phenomena in the 
 mucosa ; membrane-formation is therefore not a specific 
 anatomical evidence of such processes. It occurs after 
 scaldings of the larynx through inhalations of steam or 
 irritant gases (ammonia) and in the course of scarlet fever 
 
44 PATHOLOGY AND TREATMEST. 
 
 and small-pox. These affections are therefore identical 
 with diphtheria only in an anatomical sense, and etiologi- 
 cally qnite distinct. 
 
 It follows that the treatment is purely symptomatic, 
 directed against a possible stenosis : intubation or traclic- 
 otomy. 
 
 3. INFLAMMATIONS OF THE INTERSTITIAL TISSUE. 
 
 These may be divided, according to the kind and degree 
 of the inflammatory infiltration, into simple edema, in 
 which a serous exudation into the submucnsa is associated 
 with very slight round-celled infiltration, and jjJiIerjmoni<, 
 in which cellular infiltration is the prominent feature. 
 Although the two forms may l)e present at the same time 
 and in the same situation, and be due to the same causes, 
 we are nevertheless justified in making the anatomical 
 distinction, since the treatment will be influenced by the 
 form of the inflammation in s])ecial cases. Xor is it su- 
 perfluous to describe separately simple laryngeal erysipelas 
 with its typical general and local phenomena, in order to 
 preserve the analogy with dermatological nomenclature. 
 If we remember that all these varieties are essentially 
 identical when dependent on an ii\fectwus process, it will 
 help us to form a clear and logical idea of them. Their 
 true nature will be better understood if we divide them 
 into infectious and non-infectious forms. 
 
 (a) Infectious Interstitial Inflammations. 
 («) Primary Forms. 
 
 etiology. — Invasion by specific micro-organisms : the 
 streptococcus pyogenes, the various forms of staphylococci, 
 the pneumococcus, and possibly the bacterium coli. 
 
 The way is ()])ened by inflammations in neighboring 
 organs, especially the throat, the nasal cavities, and the 
 tongue. Entrance is eff*ected either through the lymph- 
 spaces, or through traumatic lesions which may be so 
 
ACUTE INFLAMMATIONS. 45 
 
 small as to be invisible — such as are produced by a foreign 
 body^ for instance. 
 
 Metastases through the lymphatic glands and vessels 
 are possible, though very rare. 
 
 It is quite unnecessary to construct a specific disease 
 (^^ infectious angina ^^) out of any of these inflammations. 
 They are entirely analogous to panaris (felons), erysipelas, 
 and phlegmon on the surface of the body. 
 
 lyOcal Phenomena. — In edema the swelling is sharply 
 defined, as a rule, yellowish-gray or yellow in color, occa- 
 sionally reddish and glistening ; in the erysipelatous form 
 the swelling is similar, but very red ; in the phlegmonous 
 variety the infiltration is tougher and the outline is more 
 irregular. Collateral edema may occur from pressure on 
 the veins by the infiltration. In rapidly fatal cases it 
 may be impossible to recognize any stages in the local 
 inflammation. 
 
 In the final stage there is either gradual reduction of 
 the swelling, or abscess-formation, preceded by a yellowish 
 gathering at one point. 
 
 The infiltrations are 2:reatest in the looser tissues, the 
 epiglottis or the investment of the arytenoid cartilages. 
 They usually end where these tissues have their attach- 
 ment to denser ones ; if the latter also become softened, 
 an atypical, but not abnormal, extension of the process 
 occurs. 
 
 In the laryngeal image the parts involved are seen to 
 be altered by convolutions of various shapes and hues, 
 according to the locality and the variety of infiltration 
 present : the epiglottis swells on one side (Plate 8, Fig. 1), 
 or on both (Plate 7, Fig. 2) — then usually in the form of 
 a turban ; the true vocal cords are thickened and resemble 
 sausages ; the posterior wall is converted into a thick 
 bolster (Plate 25, Fig. 1). The lumen of the larynx is 
 constricted in various planes, depending on the site and 
 severity of the process ; sometimes it becomes completely 
 obstructed, especially in swellings of the ventricles. 
 
 General Symptoms. — Fever, ranging from 38.5° to 
 
46 PATHOLOGY AND TREATMENT. 
 
 the highest temperatures, in mild, simple forms lasting 
 several days, with slight morning remissions, in others 
 presenting the jerky type of erysipelas. In cases of 
 longer duration, ending in pus-formation, the temperature 
 presents the irregular character of septic fever ; occasion- 
 ally, in the severe septic forms, the temperature may be 
 very low or even subnormal. The pulse corresponds to 
 the fever : strong and full, or very frequent, small, and 
 compressible. The patient feels very sick ; in severe 
 cases we may have the typhoid state. Frequently there 
 are headache and constipation. 
 
 Great pain in the throat on swallowing and speaking, a 
 feelincr of tension and drvness, constant desire to swallow 
 and, consequently, increased secretion of saliva and mucus. 
 
 The inflammatory swelling may spread to the glands 
 and to the connective tissue of the neck ; the swelling in 
 the latter is sometimes edematous, sometimes of a board- 
 like hardness. A corresponding affection of the fauces 
 and tongue is usually to be interpreted as a primary 
 trouble. 
 
 Dyspnea sets in as soon as the inflammation attacks the 
 aperture of the larynx or deeper parts; it is rarely caused 
 by the epiglottis alone. In the former case there are 
 hoarseness and aphonia. 
 
 The course is characterized by sudden onset and rapid 
 increase in the symptoms. Dyspnea and suffocation in 
 many cases set in early; in grave, septic cases death some- 
 times occurs from the toxemia alone, before the occurrence 
 of stenosis. In favorable cases recovery occurs in from a 
 few days to two weeks, with, at times, abscess-formation 
 as the final stage. 
 
 The diagnosis is based on the sudden onset without 
 previous disease, or immediately after a corresponding 
 inflammation in higher situations, as acute syphilitic dis- 
 ease may present the same clinical picture. The differen- 
 tial diagnosis from typhoid and meningitis is made by the 
 aid of laryngoscopy. 
 
 Treatment. — Apply moist bandages to the throat and 
 
ACUTE INFLAMMATIONS. 47 
 
 have the patient swallow cracked ice ; talking is to be for- 
 bidden and the bowels must be kept open. Possible car- 
 diac weakness must be properly treated. If stenosis 
 occurs, resort to deep puncturing of the swollen parts 
 and, if possible, inject a few drops of a 2 per cent, solu- 
 tion of carbolic acid ; early tracheotomy as a prophylactic 
 measure rather than too late. 
 
 Always search for the purulent focus and open it as 
 early as possible (phlegmons in the fauces and throat, 
 caries or periostitis of the teeth, abscess on the tongue, 
 etc.). 
 
 In all cases where the swelling extends beyond the epi- 
 glottis the patient should be kept under constant and 
 careful supervision, as life-threatening symptoms often 
 appear quite unexpectedly. 
 
 (/9) Any of the foregoing conditions may occur as sec- 
 ondary processes in the acute infectious diseases. They 
 must then be interpreted as mixed infections ; that is, as 
 the products of the above-mentioned inflammatory and 
 pyogenic bacteria, wdiose entrance was made possible by 
 the specific lesion in the mucous membrane. 
 
 Metastatic abscesses occasionally occur. The symptoms 
 are sometimes very pronounced (Plate 6, Fig. 1 ; Plate 
 26, Fig. 1). Course, diagnosis, and treatment are the 
 same as in the idiopathic form. 
 
 (b) Non=infectious Interstitial Inflammations. 
 
 The number of these is extremely small, being limited 
 to chemical and thermal lesions. Accidental corrosions 
 (from swallowing caustic lyes or acids) or the therapeutic 
 application of concentrated solutions of nitrate of silver 
 or of chromic acid may produce edema in the affected 
 parts ; it may also occur after scalding of the larynx by 
 the sW'allowing of hot liquids or the inhaling of hot va- 
 pors, or after therapeutic heat-applications. These lesions 
 present in addition other anatomical features, and will 
 therefore be treated elsewdiere. 
 
48 PATHOLOGY AND TREATMENT. 
 
 The tissue-destruction brought about by such accidents 
 may in turn give rise to infectious inflammations, so that 
 a division on etiological grounds is impossible in the later 
 stages. 
 
 4. INFLAMMATIONS OF THE MUSCLES. 
 
 These hardly ever occur as primary affections, but they 
 accompany catarrhal or interstitial processes and manifest 
 themselves in pareses or even paralyses of certain muscle- 
 groups. One of the commonest phenomena in acute or 
 subacute catarrh is paresis of the thyro-arytenoid muscles 
 (Plate 9, Fig. 1), next of the transverse arytenoid muscle 
 (Plate 8, Fig. 1) ; not infrequently the adductor muscles 
 are involved ; in fact, any simple or mixed form of paresis 
 may be met with (Plate 8, Fig. 2). The sudden appear- 
 ance of dyspnea in the course of an apparently mild or 
 interstitial inflammation is sometimes explained by an in- 
 flammatory palsy of the abductor muscles. The picture 
 of median, or at least cadaveric, position is not rare in 
 affections of the posterior wall (Plate 22, Fig. 2, and 
 Plate 25, Fig. 1), and simple swellings may produce the 
 same effect by accidental inflammation or collateral edema. 
 
 Finally, disturl>ances of deglutition (mis-swallowing or 
 mere reflex cough) are sometimes attributable to inflam- 
 matory palsy of the sphincter muscles of the larynx (all 
 except the cricothyroid and posterior crico-arytenoid mus- 
 cles) and of the depressor of the epiglottis (thyro-epiglot- 
 tideus muscle). 
 
 Apparent primary '^ rheumatic '* paresis of one or more 
 muscles ])rol>ably dejiends less on inflammation than on 
 intramuscular hemorrhages, such as sometimes follow 
 sudden exertion. Sudden paralysis occurring in the course 
 of a catarrh may be explained in this way. 
 
 The iinaf/e is always tliat of p(^ripheral palsy. 
 
 The disease usually disa})pears with the jirimary cause 
 and requires no treatment, at least in the acute stage. 
 
ACUTE INFLAMMATIONS. 49 
 
 5. INFLAMMATIONS OF THE JOINTS. 
 
 (a) These may occur as primary affections, presenting a 
 clinical j^icture which is calculated to mask the real con- 
 dition of affairs. This is true particularly of the very 
 common localization in the crico-arytenoid articulation. 
 (The author has never seen a primary lesion in other 
 joints, which, of course, does not preclude their occurrence.) 
 Of the morbid anatomy nothing is known. As in other 
 joints, there is at first probably a serous synovitis which 
 may, of course, run on to a plastic and purulent form. 
 
 The etiology embraces colds and acute infections. 
 The latter will be assumed in cases which are feverish 
 from the start, especially if they are preceded or accom- 
 panied by a lacunar angina. Occasionally the cause may 
 be found in a traumatism. 
 
 Symptoms. — The patient complains of an odd, un- 
 comfortable feeling on either side of the throat, especially 
 during the act of swallowing; it may also be referred to 
 the angle of the jaw or the hyoid bone, or the glands. It 
 is most pronounced when the patient assumes the recum- 
 bent podure (passive dorsal), especially if he swallows at 
 the same time. Palpation reveals pain on pressure of the 
 affected side, in the "region of the crico-arytenoid articu- 
 lation,'' the posterior extremity of the upper margin of 
 the cricoid. At the same time that pressure is exerted at 
 this spot the laryngoscope ought to show an inward 
 movement of the corresponding arytenoid cartilage to 
 make the diagnosis certain. Pain is also felt if the region 
 of the joint is touched with a probe from the esophageal 
 side. 
 
 If the entire cricoid cartilage is carefully fixed with 
 one hand and the right spot is pressed with the other, 
 crepitation may sometimes be both felt and heard, caused 
 by friction of the inflamed, rough articular surfaces. 
 
 Quite frequently laryngoscopy shows no alterations. It 
 is only after neighboring parts have been invaded by the 
 inflammation that periarthritis manifests itself in swelling 
 
50 PATHOLOGY AND TREATMENT. 
 
 and redness of the soft parts covering the articulation — 
 perhaps even of the posterior portions of the true and 
 false vocal cords. The mobility of the true vocal cords 
 is usually not affected except in very severe inflamma- 
 tions, in whicli case the motion is uneven and jVr/,-^ instead 
 of smooth and gliding ; or the parts may even become 
 fixed in any position. It will be impossible to distinguish 
 such cases from paralysis, except in the rare instances 
 where the abnormal position differs from that found typi- 
 cally in paralysis ; to distinguish them from perichondritis 
 during life is practically impossible. It follows that only 
 the milder stages are susceptible of diagnosis. For simi- 
 lar reasons purulent synovitis cannot be diagnosed in vivo, 
 as the symptoms must coincide with those of phlegmon 
 and attritions. 
 
 Treatment, — Priessnitz bandage ; rubbing the painful 
 spot with ung, bellad. 15.0, ung. ciner. 5.0, the size of a 
 pea ; laxatives. 
 
 (6) Secondary acute articular inflammation is unques- 
 tionably much more frequent than is generally known ; it 
 occurs principally as a localization of acute articular 
 rheumatism. Syphilitic and tuberculous processes also 
 attack this region. The former can only be recognized 
 by obtaining a clear history of infection or inheritance ; 
 the latter, no doubt on account of the virulence of the 
 specific cause, does not appear to have been met with ex- 
 cept in complication with other conditions : swelling and 
 ultimate destruction of the adjoining parts. In all cases 
 Avhere there is atypical disturbance of movement^ out of all 
 pro})ortion to visible alterations, the cause must be sought 
 in the joint, as well as in a possible dyscrasia, so that (in 
 syphilis) something may yet be accomplished by timely 
 treatment. In all such cases and in cases due to typJioid 
 and influenza we have to deal more with extensive chon- 
 dritis and perichondritis and their phenomena than with 
 simple joint-lesions ; still it may hel]) to clear up many 
 doubtful cases if the joint itself is carefully considered in 
 the diagnosis. 
 
ACUTE INFLAMMATIONS. 51 
 
 Prognosis. — Hecoveiy is the usual termination ; occa- 
 sionally, however, more or less permanent disturbances of 
 movement, witliout further inflammation, remain in the 
 form of partial or complete ankyloses. The former are 
 characterized by imperfect excursion of one or both true 
 vocal cords in both directions, or by a variation in mobility 
 — that is to say, fixation is seen in different positions at 
 different examinations — or the ankylosis may betray itself 
 by the uneven, jerky movements, as in acute inflammation. 
 Complete ankylosis can be distinguished from joaralysis 
 only when the true vocal cord is fixed in a position which 
 is atypical of muscular or nervous palsy ; ankylosis may 
 be inferred, even when the position is typical of paralysis, 
 if after prolonged observation no local or general cause 
 can be found for peripheral or central paralysis. Peri- 
 arthritic inflammations, or the remains of such, are char- 
 acterized by permanent thickening, in addition to the 
 abnormal fixation. Treatment of these ankyloses is usu- 
 ally of no avail. If, however, the true vocal cords are 
 fixed in adduction, an attempt becomes imperative on 
 account of the grave dyspnea. External massage and 
 gradual widening from within are indicated. 
 
 The treatment of active processes is therefore the 
 same as that described under the respective heads of those 
 diseases. 
 
 6. INFLAMMATIONS OF THE PERICHONDRIUM. 
 
 Primary perichondritis is very rare, and is probably 
 the expression of an infectious process which escapes de- 
 tection. "Rheumatic" forms exist only in the imagina- 
 tion of the perplexed diagnostician. 
 
 With more probability the cause has been sought in 
 traumatisms which exposed the perichondrium to direct 
 infection or favored its gradual advance. 
 
 Secondary perichondritis is more common, either as the 
 direct result of a specific infection or in consequence of a 
 mixed infection after a specific destructive process. Pyemic 
 
52 PATHOLOGY AND TREATMENT. 
 
 metastases, small-pox, and typhoid fever follow the first 
 method ; diphtheria, tuberculosis, and malignant tumors 
 prefer the second ; syphilis acts in both ways. 
 
 The morbid anatomy presents the usual variations ; be- 
 ginning with simple swelling and running on to serous, 
 later to fibroplastic and purulent, cellular exudation, and 
 finally to necrosis. The exudate usually collects between 
 the cartilage and its investing membrane (perichondrium), 
 so that the swelling is at first subperichondral. From 
 there the exudate frequently breaks through to the outer 
 surface, and gives rise to secondary swelling and infiltra- 
 tion in the interstitial tissue (secondary edema and phleg- 
 mon and superficial abscess-formation). The forcible 
 separation of the perichondrium from the cartilage is fol- 
 lowed by the changes which necessarily ensue when a 
 tissue is separated from its matrix — retrogressive nutritive 
 disturbances in the form of partial atrophy or total necro- 
 sis. If the process is arrested in the first stage and the 
 nutrition of the cartilage is restored, the changes will be 
 confined to the thickenings caused by the infiltration, or, 
 possibly, to adhesions in the region of the joints, which 
 may then give rise to motile disturbances. Sometimes, 
 especially in tuberculosis, ossification of the cartilage 
 forms the final stage of the nutritive disturbance. 
 
 In the more advanced stages and in more intense in- 
 flammations the cartilage becomes necrosed as a result of 
 the impaired nutrition. If the necrosis is only partial, 
 the necrosed parts may be absorbed and leave only a de- 
 formity ; but if the necrosis is at all extensive and the in- 
 flammatory process continues after necrosis has set in, 
 sequestra result and persist for a long time, setting up a 
 constantly recurring irritation in the soft parts, or they 
 may be cast off in a short time. Which of these pro- 
 cesses will occur in a particular case depends, of course, on 
 the primary cause ; little can be hoped for in tuberculosis 
 or in syphilis, or in any condition where there is a malign 
 influence constantly at work. 
 
 The clinical picture presents some special features, in 
 
ACUTE INFLAMMATIONS. 53 
 
 addition to those already mentioned^ according to the 
 localization of the process. Perichondritis of the thyroid 
 cartilage manifests itself on the outside by swelling of the 
 alse, which can readily be felt; the painful region is sharply 
 defined. There may also be an in^vard bulging, which is 
 then seen belo\\^ the true vocal cords in the anterior angle. 
 However, this is the least frequent localization. 
 
 The perichondrium of the arytenoid cartilages is more fre- 
 quently attacked, perhaps because they play such an active 
 part in the function of the organ. The consequences are 
 swelling over the cuneiform cartilages, abnormal move- 
 ments — that is, delayed action of the true vocal cords. 
 Whether this is due to disuse of the joint or to destruction 
 of the muscle-attachments cannot be determined during 
 life, and is quite immaterial from a clinical point of view. 
 The disease can be reco2:nized with certaintv onlv when 
 the symptoms are very pronounced, especially if the re- 
 sulting necrosis can be reached with the probe or leads to 
 the separation of a sequestrum. The swelling may ex- 
 tend beyond the vocal process — that is, over the true vocal 
 cord, and thus facilitate differentiation from other affections. 
 
 Secondary perichondritis in the cricoid cartilage is very 
 common. Typhoid, syphilis, and tuberculosis preferably 
 attack this cartilage. The posterior surface, from its ex- 
 posure to the eifects of friction and decubitus, is a favorite 
 site, although the inflammation in this cartilage commonly 
 proceeds from the upper articular surface toward the ary- 
 tenoid cartilages. The latter are almost always found to 
 be involved in an advanced necrosis. Hence the swelling 
 is often found in the same spot, as in perichondritis of the 
 arytenoid cartilages ; it is typical only when seen beneath 
 the true vocal cords in the form of sub-cordal convolu- 
 tions (Plate 28, Fig. 2). Perichondritis in this situation 
 often produces grave stenoses, as the posterior crico-aryte- 
 noid muscles and the crico-arytenoid articulation become 
 involved. 
 
 Perichondritis of the smaller cartilages cannot be re- 
 cognized clinically. 
 
54 PATHOLOGY AND TREATMENT. 
 
 The treatment depends upon the primary cause. 
 Traumatic infectious perichondritis calls for opening of 
 the foci and removal of the secretions, also incision, usu- 
 ally from without, tamponage, and drainage. A syph- 
 ilitic process may sometimes be arrested by general treat- 
 ment. Tuberculous forms are usually associated with a 
 grave general condition, so that any attempt at treatment 
 is hopeless ; still, even tuberculous necroses should be 
 treated according to general surgical principles whenever 
 they appear principally as local manifestations. 
 
 Perichondritic stenosis is the commonest indication for 
 tracheotomy in cases of chronic dyspnea. 
 
 7. SYMPTOMATIC (COMPLICATION) FORMS OF ACUTE 
 INFLAMMATIONS. 
 
 The inflammations which accompany the acute exan- 
 themata, although they have not often been described, 
 occur very frequently. 
 
 Measles rarely runs its course without laryngitis. It 
 appears usually in the mildest form of diifuse catarrh, 
 characterized by hoarseness and aphonia, and appearing 
 in the mirror as a diffuse redness and slight swelling. 
 The interstitial tissue may be invaded by the inflammation, 
 and the slight edematous swelling which results may pro- 
 duce in young children subjective or objective stenoses. 
 This incipient form of the inflammation often resembles 
 a specific exanthema ; the redness appears in spots, as on 
 the skin, and the infiltration being stronger at certain 
 points (inside the follicles) gives rise to minute papules 
 analogous to the small eminences felt in the skin and due 
 to infiltration of the hair-follicles. 
 
 Later the ei)ithelium may become macerated and cast 
 off, so that the mucous membrane assumes a dull, velvety 
 sheen. In the parts which are functionally active and 
 subject to friction erosions may appear, extending as far 
 as, or even within, the mucosa (the true vocal cords, vocal 
 processes, and especially the arytenoid region). Fibrinous 
 
ACUTE INFLAMMATIONS. 55 
 
 exudation into the epithelium and mucosa is another 
 common symptom of the local inflammation. 
 
 The symptoms are barkings and sometimes noiseless 
 coughj and eventually dyspnea. 
 
 The treatment is principally directed against the dysp- 
 nea : massage of the throat with mercurial ointment ; 
 warm, moist bandages ; laxatives ; timely tracheotomy, if 
 indicated. Generally the parts heal spontaneously. To 
 avoid ulceration, or to procure rest if it is present, the 
 cough should be controlled with small doses of morphin, 
 unless contraindicated by the condition of the lungs and 
 bronchi. Running ulcers are almost invariably tubercu- 
 lous, and do not belong here. 
 
 In scarlet fever laryngitis occurs less frequently. 
 The catarrhal inflammation presents no special features. 
 The diphtheritic form is more common (see p. 43). 
 
 In Stnall-pox the larynx is often, if not always, in- 
 volved. The clinical picture, which is that of simple 
 catarrh, frequently presents a specific discoloration from 
 the presence of small, whitish prominences which indicate 
 circumscribed epithelial necroses. If they increase in 
 size and prominence, a certain similarity to skin-pustules 
 is suggested, although not histologically, since they never 
 extend beyond the epithelium. Pus-collections also occur 
 under the epithelium, but only in the submucous layer, 
 and must therefore be regarded as pustules rather than as 
 true abscesses. After the loss of the epithelial covering, 
 the latter, like superficial necroses, result in erosions or in 
 true ulcers, which do not, however, possess any typical 
 features. The appearance of all these exanthemata be- 
 comes modified in " black " small-pox by the characteris- 
 tic hemorrhages. Either as the last stage of the process, 
 or in the early stages, we may get the typical diphtheroid 
 appearance of the larynx, in which the exudate forms a 
 membrane of mingled fibrin and blood ; the external ap- 
 pearances and clinical consequences are the same as in 
 diphtheria. 
 
56 PATHOLOGY AND TREATMENT. 
 
 The marked inflammatory appearances in the submu- 
 cosa and perichondrium have no specific character. 
 
 Typhoid fever affects the larynx l)y direct deposition 
 of the specific bacilli. Catarrh develops in the infiltra- 
 tion stage ; the epithelium is attacked and readily sepa- 
 rates, exposing the surface to superficial ulceration and 
 slight hemorrhages. The specific character shows itself 
 in the cirGumscribed nature of the invasions, particularly 
 at the aperture and at the vocal processes. The erosions 
 preferably select the sharp edge of the epiglottis. In 
 analogy with the intestinal process we further get diffuse 
 or circumscribed ^' marrow " infiltrations and secondary 
 infiltration resembling the intestinal form. Ulceration is 
 occasionally preceded by a definite scaly stage, in the form 
 of diphtheritic membranes. If the ulceration extends to 
 the perichondrium, perichondritis with all its evil conse- 
 quences ensues. According to the degree of intensity, 
 the parts either heal completely, or grave defects, tightly 
 drawn scars, membranous and other stenoses, remain 
 (Plate 17, Fig. 2). In exanthematous typhoid the phe- 
 nomena are similar, but milder. 
 
 In the treatment we must always take the laryngeal 
 complications into account. By keeping the upper parts 
 of the alimentary and respiratory passages clean we may 
 hope to influence the process favorably. Local treatment 
 accomplishes nothing. Stenoses demand early trache- 
 otomy, as the unexpected ajjpearance of secondary edema 
 is particularly common in this complication. 
 
 Influenija attacks every part of the respiratory tract. 
 In the larynx the interarytenoidal mucous membrane is 
 often found to be inflamed, and therefore (sec p. 19) we 
 have barking, dry, convulsive cough, resembling and 
 sometimes mistaken for whooping-cough. There is a 
 marked tendency to hemorrhage, and su])erficial epithelial 
 necrosis appears in the form of white spots on the true 
 vocal cords ; these result in small erosions. In rare cases 
 interstitial inflammations running on to abscess-formation 
 have been observed. The predilection of influenza for 
 
ACUTE INFLAMMATIONS. 57 
 
 the nervous system sometimes shows itself in affections of 
 the recurrent nerves. All these lesions, however, tend to 
 heal of themselves. 
 
 The treatment is purely symptomatic, and consists 
 principally in rest. Graver complications demand the 
 usual interference. 
 
 The general infection known as herpes in very rare 
 instances becomes localized in the larynx, and may or 
 may not be preceded by previous disease in the mouth 
 and fauces. The patient feels very sick and has shaking- 
 chills ; soon very minute, clear vesicles appear arranged 
 in groups on one or both sides of the larynx, usually at 
 the aperture only. The epithelium rapidly separates and 
 the vesicles are converted into small, flat ulcers with 
 sharp outlines, covered with a layer of white or yellow 
 secretion, so that usually ulcers only are seen (Plate 6, 
 Fig. 1). The pain is violent and burning, both spontane- 
 ous and on swallowing ; the voice is seldom affected. The 
 duration is from two to eight days. 
 
 Treatment consists in ordering complete rest and very 
 simple diet. The pain from the ulcers is often so great 
 as to make swallowing impossible, in which case it can be 
 allayed by carefully touching the parts with nitrate of 
 silver (see p. 33). 
 
 In whooping"- cotlg^h the laryngeal complications are 
 chiefly mechanical. In the stage characterized by re- 
 peated paroxysms the constant irritation betrays itself by 
 a redness of the anterior surface of the posterior wall ; 
 the expiratory blast is unable to remove the scanty secre- 
 tion. Ecchymoses, and even extensive hematomata, occur 
 in the laryngeal, as in other mucous membranes. Local 
 treatment is of no avail. 
 
 The most important acute infectious inflammation is 
 that which occurs in the secondary stage of Syphilis. 
 The first and mildest manifestation, a diffuse erythema, 
 can be distinguished from benign catarrh only by the 
 anamnesis and the absence of any known cause. JSTo thing 
 but the subsequent appearance of specific signs will serve 
 
58 PATHOLOGY AND TREATMENT. 
 
 to distinguish it from the catarrhal condition to which 
 syphilitic subjects are particularly liable after an eruption, 
 and ^vhich justifies the warning against catching cold 
 during treatment with unguents. Perhaps the only ex- 
 ternal characters of syphilitic erythema are found in a 
 certain velvety quality and looseness of the mucous mem- 
 brane and in a graver interference with phonation than 
 would be inferred from the appearance of the surface. If 
 a specific form is really present in a given case, the char- 
 acteristic signs soon make their appearance : the mucous 
 membrane papilla develops. The red background is over- 
 shadowed by a delicate, bluish-white veil covering the 
 redness, now in definite circumscribed areas, again in iso- 
 lated whitish spots (Plate 11, Fig. 2). The discolorations 
 rest on a swollen base and sometimes occupy the greater 
 part of the larynx. At other times the papilla appears 
 without these fijrerunners ; it is then usually isolated, also 
 in the form of a whitish eminence, but surrounded by a 
 zone of intense inflammation (Plate 12, Fig. 1). 
 
 The appearance is often so characteristic as to afford a 
 diagnosis in itself. The cervical glands are invariably 
 swollen, and traces of other secondary eruptions in the 
 infected region are rarely wanting. Until the papulae are 
 plainly made out, however, there is danger of confound- 
 ing the condition with catarrhal erosions. 
 
 The general treatment must be supplemented by local 
 measures (the author has found internal doses of hydrarg. 
 chlor. mit. 0.1, opii pur. 0.01, t. i. d. in milk, very effec- 
 tive whenever the use of unguents was impossible). Ener- 
 getic cauterization of the papulae with nitrate of silver or 
 chromic acid (caution !) fused upon the end of a probe, to 
 be repeated once or twice after the scab has come away, 
 is very efll.'ctive not only to liasten recovery, but even 
 more to allay the violent pain which accompanies and in- 
 hibits the act of deglutition. 
 
 The prognosis is good. Xeglected cases, it is true, tend 
 to interstitial proliferation and to the production of per- 
 
CHRONIC INFLAMMATIONS. 69 
 
 manent post-syphilitic hyperplasi?e (Plate 14, Fig. 1). 
 Their treatment must be purely surgical. 
 
 The rarest complications occur in connection with 
 acute articular rheumatism. Violent pain in the 
 visible and palpable cartilages, with swelling of the con- 
 nective tissue, sometimes even a thickening of the cartil- 
 age, appears to indicate that the joints of the larynx occa- 
 sionally share the fate of other joints in the body. Of 
 course, if attacks of acute articular rheumatism are fol- 
 lowed by motile disturbances (fixations or irregular inter- 
 ference with the excursions of the true vocal cords), we 
 may unhesitatingly regard them as sequelae of such severe 
 articular inflammations. 
 
 In the acute stage the general treatment may be supple- 
 mented by local cathartic measures (ung. hydr. applied to 
 the throat in small quantities and a warm, moist bandage) ; 
 later, electrical excitation and massage of the muscles may 
 be appropriate. 
 
 II. CHRONIC INFLAMMATIONS. 
 
 1. THE SUPERFICIAL FORM. 
 
 The primary forms arise either from acute beginnings 
 or as the result of repeated, though slight, irritation, such 
 as violent crying, prolonged exertion of the voice in 
 speaking, excessive smoking, singing in unsuitable pos- 
 tures, inhalation of dust, especially of a chemical nature, 
 etc. The symptoms consist in moderate hoarseness or a 
 rough, rasping voice, slight cough, and scanty expectora- 
 tion of grayish mucus streaked with dust or other impuri- 
 ties. A dusky-red hue is observed over the entire larynx, 
 or only in the parts about the true vocal cords ; the latter 
 are often slightly thickened, and slow and incomplete in 
 their closure upon phonation. Occasionally circumscribed 
 areas of hyperplastic tissue make their appearance, and 
 rapidly disappear again as soon as the above-mentioned 
 
60 PATHOLOGY AND TREATMENT. 
 
 causes are removed, thus explaining their origin. The 
 treatment nuist, therefore, be especially directed against 
 these adverse influences ; rest should be insisted on and 
 voice-use greatly restricted. The inflammation meanwhile 
 may be combated with applications of nitrate of silver (2-5 
 per cent, sol.), and, if there are hypertrophies, with ich- 
 thyol solution (see p. 33). If there is great sensibility of 
 the mucous membrane Avith a tendency to hemorrhage, 
 the local treatment must be limited to dusting with alum 
 1 : 10 sacch. i\\h. These measures are to be repeated 
 daily at first ; later, every two or three days. The func- 
 tions of the digestive tract must be carefully attended to 
 at the same time. 
 
 Secondary forms are met with much more frequently. 
 Nine-tenths of all the cases may be regarded as sequelae 
 of nose and throat disease. The constant hawking and 
 scra])ing so common in most of these troubles are very 
 injurious to the true vocal cords. Another source of in- 
 jury to the cords is the constant dripping of pus and 
 nuicus, which gradually find their way from the arch of 
 the palate to the larynx (where a layer of them is occa- 
 sionally seen in the interarytenoid space) and moisten the 
 inner surface. This secretion acts in several ways : first, 
 by direct infection ; secondly, by maceration ; and, finally, 
 the secretion dries and sticks fast, tearing off ej)ithelial 
 shreds when it is expelled by violent coughing, and even 
 giving rise to hemorrhages, which in turn expose the sub- 
 mucosa to infection. 
 
 Another cause of secondary catarrh is found in syphil- 
 itic infection. Even if the larynx is only slightly affected 
 in the beginning, it l)ecomes extremely sensitive to ordi- 
 nary adverse influences; hyperemias of long duration de- 
 velop and finally lead to hyperjilasia (Plate 14, Fig. 1), 
 or, in milder cases, to ])ermanent irritability of the mucous 
 membrane. 
 
 Alcoholism has no special effect, although it undoubt- 
 edly exercises an indirect influence on the development of 
 the disease, inasmuch as catarrh of the throat is very 
 
CHRONIC INFLAMMATIONS. 61 
 
 common among heavy drinkers, and the hawking it occa- 
 sions acts very injuriously on the larynx ; some cases are 
 aggravated })y excessive smoking, the usual concomitant 
 of alcoholic abuse. The piditre of the secondary affec- 
 tion may be very similar to, or identical with, that of 
 primary catarrh, the only feature which is at all charac- 
 teristic being the accompanying nasal affection. This is 
 usually so much in evidence tliat attem])ts have been 
 made to class it as a special disease, forgetting tliat both 
 forms are due to a common cause. 
 
 In one case we may see a pale, slightly granular mucous 
 membrane after closely adherent crusts of pus have been 
 removed by coughing, or, when necessary on account of 
 dyspnea, by direct interference ; the true and false vocal 
 cords narrowed and evidently atrophic, the surface of the 
 former a dirty yellow or dotted over with greenish spots 
 (Plate 10, Fig. 3) — the picture of so-called laryngitis 
 sicca. In another case the prominent feature may be 
 hypertrophy of the mucous membrane, especially of the 
 epithelium, giving rise to wart-like eminences (Plate 22, 
 Fig. 3); again, wheals ap])ear on one or both true vocal 
 cords, presenting by certain indentations, which corre- 
 spond in i)osition to the points where they are firmly at- 
 tached to the cartilage below, and by the formation of 
 ridges from the reciprocal pressure, a clinical picture 
 which has been described as ^^ pachydermia verrucosa," 
 and, with small show of reason, classed as a special dis- 
 ease (Plate 10, Fig. 1). In addition to hyperplasia and 
 the maceration already referred to, the reaction of the 
 epithelium to the constant irritation may sliow itself in 
 hemorrhages, brought about by laceration of the mucous 
 membrane as the secretion is coughed up ; these hemor- 
 rhages are characteristically foimd associated with liyper- 
 trophies (Plate 10, Fig. 1). 
 
 The prognosis may be epitomized in the maxim : Tin- 
 manente causa non cessahit effectus. The fundamental 
 principle in the treatment is, therefore, removal of the 
 nose and throat disease. This in itself often suffices to 
 
62 PATHOLOGY AND TREATMENT. 
 
 bring about recovery. If the primary trouble cannot be 
 got rid of at once, it should at least be kept within bounds 
 as much as possible by frequent and thorough cleansing 
 of the nasal and postnasal cavities. The larynx must 
 also be treated ; the use of the voice must be absolutely 
 prohibited for weeks ; all irritating food and drink must 
 be eschewed. Ichthyol applications (p. 33) are very good ; 
 large hyperplasiae may be treated Avith electrolysis, or re- 
 moved with the curet, snare, etc. It is hardly necessary 
 to add that intemperance must be combated in the alco- 
 holic, that abdominal plethora must be removed, and that 
 antisyphilitic measures must be resorted to if necessary. 
 The last direction, of course, does not apply to affections 
 of a clearly postsyphilitic nature. 
 
 2. INFLAMMATIONS OF THE SUBMUCOSA 
 
 are rarelj primary. As soon as the causes Avhich we have 
 just discussed in connection with chronic superficial 
 aifections exert a deeper eifect, they may give rise to in- 
 terstitial infiltration, and later to sclerosis and hyper- 
 plasia. 
 
 /Secondary forms following a specific infection are far 
 more common. 
 
 Syphilis, on account of its predilection for connective 
 tissue, plays a prominent part ; by means of the secondary 
 disease of the vessels which it entails, extensive altera- 
 tions are often brought about in the deeper layers. New 
 growths of a tough, fibrous nature develop, together with 
 active superficial proliferations (Plate 5, Figs. 1 and 3), 
 either at once or after more or less tissue-destruction has 
 taken place. True fibromata may be simulated in tliis 
 way. The subcordal mucous membrane is another favor- 
 ite seat of such processes, with the result that grave sten- 
 oses develop. 
 
 The same locality is frecjuently chosen by typhoid 
 (Plate 17, Fig. 2)/and tuberculosis also occasionally 
 produces here similar convolutions to those to which 
 
CHRONIC INFLAMMATIONS. 63 
 
 it gives rise in the interarytenoid mucous membrane 
 (Plate 14, Fig. 2). 
 
 But it is in scleroma that we find this disease, syph- 
 ilis, in its most typical form. The thick, firm, uneven, 
 pale swellings and the extensive cicatricial contractions 
 are most characteristic of this disease, which practically 
 attacks the submucosa exclusively and inevitably results 
 in grave and extensive stenoses. 
 
 £eprosy also shows a preference for the connective 
 tissues, where it first forms hyperplastic tubercles and 
 eventually leaves an exceedingly tough, fibrous growth 
 productive of the gravest stenoses. 
 
 The treatment in most cases is necessarily mechanical. 
 The new growths must be destroyed with "fire and sword,^' 
 either from within or after thyreotomy ; if that is impos- 
 sible, the stenosis must be combated with bougies or by 
 means of intubation, and, if necessary, tracheotomy. 
 
 3. CHRONIC INFLAMMATIONS OF THE MUSCLES 
 
 are always secondary, so far as our present knowledge 
 goes. We really have very little positive knowledge; 
 even those tuberculous infiltrations of the muscles which 
 are sometimes the first visible signs of the infection are 
 but imperfectly understood. So-called atony of the true 
 vocal cords, especially if unilateral or otherwise isolated, 
 is probably to be explained in this way (Plate 9, Fig. 2). 
 In tuberculosis there is probably a toxic degeneration of 
 the muscle-substance ; trichinosis attacks the muscle 
 directly. 
 
 We can, of course, readily understand that the muscu- 
 lar tissues should be involved in any extensive process of 
 infiltration or ulceration of whatsoever description, but 
 the fact has no special importance except in affections of 
 the abductors of the vocal cords (see below). 
 
 4. CHRONIC INFLAMMATIONS OF THE JOINTS 
 
 are more easily recognized. They are practically always 
 
64 PATHOLOGY AND TREATMENT. 
 
 the result of acute iuflammatious (see p. 49) : the symp- 
 toms are similar, ouly not quite so severe. 
 
 Many a so-called " rheumatic " paralysis of the recur- 
 rent nerves is, in fact, nothing but an ankylosis of the 
 arytenoid cartilage. The differential diagnosis will be 
 found under the head of Hypokinesis. 
 
 The treatment promises very little. Electrical stim- 
 ulation of the muscular activity and massage of the artic- 
 ular region constitute the only available measures. 
 
 0. CHRONIC INFLAMMATIONS OF THE PERICHONDRIUM 
 
 AND CARTILAGES 
 
 present exactly the same phenomena as the acute forms 
 which we have described, and to which we therefore refer 
 the reader (p. 49). The symptoms may be less pronounced, 
 or, if the formation of sequestra has led to separation of 
 the cartilages, more intense. 
 
 In regard to the etiology, it must be added that both 
 gout and arthritis deformans occasionally form deposits in 
 the larynx whose true nature can only be recognized by 
 their intimate relation to other unmistakable localizations. 
 The treatment in such cases can only be general ; occa- 
 sionally, however, the gouty foci may soften and eventu- 
 ally demand surgical interference. We have very little 
 knowledge of this latter process. 
 
 6. COMPLICATED FORMS OF CHRONIC INFLAMMATION. 
 (a) Tertiary Syphilis of the Larynx 
 
 manifests itself in diffuse or circumscribed hifiUrations^ in 
 swellinr/s, and in ulcerations. The latter appear either at 
 once or after tlie two first-named conditions. 
 
 The diffuse infiltration is seldom limited to the mucous 
 membrane ; it usually j^cnetrates tlie submucosa and often 
 extends to the muscles and to the ])erichondrium, as is 
 proved by the marked interference with movement which 
 occurs very early. The mucous membrane is red and 
 
CHRONIC INFLAMMATIONS. 65 
 
 velvety ; the normal shape is masked by thick convolu- 
 tions more or less clearly outlined against the surrounding 
 parts (Plate 13, Fig. 1). Purely inflammatory swelling 
 and edema often complicate the picture (Plate 23, Fig. 2). 
 If the infiltrations are round and distinctly separated 
 from the healthy tissue, they may be termed gummata, as 
 in other parts of the body (Plate 4, Fig. 1). This char- 
 acter becomes accentuated if they are elevated above the 
 surface and form true sivellings (Plate 18, Fig. 3, and 
 Plate 22, Fig. 2). Histologically such swellings are 
 found to be true sypMlomafa (Plate 41, Fig. 2). These 
 appearances, however, do not persist for any length of 
 time; disintegration early supervenes, and we get the 
 typical ulcers with red, steep, clear-cut ("punched-out^^) 
 edges and a greenish-gray depression (Plate 5, Fig. 2j. 
 Usually the two conditions are seen at the same time. 
 
 The favorite seat is the ^superior aperture of the larynx, 
 especially the epiglottis, though any other part may also 
 be involved. The principle of least resistance asserts 
 itself in the greatest frequency of the ulcers on the true 
 vocal cords, as they are most concerned in the function of 
 the organ, and, after that, on the lingual surface of the 
 epiglottis, which is most exposed to injury from ingested 
 food (chilling and over-heating) and to infection from the 
 mouth. 
 
 In the first, the infiltration-stage, the course is treacher- 
 ously sloiv. The deposit may accumulate for weeks with- 
 out betraying its nature by any perceptible characteristic 
 signs. The patients during this period feel so little dis- 
 comfort that they rarely present themselves for examina- 
 tion. In most cases they consult a physician only when 
 they begin to feel serious inconvenience, w^hich does not 
 occur until nearly the end of the infiltration-stage or in 
 the beginning of degeneration. Before this time — de- 
 pending upon the seat of the affection — the voice may 
 have become impaired, or the patient may have felt a 
 dryness and ^^ scratchy ^' feeling in the throat; but now 
 he complains of pain, usually slight but sometimes violent^ 
 5 
 
66 PATHOLOGY AND TREATMENT. 
 
 stabbing and burning in character during the act of swal- 
 lowing, after sleeping, and also in speaking, and there are 
 marked vocal disturbances. The epiglottis may fail to 
 act as a result of mechanical interference, and there may 
 be consequent dysphagia. 
 
 The ulcerative stage is succeeded by ciGatrization. The 
 original marked increase of connective tissue is replaced 
 by a corresponding contraction ; where the infiltration 
 occupied the place of normal parts we get greatly dimin- 
 ished volume ; and, on the other hand, masses of tissue 
 may be deposited in places where there was none before. 
 In one case we shall have defects (Plate 4, Fig. 3) ; in the 
 other, marked cicatricial contractions and membrane-for- 
 mation (Plate 30, Fig. 3). 
 
 The disease does not always end with the effects of 
 syphilitic infection ; mixed infections may continue their 
 work in spite of antisyphilitic treatment, especially in 
 situations unfavorable to the elimination of the morbid 
 products — the submucous layer, the perichondrium, and 
 the articulations ; the only hope then lies in the recupera- 
 tive powers of the organism or in operative interference. 
 The latter is to be considered only when larger necrosed 
 particles — sequestra — are to be eliminated ; their presence 
 is often an indication of a constant or recurring reaction 
 in any one situation. 
 
 Such postsyphilitic complications following the specific 
 cure betray themselves by persistent swellings, etc., some- 
 times, too, by the subsequent recurrence of proliferation. 
 The former condition is illustrated in Plate 13, Fig. 3; 
 the latter, in Plate 5, Figs. 1 and 3. 
 
 The difference between such postsyphilitic inflamma- 
 tions and specific granulomata is best seen histologically : 
 Plate 40, Fig. 2, and Plate 41, Fig. 1, represent the first 
 variety, secondary wart-formations ; while Fig. 2 on 
 Plate 41 shows a true syphiloma. 
 
 The diagnosis of tertiary disease will rarely be based 
 on the findings in one situation only, as, for instance, in 
 the larynx ; anamnesis, other accompanying symptoms, 
 
CHRONIC INFLAMMATIONS. 67 
 
 and, above all, remains of former specific disease in other 
 parts of the body, must be taken into account. The 
 marked inflammation of surrounding structures in the 
 active stage, the painful swelling of the glands, the 
 smooth, steep edges of the ulcers, the rapid degeneration 
 in infiltration, the wide extent of both ulceration and in- 
 filtration — all these factors afford valuable signs for differ- 
 entiation from other processes. 
 
 The duration of the disease and the condition of lungs 
 and character of sputum serve to distinguish it from tu- 
 berculosis, while malignant growths are excluded by ob- 
 serving the advance of the process and whether the 
 infiltration degenerates rapidly — above all, by noting the 
 effect of antisyphilitic treatment. Hence diagnosis is 
 often arrived at ex juvantlbus. 
 
 It is eveii more difficult to recognize postsi/phlUtic pro- 
 cesses as such. The anamnesis must be absolutely posi- 
 tive. It is to be remembered that they are very common ; 
 many a stubborn " hypertrophic catarrh," many motile 
 disturbances described as " nervous '' or paralytic, are 
 really nothing but the remains of earlier infectious pro- 
 cesses. 
 
 The treatment cannot be begun too early, if it is to be 
 effective. Infiltrations mav show no chano'es for weeks, 
 and thus deceive the practitioner as to their true nature, 
 whereas they can be reduced by therapeutic measures. 
 When the characteristic, ulcerative degeneration has once 
 set in, its progress can no longer be arrested ; it is (simply) 
 a sign that necrosis is already completed. Hence the im- 
 portance of the maxim, ohstare principlis. 
 
 As in all the graver forms of syphilis, among which 
 laryngeal syphilis must be included in spite of its com- 
 parative infrequency, iodid of potassium alone, especially 
 in small doses, sometimes fails to act. The following 
 mixture is recommended : 
 
68 PATHOLOGY AND TREATMENT. 
 
 ^. Sol. pot. iod., 10.0 : 150.0 ; 
 
 Sod. carb., 5.0 ; 
 
 Syr. cort. aurant., 25.0. — M. 
 
 Sig. One tablespoonful three times daily before 
 meals. 
 
 This should be supplemented, if possible, by unguents 
 or the hypodermic injection of a mercurial salt; the 
 author prefers 
 
 Hydrarg. salicyl., 1.0; 
 
 Paraffin, liquid., 9.0. 
 
 Sig. One Pravaz syringeful every three days. 
 
 Local treatment is required only in complications : in 
 the mixed infection following ulcerative degeneration, of 
 course ; and in sequelae of other diseases or other threat- 
 ening symptoms. 
 
 The first of these — ulceration — may be effectively com- 
 bated by cauterization with solid nitrate of silver, not to 
 be repeated until after the scab has come away ; the scab 
 acts as a bar to the constant infection by contact, as a 
 means of removing necrosed tissue more quickly, and also 
 as a protection against pain. 
 
 Dyspnea should be relieved, if possible, by mechanical 
 means : scarification of infiltrated parts, removal of SAvell- 
 ings, and, if necessary, tracheotomy. 
 
 The sequelae are sequestra, the discharge of which is 
 hastened by curettage, but may sometimes demand thyre- 
 otomy ; deep abscesses, which must be opened fi-om witliin 
 or from without ; swellings, which must be removed ; 
 finally, cicatricial contractions or hyperplasi^e, which call 
 for mechanical stretching or operative removal. 
 
 (b) Tuberculosis of the Larynx. 
 
 Ktiology. — The infection may invade the organ pri- 
 marily, as it does practically every other organ in the 
 body, but is more often secondary to disease elsewhere. 
 
CHRONIC INFLAMMATIONS. 69 
 
 The path of the infection is, if anything, more difficult to 
 explain than it is in other localities. Either it traverses 
 apparently intact or injured epithelium, or it follows the 
 course of the lymph-channels : the former is most likely in 
 the diseases secondary to pulmonary phthisis ; the latter, 
 in the forms which at first sight appear to be primary, 
 but are in reality the result of latent disease in the upper 
 portions of the respiratory and alimentary tubes. There 
 is no doubt that diseased cervical glands are capable of 
 infecting the larynx ; many a so-called " primary ^' case 
 is no doubt due to this cause. 
 
 Morbid Anatomy. — The principal feature is the 
 tuberculous infiltration, usually showing the structure of 
 the Schiippel-Langerhaus tubercle very plainly, some- 
 times taking the form of irregular, diffuse, round-celled 
 infiltration, especially about the vessels and glands. The 
 seat of predilection is the middle of the posterior wall 
 (Plate 19, Fig. 3; Plate 21, Fig. 1), by reason of the 
 loose arrano^ement of the tissue and the accumulation of 
 (pulmonary) sputum in that locality. Other parts are 
 occasionally attacked first ; the epiglottis less frequently 
 than any other. Sometimes the infiltration is circum- 
 scribed ; at others very extensive both in width and in 
 length. The reaction of neighboring structures is, in 
 general, very slight, and their resistance proportionately 
 feeble. If, however, the advance of the infection is 
 checked before it has reached the deeper layers, we get 
 the lupoid form of the disease, characterized by numerous 
 protuberances in the infiltration, a very slow progress, and 
 showing histologically marked reactionary proliferation of 
 epithelium. 
 
 If, on the other hand, the process continues, the infil- 
 tration soon undergoes necrosis, forming ulcers on the 
 surface and hard or soft sequestra in the deeper layers 
 (Plate 12, Fig. 2 ; Plate 20 ; Plate 21, Fig. 2 ; Plate 29). 
 
 The first condition opens the way for a mixed infection, 
 although (infective) reaction may in rare instances be 
 strong enough to drive out the focus of the disease. De- 
 
70 PATHOLOGY AND TREATMENT. 
 
 generation is more likely to occur where function has be- 
 come impaired, the infiltration extending far beyond the 
 limits of the visible ulcer (Plate 20). 
 
 In some cases the tubercle-formation proceeds for a 
 long time within the deep layers, and occasionally gives 
 rise to non-specific proliferations in the epithelial and 
 mucous layers. These appear as swellings and are usu- 
 ally found to consist also of diseased tissue. The pro- 
 liferations may lead to the formation of actual tumors, 
 their true nature being masked by the intact appearance 
 of the surface and the presence of a pedicle (Plate 21, 
 Fig. 2; Plate 21, Fig. 1; Plate 26, Fig. 2; Plate 28, 
 
 If the perichondrium is more extensively invaded, 
 there result edematous swellings, and later necroses, pre- 
 fera])lv in the cricoid and arytenoid cartilages, correspond- 
 ing to the most frequent localization in the mucous mem- 
 brane of the posterior Avail. 
 
 All these various anatomical features are very often 
 blended in a strange ])icture of deformity and devastation. 
 
 I/aryng"OSCOpic Image. — In the initial stages we 
 often see round or pointed eminences projecting from the 
 interarvtenoidean region, beneath which ulceration may 
 liave already begun. These projections are usually pale ; 
 in fact, the entire larynx and even the fauces are usually 
 anemic : there are, however, many exceptions to this rule. 
 Sometimes the process first betrays itself by paresis or 
 redness of one or both true vocal cords. These also 
 may be the seat of slight hypertrophies and excres- 
 cences. If the infiltration in the vocal cords breaks 
 down, we see discolored yellow, and sometimes, from pro- 
 trusion of the granulated background, reddish erosions 
 with more or less swollen or uneven edges (Plate 12, Fig. 
 2; Plate 21, Fig. 2). The decubital action of the other 
 vocal cord leads to com]>lete longitudinal fission of the 
 affected one, so that it ajipears to be divided into an upper 
 and a lower half (Plate 16, Fig. 2). 
 
 The false vocal cords are usually somewhat thickened. 
 
CHRONIC INFLAMMATIONS. 71 
 
 and, if infiltration is present, they will appear to be nar- 
 rowed (Plate 25, Fig. 2). 
 
 In the epiglottis the follieles are frequently attacked, 
 especially at the edges, and soon degenerate ; the extreme 
 thinness of the investing membrane there often gives rise 
 to perichondritis with enormous swellings (Plate 6, 
 Fig. 2). 
 
 Tuberculomata are common ; they are recognized by 
 unmistakable accompanying symptoms and also by their 
 general appearance, irregular, uneven surface, and broad 
 base. 
 
 The diagnosis is often quite difficult. The first thing 
 to bear in mind is that tuberculosis of the larynx usually 
 forms only a part of a general process ; but, on the other 
 hand, it must not be forgotten that a patient may have 
 pidmonary phthisis and laryngeal syphilis at the same 
 time ; in fact, the two diseases have even been observed 
 in the larynx at the same time (Plate 21, Fig. 1). 
 
 In general, tuberculous deposits in the larynx are char- 
 acterized by slow development, moderate redness, and 
 uniform extension to the adjoining tissue. Tuberculous 
 ulcers are distinguished by raised and slightly papillary 
 or convoluted edges ; often the edges alone are visible in 
 the form of pointed eminences on the posterior wall. 
 This phenomenon is so frequent in the early stages of the 
 disease that its appearance in this locality has been con- 
 sidered pathognomonic. 
 
 Tubc^rculomata, we repeat, are recognized by their broad 
 base and uneven surface ; infiltrations, by their rigidity 
 and pale color. Plain as all these phenomena may be to 
 the eye of the experienced, a combination of all, or of 
 some of them, which is usually present, will materially 
 facilitate the diagnosis, especially if the individual forms 
 are atypical, for the picture is often greatly altered by 
 mixed infections and by functional irritation. 
 
 It is absolutely indispensable to collect all the corrobo- 
 rative evidence possible by thorough examination of the 
 entire body, and especially of the lungs, as well as of the 
 
72 PATHOLOGY AND TREATMENT. 
 
 secretions of ulcers and of extirpated portions of swellings. 
 In obtaining the secretions the parts must be previously 
 cleansed with the greatest possible care to guard against 
 contamination with lung-sputum. The course of the dis- 
 ease is compared with that of syphilis, carcinoma, etc. ; 
 sometimes it is advisable to try the effect of antisyphilitic 
 treatment. In general, it may be said that it is impossi- 
 ble to teach anyone theoretically how to make a diagnosis 
 from the picture in any given case, because, in order to 
 arrive at a decision, one must first learn the development 
 of many successive pictures by long personal observation. 
 Not the picture of to-day, but that of yesterday and that 
 of to-morrow must decide for or against laryngeal tuber- 
 culosis. 
 
 The symptoms are vocal disturbances, often very early, 
 due to degeneration or infiltration of the muscles, later to 
 alterations in the mucous membrane of the vocal cords or 
 of the interarytenoidean space ; in inflammations, particu- 
 larly of the posterior wall, great desire to cough ; dys- 
 phagia, due to ulceration of the parts concerned in func- 
 tion ; and, finally, dyspnea in cases of perichondritis, ex- 
 tensive infiltration, and large tumors. 
 
 The treatment is strictly divided into curative and 
 symptomatic treatment. 
 
 The former is to be employed in all cases which, from 
 tlie condition of the lungs, the general health, and the 
 previous course of the disease, promise permanent, com- 
 plete recovery after the laryngeal trouble shall have been 
 removed. Spontaneous cure of the local affection is so 
 rare that it practically need not be taken into considera- 
 tion. Tlie curative measures are, in circumscribed incipient 
 infiltrations, thorough curettage, and, if necessary, destruc- 
 tion of the base with the cautery-needle or by electrolysis ; 
 in more diffused forms, excision witli double curet, espe- 
 cially on the upper surface of the posterior wall ; in ulcer- 
 ations, vigorous scra])ing and painting with 30-80 per 
 cent, solution of lactic acid ; tumors must be removed 
 with curet or galvanocautery. If the extent or the seat 
 
CHRONIC INFLAMMATIONS. 73 
 
 of the morbid process is such as to make complete ex- 
 termination of the diseased tissue jper vias naturales im- 
 practicable, thyreotomy should be practised, and be followed 
 up with a thorough cleansing. It is advisable to examine 
 the wound again after two or three days, as important 
 points are often overlooked during the operation on ac- 
 count of the hemorrhage. In our opinion, extirpation of 
 the larynx is not practicable even in very extensive dis- 
 ease ; partial excision of diseased cartilages, on the other 
 hand, may be practised with good results in chondro- 
 perichondritis. 
 
 The symptomatic treatment must be employed when the 
 condition of the larynx requires interference and the gen- 
 eral condition is such that permanent cure or even lasting 
 improvement is not to be expected. 
 
 Painful ulcers which impede deglutition are treated 
 with lactic acid, and, if the underlying infiltration is very 
 extensive, with energetic curettage ; tumors interfering 
 with respiration must be removed ; perichondritic abscesses 
 must be drained ; if the dyspnea continues and cannot be 
 relieved in any of these ways, especially if it is due to 
 perichondritis or to subcordal abscess, tracheotomy must 
 be resorted to. This operation is also indicated in exten- 
 sive ulcer-formations, for complete rest of the larynx will 
 do much to lessen the pain and discomfort, and may be 
 followed by actual improvement. In addition, morphin 
 should be freely used in hopeless cases, remembering that 
 the patient cannot in any case live long enough to contract 
 the morphin-habit. (We say nothing here of general 
 treatment, such as is required in tuberculosis.) Inhala- 
 tions of balsamic substances may be employed with ad- 
 vantage, if only to cover up the offensive odor ; their 
 therapeutic value is doubtful, to say the least. Let the 
 patient inhale turpentine, menthol, Peruvian balsam, or 
 ol. pini pumilionis from a cotton pledget saturated with 
 any of these substances and placed in the bowl of a clean 
 earthenware pipe, or the drug may be poured on hot water 
 and the vapor inspired through a paper funnel. 
 
74 PATHOLOGY AND TREATMENT. 
 
 For general treatment we will emphasize the import- 
 ance of staying in a quiet place where the air is free from 
 dust. Whether the treatment is symptomatic or curative, 
 talking should be strictly prohibited, so as to insure abso- 
 lute rest for the organ. In conclusion, let it be remem- 
 bered that occasionally the symptomatic treatment has the 
 effect of a curative one, agreeably surprising the practi- 
 tioner by unexpected recovery. 
 
 (Cj Leprosy of the Larynx, 
 
 although only a rather unusual complication of a general 
 infection, is important on account of the fatal stenosis 
 which it occasions. The rigid, nodular infiltration, which 
 is quite analogous to the phenomena in the skin, encroaches 
 upon the lumen considerably, and the condition is further 
 aggravated by the resulting ulcers and cicatricial contrac- 
 tions. 
 
 Mutilations of the organ from extensive tissue-destruc- 
 tion, especially in the epiglottis, are not rare. 
 
 The diagnosis is very simple, as the disease never at- 
 tac'ks the larynx alone. Tracheotomy is the only possible 
 treatment. 
 
 (d) Scleroma 
 
 is more commonly seen in Germany. Until a short time 
 ago it was known only in the form of rhinoscleroma, 
 which is suggestive of the important fact in the diagnosis 
 that the larynx and trachea are always attacked second- 
 arily. The same charactei-istic ])ale, gristle-like, wide- 
 spread infiltrations and flat, lumpy ulcers, covered with 
 dry pus-scabs, are seen as in the nose. The subcordal 
 space is ])articularly liable to be attacked, so that we see 
 thick, soft wheals projecting into the lumen. 
 
 In doubtful cases the diagnosis is made certain by the 
 presence of the characteristic bacteria in the excised 
 tissue. 
 
 So far as our present knowledge goes, any attempt to 
 
NEOPLASMS OF THE LABYNX. 75 
 
 combat the disease is hopeless; tracheotomy often be- 
 comes necessary. 
 
 (ej Gout and Arthritis Deformans, 
 
 according to some observers, furnish a few cases of 
 chronic inflammation in the hirynx. Gouty deposits are 
 found on the epiglottis and also on the large cartilages. 
 The mucous membrane bulges out in broad and circum- 
 scribed areas and possesses a conspicuous light yellowish- 
 red color ; the infiltration is hard and gritty. Softening 
 with ulceration is, of course, possible as in other locali- 
 ties. 
 
 The second disease attacks the joints of the larynx and 
 gives rise to motile disturbances (see p. 51), the true cause 
 of which, as in gout, can only be determined by their 
 close relation to the general symptoms. 
 
 III. NEOPLASMS OF THE LARYNX 
 
 may be divided into homologous, the tissue and structure 
 of which correspond to those of the fundamental tissue or 
 parts of it; and heterologous, in which either tissue or 
 structure is different, giving rise, in the latter contingency, 
 to an atiipical growth. The first category may be further 
 divided into neoplasms of individual tissues, and hyper- 
 plasise containing several or all the histological con- 
 stituents. 
 
 1. HOMOLOGOUS TUMORS. 
 (a) Neoplasms of Individual Tissues. 
 
 F'ibroma, defined as a pure connective-tissue tumor, 
 associated with some extension of the epithelium which 
 is only secondary and does not attain the same degree of 
 proliferation, is, in reality, very rare, although the diagnosis 
 
76 PATHOLOGY AND TREATMENT. 
 
 of fil)roma is often made, as it is readily confounded with 
 inflammatory hyperplasiae. 
 
 The histological constituents of the tumor are chiefly 
 fibrous tissue, a few (yellow) elastic fibers, and no round 
 cells, or only a few on the surface, probably due to 
 mechanical irritation. 
 
 Edematous and mucous degeneration often exists in the 
 interior witliout materially altering the character of the 
 tumor. If the process goes on to a softening of the tis- 
 sues, they may be completely absorbed and a cyst may be 
 formed (Plate 39, Fig. 1). 
 
 The sff((t of the tumor varies ; usually it is in the looser 
 parts of the tissue ; the cvppearance is pale to light red, 
 sometimes white or spotted from maceration and fatty or 
 horny degeneration of the epithelium (Plate 31, Fig. 2). 
 The surface is smooth or slightly convokited, or it may 
 present papillary elevations and a mulberry outline, as is 
 so frequently seen in the nose. It is then termed papillary 
 fibroma. 
 
 Fibroma usually occurs in middle-aged men (between 
 thirty and fifty), sometimes much later in life ; it is per- 
 fectly innocent. 
 
 Chondromata are very rare ; they are really ecchon- 
 droses of the laryngeal cartilages, causing the mucous 
 membrane to bulge out. Their origin is unknown. 
 
 Adenomata. — We know them only in the form of 
 cysts, due to dilated, obsolete glands. Their favorite seat 
 is the epiglottis, where they may be so large as to interfere 
 with respiration. 
 
 epithelioma. — This term may be applied to prolifer- 
 ations of the epithelium which grow toward the surface, 
 and in which, therefore, the ground-tissue is not crowded 
 aside nor involved in the proliferation. Such isolated 
 growths are, however, very rare ; an example is seen in 
 Plate 34, Fig. 3. It is a benign growth and does not 
 recur even after many years. 
 
 True angiomata arise from dilated veins or capillaries. 
 Plate 39, Fig. 2, shows an example of the former variety. 
 
NEOPLASMS OF THE LARYNX. 77 
 
 The enormous alveoli are included in a slender stroma of 
 fibrous^ partly edematous connective tissue. The surface 
 of the tumor may be rough or smooth ; the color varies 
 from red to purple (Plate 21, Fig. 2) ; the volume is sub- 
 ject to variations. They are much given to internal or 
 external bleedins;. These tumors are bv no means com- 
 mon ; quite often the ground-tissue becomes involved. 
 
 The lymphatics occasionally undergo dilatation to the 
 extent of forming tumors. I/ymphangiomata then 
 develop either from simple dilatation or from proliferation 
 of the vessel-\yalls ; sometimes they, too, lead to the for- 
 mation of cysts. They usually exhibit hydropic degener- 
 ation of tissue in certain places. In their external appear- 
 ance they do not differ materially from fibromata or from 
 hyperplasi?e. 
 
 Another part of the lymphatic apparatus, the follicles, 
 occasionally degenerates in the course of general leukemia. 
 The favorite seat of these lymphomata is the epiglottis, 
 which is normally very rich in follicles ; they are also 
 found at the aperture of the larynx. They appear as 
 whitish, spherical segments. Tlieir identification (except 
 by microscopical examination) will depend on other locali- 
 zations and on the blood-count. The treatment can only 
 be general. 
 
 Far more common than these simple structures are 
 mixed tumors. 
 
 (b) Hyperplasia of Entire Layers. 
 
 l^tiology. — They generally originate in an inflamma- 
 tion, sometimes obtained from the anamnesis, and are 
 characterized anatomically by more or less disease in the 
 vessels. The latter is particularly marked in syphilitic 
 forms, while in the non-specific hypertrophies secondary 
 to tuberculosis the epithelial proliferation is the prominent 
 feature. In view of this constant extraneous origin, the 
 term Secondary Neoplasms might be fitly applied to this 
 
78 PATHOLOGY AND TREATMENT. 
 
 group. These tumors do not usually attain the size of 
 those described above; still they are capable of producing 
 grave disturbances in both phonation and respiration. 
 
 We may further subdivide this intrinsically homogene- 
 ous class, if not by clinical, at least by histological char- 
 acters, bearing in mind, however, that the various subdi- 
 visions are essentially alike. 
 
 Fibro-epithelioina is the most frequent form ; at times 
 proliferation predominates in the epithelium (Plate 33, 
 Fig. 3 ; Plate 34, Fig. 1), at others in the connective 
 tissue (Plate 33, Fig. 1); while in a third class of cases 
 the overgrowth is uniform in both (Plate 33, Fig. 2 ; 
 Plate 35, Fig. 1 ; Plate 40, Fig. 2 ; Plate 41, Fig. 1). 
 
 The connective tissue is more or less rich in fibers, 
 according as the inflammatory round-celled infiltration is 
 more or less prominent. It develops preferably about the 
 vessels, forming at times dense conglomerations, at others 
 long streaks under the epithelium, or the fibers may be 
 distributed more widely. The vessel-Avalls (arteries) them- 
 selves are often affected ; the media in particular reaches 
 enormous proportions, although intima and adventitia also 
 occasionally constitute the most conspicuous features of 
 the picture. These hypertrophies of the vessel-walls are 
 always most pronounced in postsyphilitic proliferations. 
 
 The veins are less frequently affected ; dilatation is met 
 with occasionally, and may lead to the formation of 
 angiomata (Plate 33, Fig. 1). The epithelium really fur- 
 nishes the typical appearance in these tumors, notwith- 
 standing its overgrowth is only a secondary phenomenon ; 
 nothing could be more conspicuous than its excessive pro- 
 liferation. If the section examined is too superficial, the 
 inexperienced may even be led to suppose cannnoma, as 
 the far-reaching projections on half horizontal section 
 appear completely isolated in the surrounding tissue. The 
 picture is further complicated by enormous horny excres- 
 cences and bv fattv and colloid dcofcnerations. 
 
 If the blood-vessels are hypertrophied either in the 
 direction of their axis (Plate 40, Fig. 1), or transversely 
 
NEOPLASMS OF THE LARYNX. 79 
 
 (Plate 39, Fig. 3), the tumor may be termed an angio- 
 fibroma ; overgrowths of the lymphatics (Plate 33, Fig. 2) 
 constitute a lymphangio-fibroma. 
 
 If the glands are much involved in the proliferation, 
 their epithelium degenerates, and we get colloid tumors, 
 which may lead to the formation of cysts. 
 
 The most interesting of these neoplasms are the jjapil- 
 lary forms. T\\q jjapillary fibro-epithelioma even presents 
 some clinical peculiarities. The histological characters 
 consist in branch-like processes of connective tissue, ema- 
 nating either from a broad base parallel to the surface, or 
 from a thick stem, covered with an exceedingly thick 
 coating of epithelium. Each branch is supplied by a 
 vascular loop containing an artery and a vein. Of the 
 origin of these neoplasms in adults, we know nothing ; 
 the theory that their peculiar forni depends upon specific 
 irritation finds much support in the fact that the same 
 tumors in children are unquestionably due to acute infec- 
 tious processes (like measles and whooping-cough). 
 
 These tumors also exhibit at times angiectatic and arte- 
 ritic phenomena, as well as round-celled infiltration, as 
 signs of inflammatory irritation. 
 
 According to their seat, appearance, and clinical behav- 
 ior, the tumors of this group have received various 
 names, without regard to etiology or histological classifica- 
 tion. In general, their seat depends on the kind of irri- 
 tation to which they are due. 
 
 Small, hard neoplasms are often seen on the free edge 
 of the vocal cords between the middle and anterior thirds ; 
 they are called singer's nodules (Plate 14, Fig. 2 ; Plate 
 33, Fig. 1). In this situation they are usually caused by 
 excessive functional irritation.^ 
 
 ^ [The theory that the origin of these nodules, otherwise known as 
 chnrditis tuberosa, is due solely to the method of tone-production termed 
 "coup de glotte" or ''stroke of the glottis," cannot be sustained. They 
 are a clinical variety of pachydermia, and are to be attributed rather 
 to overuse of the voice than to merely its faulty or inartistic use. If 
 the singing voice is accurately "placed," or, in other words, if the direc- 
 tion and reinforcement of the tone are proper, the mere mode of attack 
 
80 PATHOLOGY AXI) TREATMENT. 
 
 If fibro-epitheliomata develop on the vocal processes, 
 they often take the form of cup-shaped deposits on one 
 side and wart-like excrescences on the other, so that the 
 latter are pressed into the former during phonation. The 
 posterior wall presents similar dense, flat formations, 
 either in connection witli the former or independentlv 
 (Plate 10, Fig. 1 ; Plate 16, Fig. 1 ; Plate 22, Fig. 3j. 
 On account of the altered appearances Mhich are the 
 mechanical result of this localization, observers have been 
 led to describe them as a specific disease under the name 
 of pachydermia larvngis. For the etiology of this variety 
 of irritative hypertrophy see p. 60. 
 
 Larger neoplasms of this kind are most apt to be found 
 where the connective tissue is loose, and may look exactly 
 like ordinary fibromata (Plate 31, Fig. 1). 
 
 If portions of the mucous membrane of the ventricles 
 become hypertrophied, they may loosen the ground-tissue 
 by their weight to such a degree that the tumor may be 
 moved in and out of the ventricle either with a probe or 
 by the movement of the larynx alone ; we thus get the 
 picture of prolapse of the ventricle of Morgagni (Plate 18, 
 
 The proliferations which accompany syphilis and tuber- 
 culosis also elect the seats of greatest irritation, either in 
 the neighborhood of ulcers or over infiltrations ; if they 
 follow in the wake of syphilis, it is safe to assume a 
 hidden inflammatory focus, though it may remain latent 
 for a long time. 
 
 The symptoms of homologous tumors are, according 
 to the situation, dysphonia (mufiled or peculiar "gruff'' 
 quality, subdued voice, tem})orary or permanent aphonia), 
 occasionally irritative cough with reflex spasms of the 
 cords (attacks of dyspnea), and, if size and situation are 
 such as to produce it, constant dyspnea. If the tumor is 
 movable, the symptoms may vary a good deal from time 
 to time and a new symptom may arise : a rattling noise, 
 
 is of but little, if any, consequence considered in its relation to diseases 
 or injuries of the vocal cords. — Ed.] 
 
NEOPLASMS OF THE LARYNX. 81 
 
 heard either in respiration or in phonation, and caused by 
 the striking of the mass against the walls of the organ as 
 it is moved by the current of air (Plate 31, Fig. 2). 
 
 The treatment of the larger tumors consists in me- 
 chanical removal ; in hypertrophies special attention must 
 be paid to the etiology, if they are to be successfully exter- 
 minated. If the irritation is functional, smoking, talking, 
 singing, or, at least, incorrect singing, must be forbidden ; 
 if the cause lies in disease of nose and fauces, it must be 
 effectively treated ; any foci of syphilitic or tuberculous 
 infection must be carefully searched for. 
 
 It is to be remembered that the papillary forms un- 
 questionably originate in the basal connective tissue, al- 
 though the method of growth is unknown. To avoid re- 
 currence of the tumor, the tissue in question must there- 
 fore be extirpated. In papillary tumors with broad bases, 
 especially in children, the operative field may have to be 
 laid open by means of laryngotomy in order to accomplish 
 this end. 
 
 We need not here go into the technic of tumor- 
 excision. 
 
 2. HETEROLOGOUS NEOPLASMS. 
 
 Two kinds of tumors, lipoma and struma, are types of 
 this class. 
 
 I/ipoma occurs in the form of broad, deeply lobulated 
 tumors with finger-shaped projections in places where the 
 mucous membrane is loosely attached, especially at the 
 aperture of the larynx. They rarely develop from metas- 
 tasis, and must be attributed to fatty degenerations of 
 fibromata. 
 
 Tumors consisting of thyroid-gland tissue sometimes 
 spring from dislocated portions of the gland ; that is to 
 say, a malformation (struma accessoria). They are cov- 
 ered with normal mucous membrane, and usually are of 
 slow growth. They must not be confounded with true 
 struma bulging into the pharynx or larynx (Fig. 17). 
 
 In contrast with these foreign tumors the malignant 
 
 6 
 
82 PATHOLOGY AND TREATMENT. 
 
 growths spring from normal tissues, and only become 
 heterologous through their atypical growth. 
 
 Carcinoma. 
 
 Carcinotna is practically always primary. 
 
 Of the origin of cancer we know nothing positive ; 
 heredity, no doubt, has something to do with it.^ It is 
 also known that syphilitic and other ulcerations may set 
 up an atypical proliferation of the epithelium. The 
 structure is usually that of the so-called epithelial cancer ; 
 more rarely the tumors spring from the glands. Usually 
 the cancerous growth infiltrates the surrounding tissues, 
 which remain passive ; in rare cases (Plate 27, Fig. 1 ; 
 Plate 28, Fig. 3) the connective tissue grows so as to form 
 a dense pedicle on which the carcinoma rests ; sometimes 
 the connective tissue surrounds the invading tumor with a 
 network of dense fibers and arrests its growth (scirrhus). 
 
 The laryngoscopic image varies greatly ; quite often the 
 tumor itself cannot be seen, and all that appears is a sec- 
 ondary superficial proliferation of benign character, caused 
 by the irritation in the deeper layers. Such innocent 
 tumors may exist for years before the malignant growth 
 becomes manifest, and this has given rise to the theory 
 that innocent tumors may become converted into car- 
 cinoma. 
 
 The tumors assume the most variegated forms : in one 
 case, multiple papillary proliferations are seen on the 
 edges of the vocal cords ; in another, a general metamor- 
 phosis of a part of the larvnx into rigid knots or nodules 
 (Plate 14, Fig, 2), or a flat papillary layer (Plate 28, 
 Fig. 1) ; again, a rigid, slightly roughened, widespread 
 infiltration; finally, very large, lumpy tumors (Plate 17, 
 Fig. 1). As the process goes on, the tumor always breaks 
 down, and the combination of evident neoplasm with the 
 
 ^ [So far from increasing his belief in the hereditary tranbniis&ion 
 of cancer, Herbert Snow says that his experience makes iiim the more 
 doubtful of the malignant nature of a new growth, if there happens to 
 be a history of such disease in the patient's ancestry. — Ed.] 
 
NEOPLASMS OF THE LARYNX. 83 
 
 signs of tissue-destruction becomes most characteristic 
 (Plate 28, Fig. 1). Sometimes, however, especially in the 
 absence of secondary proliferations, the centrally located 
 tumor may hide itself under the appearance of a uniform 
 s^Yelling of some part of the larynx, especially the ven- 
 tricular band. Later on the picture is complicated by 
 alterations due to infection of the ulcerated portion?, by 
 edema and abscesses, and finally by necrosis of the cartil- 
 age after the perichondrium has become absorbed. A 
 most conspicuous feature is the early interference with 
 function ; if the tumor is situated on the true vocal cord 
 or near the crico-arytenoid articulation, as is usually the 
 case, motile disturbances (sluggish action) manifest them- 
 selves out of all proportion to the small tumor ^vhich may 
 be visible ; the appearance of this symptom should lead 
 us strongly to suspect cancer. 
 
 Metastases into the glands usually occur very late ; 
 sometimes they far surpass the original tumor in extent.^ 
 
 The diagnosis can be made without much trouble in the 
 advanced stages by the characteristics just enumerated ; 
 in the early stage it may sometimes be suggested by the 
 last-named symptom. Any marked subjective symptom 
 where little objective alteration is visible must be looked 
 upon with suspicion. Pronounced sensibility, periodic 
 hemorrhages, or obstinate hoarseness, the smallest uni- 
 latei^al proliferation or infiltration that cannot be easily 
 accounted for, in patients over forty years of age, are 
 most suspicious signs of cancer. The diagnosis is con- 
 firmed by clinical observation or microscopic examination. 
 In elderly people the rigidity which has been mentioned 
 almost suffices for the diagnosis. In obscure cases, if the 
 
 ^ [The time at whicli secondary infiltration of the neighboring lym- 
 phatic glands occurs varies with the situation of the primary growth. 
 Krishaber, Butiin, and others classify malignant growths of the larynx 
 into extrinsic and intrinsic. The former include those involving the epi- 
 glottis, arytenoids, aryepiglottic folds, and pyriform sinuses, and the 
 latter those affecting the vocal cords and ventricular bands, and the 
 infraglottic growths. It is the extrinsic which earliest lead to secondary 
 adenopathies. — Ed.] 
 
84 PATHOLOGY AND TREATMENT. 
 
 presence of some kind of tumor is evident, the diagnosis 
 of cancer is confirmed by the results of continued obser- 
 vation, such as : rapid growth, increased pain and dis- 
 comfort, and rapid recurrence of superficial portions of 
 the tumor after excision, even when the microscopic ex- 
 amination gives a negative result. 
 
 In the early stages microscopic examination is not 
 always decisive, as the real tumor may be seated far below 
 the surface. If the changes in the latter are not advanced 
 enough for a vertical section to exhibit distinct carcinom- 
 atous characters (epithelial outgrowths and cancer-nests 
 pervading normal or newly formed tissue), it becomes our 
 duty, as well as our right, to secure deeper-lying portions 
 for examination, even if it should necessitate performing 
 thyreotomy. 
 
 Such an exploratory operation in the early stages (pro- 
 viding, of course, there are strong grounds for suspecting 
 cancer) is the more justifiable, as it is frequently followed 
 by complete recovery. 
 
 In doubtful cases, even if there are no indications of 
 syphilis, it is always well to try potassium iodid ; it is 
 astonishing what good results sometimes follow the exhi- 
 bition of this drug. Tuberculosis of the larynx in the 
 advanced stages is also a frequent source of error (Plate 
 28, Fig. 2) ; this mistake is not so fatal, however, as 
 failure to recognize curable syphilis or the early, operative 
 stage of cancer. 
 
 The only treatment is total excision of the tumor with 
 a surrounding zone of healthy tissue. If the diagnosis is 
 made earlv, this can usually be done bv means of larvn- 
 gotomy ; the prognosis is, of course, much better if the 
 process is circumscribed than in extensive disease neces- 
 sitating partial or total extirpation. The fiite of cases 
 not operated on is sad indeed — death from asphyxia, dys- 
 phagia, or sepsis. 
 
 One of the forms of papillary fibroma deserves mention 
 on account of its tendency to atypical growth ; it is the 
 very rare 
 
NEOPLASMS OF THE LARYNX. 85 
 
 Destructive Papillary Fibro=epithelioina. 
 
 It is a papillary (" Brussels sprouts ") tumor which is ex- 
 ceedingly prone to recur in loco after removal^ and even 
 carries its infection by leaping^ as it were^ to other parts 
 of the mucous membrane. The first characteristics can 
 be explained on histological grounds ; the epithelial masses 
 spread not only about and into the ne^Yly formed connec- 
 tive tissue^ but^ also^ to the basal tissue and even into the 
 glandular layer (Plate 36, Figs. 1 and 2). Even here, 
 however, the connective tissue seems to play the principal 
 part, on the one hand, by throwing out processes, on 
 the other, by drawing the epithelium down with it into 
 the deeper layers. More advanced cases are needed to 
 throw further light on the subject. 
 
 Sarcoma 
 
 in the larynx probably always springs from the endothe- 
 lium or from the adveutitia of blood-vessels or lymphatics. 
 It may retain the alveolar type (Plate 37, Figs. 1 and 2), 
 or it may diffuse itself into the adjacent tissues ; if its 
 origin is endothelial, it may take on a papillary character 
 by proliferation into the open spaces and be mistaken for 
 an epithelial tumor. The usual varieties occur here as 
 elsewhere : medullary, round-celled, fibroid, giant-celled, 
 and melanotic sarcoma. It is worth noting that occasion- 
 ally the tumor is separated from the healthy tissue by a 
 fibrous stalk. 
 
 Before the growth breaks through to the surface, it is 
 often accompanied by excessive proliferation of the epi- 
 thelium ; the adjacent connective tissue also reacts to the 
 irritation bv small-celled non-heterologous proliferations 
 (Plate 37, Fig. 1). 
 
 As regards symptoms, physical characters, metastasis, 
 and the diagnosis, sarcoma is essentially the same as car- 
 cinoma. Possibly the sarcomata are distinguished by a 
 more uniform surface. 
 
 One final warning for the diagnosis seems apposite : if, 
 
86 PATHOLOGY AND TREATMENT. 
 
 in examining an extirpated portion for malignancy, we 
 think only of cancer, the finding of epithelial prolifera- 
 tions — not an uncommon occurrence in sarcoma — may 
 cause us to exclude cancer without at the same time 
 awakening a suspicion of .sarcoma. AVe must not forget, 
 therefore, that sarcoma may be present even when the ex- 
 amination gives a negative result for cancer. 
 
 IV. DISTURBANCES OF MOTILITY. 
 
 1. MECHANICAL. 
 
 Mechanical disturbances are directly due to muscula}- 
 insufficiency. These develop in acute and chronic inflam- 
 mations and infiltrations, as the result of muscle-degener- 
 ation in general tuberculosis, in trichinosis, in grave an- 
 emias, and after grave acute infections (typhoid, diphtheria, 
 etc.) ; also from overexertion in singing and speaking. 
 The diagnosis is based on typical positions of the vocal 
 cords during phonation or respiration. 
 
 Palsv of the lateral crico-arytenoid muscle causes a 
 gaping of the glottis cartilaginea with the angle formed 
 by the two cartilages opening forward (p. 15, Fig. 5), 
 while in paralysis of the transverse arytenoid muscle the 
 angle of divergence looks backward (p. 15, Fig. 4). In 
 paralysis of the thyro-arytenoid muscles the glottis liga- 
 mentosa forms a semi-elliptical or elliptical cleft in pho- 
 nation, according as the paralvsis is unilateral or bilateral 
 (p. 16, Fig. 6; Plate 9, Figs. 1 and 2). If the lateral 
 crico-arytenoid muscle is affected at the same time, this 
 cleft extends to the cartilaginous portion ; if the trans- 
 verse arytenoid is involved in conjunction with the thyro- 
 arytenoids, a double ellipse is seen, the point of contact 
 corresponding to the apices of the vocal processes. If 
 all three muscles are paralyzed, the corresponding vocal 
 cord is arrested in respiratory posture. 
 
DISTURBANCES OF MOTILITY. 87 
 
 Paralysis of the posterior crico-arytenoid muscle pro- 
 duces arrest of the vocal cord in respiration at or very 
 near the middle line (Figs. 21 and 22). 
 
 The symptoms of these paralyses are (in the adductor 
 group) vocal disturbances running on to complete aphonia. 
 In rare instances the ventricular bands, by a vicarious 
 action, arc drawn over the true vocal cords (which are not 
 sufficiently adducted or stretched), so as to eifect phona- 
 tion ; the result is a rough, rumbling voice (Plate 3, 
 Fig. 2). Paralysis of the posterior crico-arytenoid, if 
 unilateral, may present no symptoms ; bilateral paralysis 
 necessarily produces intense dyspnea, which is often aggra- 
 vated (in unilateral paralysis produced) by perverse con- 
 traction of the adductors brought on by the efforts to 
 overcome the dyspnea. 
 
 The treatment must be cliiefly directed against the pri- 
 mary trouble ; in addition to this, direct excitation of the 
 muscles by electricity from within or without may be 
 employed with advantage (p. 35). 
 
 That inflammation in and about the crico-arytenoid 
 articulation may be attended by motile disturbances has 
 been mentioned (p. 49 et seq.), and the diagnosis in the 
 active stage described in the same connection. We shall 
 now bring out those points which, after the disappearance 
 of all symptoms referring to the joint, establish with 
 more or less certainty the presence of an articular obstacle. 
 It is quite clear that all such phenomena must be due to 
 diminished passive mobility. 
 
 First, we would mention any fixation of the vocal cords 
 which does not correspond in position with any of the 
 muscular paralyses just described, or with the nervous 
 paralyses to be described in the next section ; if, for in- 
 stance, a vocal cord assumes a position midway between 
 that of the cadaver and that of respiration or phonation, 
 or if, during phonation, it is adducted only to the cadaveric 
 position — if, in short, its excursions are incomplete. Sec- 
 ondly, the jerky movements of the cords, which have 
 been mentioned, as if they were being dragged over ob- 
 
88 PATHOLOGY AXD TREATMENT. 
 
 stacles. In addition, we have those cases where the vocal 
 cords at first functionate properly enough and gradually 
 become more and more sluggish and insufficient in their 
 movements, or where the opposite takes place. If the 
 motile disturbances alternate in position between adduc- 
 tion and aVjduction, we can exclude muscular or nervous 
 paralysis with certainty. Often we have to content our- 
 selves with a theory, especially when the condition does 
 not present fixation, but only impeded motion. 
 
 2. NEUROTIC DISTURBANCES. 
 (a) Hyperkinetic Neuroses. 
 
 Both tonic and clonic spasms occur in practically all 
 the laryngeal muscles. 
 
 Tonic spasms of the abductors have a central origin ; 
 they are frequently seen in tabes dorsalis, and give rise to 
 the well-known laryngeal crises : sudden attack of dyspnea 
 with loud inspiration, the cords often remaining fixed in 
 adduction for a considerable length of time ; they also 
 occur in tetanus and in tetany and occasionally in hydro- 
 phobia 
 
 Spasms sometimes proceed from the timnJcs of the 
 recurrent nerves as forerunners of a paralysis, when the 
 causal injury is slight and temporary in its action. 
 
 Reflex adduction forms follow direct irritation of the 
 larynx or even of the mucous membrane of the fauces, 
 by therapeutic applications, by the entrance of foreign 
 bodies, or by the aspiration and unintentional swallowing 
 of intensely irritating materials (" irrespirable " gases), 
 and by tumors in or near the larynx. The spasm may 
 also be excited by irritation in other parts of the body, 
 especially if reflex irritability is great. This is always 
 the case in the early years of childhood — in fact, these 
 spasms are so frequent and so dangerous that they have 
 been described as a special disease under the name of 
 laryngosjjasmus infantum. Nevertheless, it is only a 
 
DISTURBANCES OF MOTILITY. 89 
 
 symptom, not a disease, and may be due to the most 
 varied causes. If it cannot be referred to a veiled and 
 obscure tetany, its cause is usually found in intestinal 
 disturbances, brought on by artificial foods in sucklings, 
 by intestinal catarrh, tape- worm or constipation in older 
 children. 
 
 Tonus of the abductors has been observed in hvdro- 
 phobia. The vocal cords are fixed in extreme abduction. 
 
 Clonic Spasms are also usually seen in the adductor 
 muscles, and always have a central origin. They are 
 characterized by a rhythmical tw^itching inward of the 
 vocal cords, sometimes persisting for months. Such 
 spasms have been observed in conjunction with similar 
 ones in the pillars of the fauces, on one or both sides, in 
 brain syphilis, after meningitis, direct or indirect disease 
 of the medulla oblongata in the neighborhood of the 
 accessory nucleus, pressure on the medulla from tumor of 
 the cerebellum. They have also been seen in paralysis 
 agitans, accompanying the tremulous movements of the 
 extremities — the effect probably of increased irritability 
 by psychical impressions. 
 
 A mixture of clonic and tonic spasms has been observed 
 in the depressors of the epiglottis ; the organ would sink 
 dow^n upon the aperture for variable periods of time, or 
 merely exhibit slight twitchings. 
 
 The treatment of spasms of central origin is purely 
 symptomatic, as the primary disease is usually incurable. 
 In tabetic crises and in all longer attacks it is best to 
 reduce the excitability of the respective centers by means 
 of morphin injections, especially as the violent, forced 
 inspirations only tend to increase the dyspnea by sucking 
 in the vocal cords and the epiglottis. If the dyspnea is 
 prolonged, tracheotomy is indicated. 
 
 Spasm of the glottis in children endangers life and 
 must be allayed ; cold douches in a warm bath are em- 
 ployed with good success ; the etiological factors must, of 
 course, be looked for and removed. A change from 
 artificial food to the breast often puts an effectual stop to 
 
90 PATHOLOGY AND TREATMENT. 
 
 the attacks. Attention must be given to the functions of 
 the gastro-intestinal tract. 
 
 (b) Hypokinetic Neuroses. 
 
 Paralyses or pareses affect the muscles supplied by the 
 superior and inferior laryngeal nerves. Those innervated 
 by the recurrent nerves are the most frequently involved. 
 
 The picture in paralysis of the recurrent nerve varies 
 according as the paralysis is unilateral or bilateral, partial 
 or total. 
 
 In total paralysis the affected vocal cord is fixed mid- 
 way between respiration and phonation — the so-called 
 cadaveric position. We regard this as the position of 
 passive equilibrium, as neither adductors nor abductors are 
 acting. In addition, the free edge of the vocal cord 
 appears more concave than usual, showing a loss of 
 physiological tonus in the stretching muscle (Fig. 17); if 
 the attack is prolonged, the muscle atrophies and the 
 vocal cord loses in width (Plate 13, Fig. 2). The aryte- 
 noid cartilage on the affected side projects forward (Figs. 
 17, 18, and 19). 
 
 In j)honation one vocal cord remains immovable, while 
 the other, as usual, moves to the middle line (Fig. 17), and 
 sometimes beyond it as a compensation (Fig. 18). At the 
 same time the arytenoid cartilage of the sound side is 
 advanced in front of that of the affected side, which is 
 pushed aside ; not infrequently, however, the latter is 
 seen to twitch slightly inward and forward, as the trans- 
 verse arytenoid muscle is often supplied by the superior 
 laryngeal nerve, instead of the recurrent, and therefore 
 retains its efficiency even in paralysis of the recurrent. 
 As this movement, when present, is proof of the passive 
 mobility of the articulation, it constitutes a reliable 
 means of excluding joint-disease. The epiglottis is also 
 occasionally seen to twitch on the sound side whenever 
 the depressor of the epiglottis is ''sup])lied by the recur- 
 rent instead of by the superior laryngeal. It is also a 
 
DISTURBANCES OF MOTILITY. 91 
 
 .certain sign that the lesion is nervous and not articular. 
 In bilateral paralysis both vocal cords remain immovable 
 in the cadaveric position. 
 
 The symptoms of unilateral paralysis are : at first rough, 
 feeble voice, later somewhat improved through compensa- 
 tion ; so called air- waste, which can be felt by the hand 
 held over the mouth as superfluous air rushes through the 
 excessive cleft of the glottis. Bilateral paralysis pro- 
 duces complete aphonia. A want of vibration in the 
 thyroid cartilage of the affected side is not without signif- 
 icance. In the beginning we sometimes have mis-swallow- 
 ing, due probably to paresis of the epiglottis. 
 
 Total paralysis is always preceded by partial paralysis, 
 although the latter may sometimes escape observation. 
 It is confined to the abductors, so that the pActure shows 
 one or Ijoth vocal cords in the median position (Figs. 23 
 and 24). (The arytenoid cartilage of the affected side is 
 in front of that of the sound side.) The reason must 
 be sought in the greater vulnerability of the abductor 
 fibers. 
 
 In unilateral median posture there are practically no 
 sympjtoms ; the voice is good and respiration is not impaired 
 except upon great exertion. Bilateral median posture, on 
 the other hand, interferes seriously with respiration, as 
 the respiratory cleft is excessively narrowed (even more 
 than is shown in Fig. 22). 
 
 Paralyses originate by injury to the centers, to the vagus 
 at afiy point in its course, or to the recurrent laryngeal 
 itself. 
 
 Central paralyses we know only in connection with 
 diseases in the medulla oblongata, more particularly of 
 the accessoriovagal nucleus. Kothing positive is known 
 of any cortical origin. We know only that disease about 
 Broca^s speaking-center (left inferior frontal convolution) 
 mhWAi^ functional movement of the larynx. 
 
 Positive signs of a central paralysis can be obtained 
 only by a general examination and the recognition of a 
 general disease, or by other symptoms pointing to a focus. 
 
92 PATHOLOGY AND TREATMENT. 
 
 Among the known causes are : thrombotic or apoplectic 
 softening of the medulla oblongata, neoplasms, abscesses, 
 and aneurysm compressing and destroying the bulb, dis- 
 ease of the nuclei in the medulla (bulbar paralysis), lateral 
 sclerosis, progressive muscular atrophy, syringomyelitis, 
 and tabes cervicalis ; finally, general nutritive disturb- 
 ances such as are produced by syphilitic disease of the 
 blood-vessels. It goes without saying that the diagnosis 
 of all these diseases (which we will not go into here) 
 must be established before it can be made use of as an 
 etiological factor. 
 
 Peripheral palsies follow disease of the vagus, direct 
 traumatic or operative injury, aneurysm of the internal 
 carotid, malignant tumors on the base of the brain, in the 
 glands or in the mediastinum, struma, and cervical phleg- 
 mon (purulent neuritis). 
 
 Any one of these causes can be recognized by the pulse- 
 acceleration which always accompanies injury in this 
 region ; if the paralysis begins above the origin of the 
 superior laryngeal nerve, the latter will, of course, be 
 involved also, and eventually the paralysis will extend to 
 the pharynx (through the pharyngeal branch). Some- 
 times the pharynx is involved in paralysis of the recur- 
 rent alone, probably as a result of an ascending neuritis. 
 In most cases other cerebral nerves are paralyzed, so that 
 we often get the picture of pseudobulbar ])aralysis. 
 
 Disease of the recurrent nerves is in the majority of 
 cases caused by some morbid process in the adjacent tis- 
 sues, and is, therefore, an important factor in the diagnosis 
 of such lesions. The latter include : aneurysm of the 
 arch (especially for the left nerve), aneurysm of the innom- 
 inate artery (for the right), pericarditis (left), pleuritis 
 of the apices (more right), and large pleural exudates ; all 
 the diseases of the mediastinal tissues and of the medias- 
 tinal glands (carcinoma, sarcoma, tuberculosis, syphilis, 
 malignant lymj)homa, echinococcus, etc.), very frequently 
 g(^iter (more on the left side), and cancer of the esophagus 
 (more on the right side); rarely, direct injuries (in stru- 
 
DISTURBANCES OF MOTILITY. 93 
 
 meotomy, injections into the parenchyma of a goiter^ l^g^" 
 tion of vessels). 
 
 Infectious neuritis of the trunk occurs in syphilis, 
 diphtheria, the acute exanthemata, influenza, pneumonia, 
 and typhoid ; toxic neuritis in lead-poisoning and, per- 
 haps, in alcoholism. A " rheumatic " origin is very 
 problematical. 
 
 The diagnosis of paralysis of the vocal cord is based on 
 the laryngoscopic image, on the course of the disease, and 
 on the exclusion of etiological factors. The signs of 
 total paralysis of the recurrent in the laryngoscopic picture 
 are : cadaveric position and twitching either of the dis- 
 eased arytenoid cartilage, or of the sound side of the 
 epiglottis. 
 
 A median position is shown to be due to a nerve-lesion 
 by the subsequent course of the disease — that is to say, if 
 it is followed by perfect mobility or by the cadaveric 
 position ; conversely, a cadaveric position is of a nervous 
 nature if it was preceded by a median position. 
 
 If the above factors are not, or have not been, present, 
 we cannot at once decide wdiether a fixation of one or 
 both cords is due to paralysis or to ankylosis. We must, 
 before making a diagnosis, establish the existence of a 
 central or peripheral lesion which can produce paralysis, 
 and cannot produce mechanical alterations in or about the 
 joint. For instance, struma or cancer of the esophagus 
 can affect the nerve only, while tuberculosis and syphilis 
 can affect the nerve through the pleurae or the glands, and 
 also the joint either directly or through the perichondrium. 
 If such an ambiguous process is at work, paralysis of the 
 recurrent can be recognized only by the subsequent course, 
 or if the laryngoscopic image is unmistakable. Other- 
 wise the diagnosis had best be left open. There is no 
 doubt that the cadaveric position in so-called rheumatic 
 palsies (w^hich means that no cause can be found) is often 
 due to mechanical disturbances, and not to paralysis. In 
 the absence then of a nervous origin and of unmistakable 
 signs in the course of the disease, or of a characteristic 
 
94 • PATHOLOGY AND TREATMENT. 
 
 laryngeal condition, cadaveric position alone cannot be 
 regarded as sufficient proof of total, nor median position 
 of partial paralysis of the recurrent. 
 
 The prognosis of paralysis of the recurrent is, in gen- 
 eral, unfavorable, as most of the causal conditions are 
 incurable. If the cause can be removed, as in goiter, 
 syphilis, etc., it must be done as early as possible ; partial 
 paralysis in such cases disappears without further trouble ; 
 but if the paralysis was complete, irreparable atrophy of 
 nerves and muscles (Plate 13, Fig. 2), or at least abnormal 
 movements, may be the result (Fig. 25). 
 
 The treatme)d must, therefore, be directed against the 
 primary cause. Local applications (internal and external 
 electricity) may be advisable to combat the muscular in- 
 activity ; their value in so-called rheumatic paralysis is, 
 of course, proportionate to the problematical nature of 
 that condition. 
 
 Paralyses of the superior laryngeal nerves are of very 
 rare occurrence. They manifest themselves by inaction 
 of the cricothyroid muscle, and later of the depressor of 
 the epiglottis, and by anesthesia of the laryngeal mucous 
 membrane. 
 
 The first lesion relaxes the true vocal cords, as tlie ten- 
 sor muscles can no longer put them on the stretch in the 
 absence of a resisting force ; the free edges, therefore, 
 show a wavy outline (Fig. 23). 
 
 If the cricoid and thyroid cartilages are approximated 
 mechanically, the voice is immediately improved. 
 
 The paralysis occurs as a result of direct injury (opera- 
 tive); more frequently, in part at least, as a sensory paral- 
 ysis after diphtheria. 
 
 Concerning the etiology we are still very much in the 
 dark. 
 
 (c) Parakinetic Neuroses. 
 
 This term is applied to disturbances of innervation in 
 which deviations from the normal movements take place. 
 
 They are few in number, and may be divided into 
 organic and Junctional. 
 
DISTURBANCES OF MOTILITY. 95 
 
 To the first class belong the disturbances of motility 
 met with in multiple sclerosis and in tabes. In the 
 former it has been observed that the vocal cords in phona- 
 tion alternately relax and contract (intention-tremor) ; 
 they exhibit fibrillar twitehings and sluggish closure of 
 the glottis ; then^ in inspiration^ the glottis is closed so 
 that the inspirations are shrilly especially in laughing. 
 Sometimes the glottis is closed by a spasmodic movement 
 in phonation. 
 
 In tabes the vocal cords have been observed to move 
 by jerks and to stop half-way, both when phonation and 
 inspiration Avere attempted, constituting therefore a true 
 ataxia. Similar phenomena have been observed in hemi- 
 plegias, as a kind of fatigue-symptom. 
 
 FundionaUy aberrant movements in the opposite direc- 
 tion to the one intended are quite common ; they must all 
 be regarded as the effects of perverse innervation. The 
 latter occurs as the result of an existing paralysis, oi through 
 physical or psychical association-fatigue. Thus we have a 
 convulsive respiratory closure of the glottis in tabetic or 
 other neurotic median position, or in median position on one 
 side and cadaveric position on the other ; also in the so- 
 called respiratory spasm of the glottis, in which the vocal 
 cords after phonation scarcely separate at all, or only as far 
 as the cadaveric position. The false movements are most 
 pronounced in moments of psychical excitement, or Avhen 
 an attempt is made to breathe properly. In paralysis 
 of the abductors the false movements may be regarded as 
 deviations of the innervation from the proper paths, 
 which are closed, into improper channels, while sponta- 
 neous resj^iratory spasm may be explained on the ground 
 that the correct anatomical innervation is disturbed by 
 the intervention of consciousness (attention). This is a 
 matter of e very-day occurrence in other parts of the 
 body whenever coordinated movements, which are usually 
 performed semi-consciously, are forcibly brought under 
 the sway of conscious will-power. Thus a well-drilled 
 recruit may suddenly turn to the right, instead of to the 
 
96 PATHOLOGY AND TREATMENT. 
 
 left, when a new inspection takes place, and the stutterer 
 stutters most when he is trying hardest to avoid stutter- 
 ing. 
 
 Another form is phonic spasm of the vocal cords, in 
 which the cords, instead of being simply approximated in 
 phonation so as still to allow the passage of some air, are 
 convulsively pressed together, so that not a sound can 
 pass. This overadion is probably susceptible of the same 
 explanation as perverse innervation. When this condi- 
 tion has persisted for some time, it is no doubt aggravated 
 subjectively by the patient's conviction that he could not 
 do otherwise if he tried. 
 
 As these two forms of parakinesis are of a purely 
 psychical character and probably occur only in " nervous'' 
 patients, the treatment must be purely psychical : revive 
 the patient's fallen self-confidence, raise his powers of 
 resistance, and divert his attention from his ailment, espe- 
 cially from its symptoms. 
 
 Sometimes we meet with such intention-disturbances 
 and irregular phonatory movements, manifesting them- 
 selves in tremulousness of the voice in professional men, 
 as the result of over-exertion of the voice — i. e., fatigue- 
 symptoms. The term mogiphony has been used. It is 
 characteristic that they manifest themselves only during 
 the acts which produced them in the first place — preach- 
 ing, reading aloud, singing, etc. They are, therefore, 
 true occupation-neuroses, and their cause must be sought 
 in the difficulty experienced in bringing the tired muscles 
 and nerves into action. 
 
 V. DISTURBANCES OF SENSIBILITY. 
 
 They take the form of increased, diminished, or absent 
 sensibility of the larynx. 
 
 Hyperesthesia is very hard to define, as the reflex 
 
DISTURBANCES OF SENSIBILITY. 97 
 
 sensibility of the larynx is normally very great. Reflex 
 sensibility is much more marked than normal sensation. 
 Hyperesthesia of the superior laryngeal nerve, which can 
 sometimes be determined by palpating the upper lateral 
 border of the thyroid at its centre, belongs under this 
 head. It is important to become familiar with it, so as to 
 be able to distinguish it from sensitiveness of the crico- 
 arytenoid articulation, which lies more posteriorly. 
 
 Organic anesthesia and hyperesthesia are met with in 
 total paralysis of the superior laryngeal nerve (see p. 94), 
 or in partial paralysis aflPecting only the sensory fibers 
 (after diphtheria, etc.). Functional anesthesia, so far as 
 our observations have gone, occurs only as a psychical 
 disturbance (hysteria). Even the healthy larynx is some- 
 times very callous to irritation (with the sound), without 
 the conditions, indicating hyphesthesia. 
 
 Paresthesiae of the larynx cannot very well be dis- 
 sociated from paresthesiae of other organs in the throat ; 
 they consist simply of abnormal sensations without any 
 organic foundation or definite localization. They are 
 identical with general paresthesiae in the region of the 
 throat and esophagus, and are produced by the same 
 cause — the attention being unduly directed to the organ 
 by unusual . conditions (general excitement, pregnancy, 
 climacteric, menstruation, dread of impending disease). 
 
 Suggestion-therapy offers the greatest promise of suc- 
 cess, unless the subjective resistance is too great or the 
 psychical cause cannot be determined. 
 
 V«. COMPLICATED (FUNCTIONAL) MOTOR AND SEN- 
 SORY DISTURBANCES. 
 
 These forms must be discussed separately, if only on 
 account of their peculiar etiology, since they are nothing 
 but local manifestations of hysteria. Every variety of 
 muscular or nervous paralysis or hyperkinesis may be 
 functionally simulated by reason of the psychical excite- 
 ment. The hysterical symptoms do not in any sense 
 t 
 
98 PATHOLOGY AND TREATMENT. 
 
 depend upon paralysis, but are due to defective function 
 from want of volitional impulse ; they are not true 
 spasms, but simply the expression of perverted or exces- 
 sive, semi-conscious volitional impulses. As in other 
 parts of the body, so in the larynx the hysterical phenom- 
 ena are the external manifestations of imperfect psychical 
 processes, the bodily recollections of unconscious experi- 
 ences. 
 
 The phenomena are of the most varied description ; 
 they range from loss of function of single muscles or 
 areas of sensibility to total loss of movement and sensa- 
 tion ; from the insignificant " globus " paresthesia to grave 
 laryngeal crises ending in vertigo and unconsciousness, 
 the so-called laryngeal vertigo. 
 
 The surest sign of movements and paralyses being in- 
 dependent of the will or of reflexes is the disappearance 
 of the symptoms when the (morbid) will is eliminated. 
 Patients with complete aphonia (from inability to adduct 
 the vocal cords) have a loud cough (Fig. 16), and spasms 
 of the adductors, or paralyses of the abductors with in- 
 tense dyspnea, disappear in narcosis. The phenomena 
 are so very variable that we must not pronounce certain 
 conditions, as, for instance, that of isolated anesthesia of 
 the larynx, hysterical, even if no organic foundation can 
 be demonstrated. 
 
 The latter may at first be entirely latent, and only 
 manifest itself later in the disease ; or it may be actually 
 absent, as in functional neuroses, without proving that 
 the psychical phenomena are produced by that peculiar 
 perversion of the will-power found only in hysteria. 
 
 The fundamental difference between purely functional 
 and hysterical disturbances is that the former are always 
 intentional, while the latter a])parently appear and disap- 
 pear spontaneously. This variability or constancy of the 
 phenomena, which must appear inexplicable and "capri- 
 cious" to the observer, depends on certain latent psychical 
 processes in the mind of the patient which interrupt or 
 sustain them. 
 
DISTURBANCES OF SENSIBILITY. 99 
 
 The hysterical akineses may be momentarily or per- 
 manently interrupted by the sudden assertion of the will- 
 power ; sometimes the motile disturbance has ceased 
 to be caused by psychical conditions, and simply persists 
 from force of habit by vis inertke ; such cases are the 
 most grateful and j^romise a speedy cure. But where the 
 psychical chain is still unbroken every eifort fails ; we 
 may, for instance, restore the voice to-day by some means 
 or other, only to find it absent again to-morrow. The 
 treatment must, therefore, concern itself primarily with 
 the discovery and removal of the latent psychical process. 
 As long as that continues all remedies will fail. A great 
 many have been recommended : pressure on the ovaries, 
 shaking the larynx during attempted phonation, elec- 
 tricity. 
 
 The patients themselves are usually not cognizant of 
 the psychical cause, and the best way to find it out is to 
 inquire into the events, both physical and psychical, which 
 accompanied the first appearance of the symptom. 
 
 If the psychical chain has been broken, either through 
 the efix»rts of the physician or by accidental, unknown 
 events, our professional assistance may still be required 
 to restore the will-power or power of coordination lost 
 throuo^h disuse. 
 
 This is best accomplished by gradually converting in- 
 voluntary into voluntary movements : have the patient 
 cough and sustain the sound he makes in the act ; once 
 the larynx has become accustomed to the unwonted action, 
 improvement is rapid. Occasionally the patient has to be 
 taught to speak all over again. If the psychical cause is 
 deeply hidden and cannot be exterminated, we can readily 
 understand that the case will be hopeless. Symptomatic 
 treatment is required only when the symptoms threaten 
 health and life : crises and convulsions. The former 
 must be treated by anesthesia during the attack and by 
 general tonics ; the latter may call for tracheotomy. 
 
100 PATHOLOGY AND TREATMENT. 
 
 VI. DISTURBANCES OF THE CIRCULATION. 
 
 They occur in tlie larynx as accompaniments or sequelae 
 of disease in other situations, or as idiopathic affections. 
 
 Among the former we have edema from stasis, Avhich 
 occurs with chronic or acute nephritis, cirrhosis of the 
 liver, or cardiac insufficiency; sometimes, too, in conse- 
 quence of jiressure on a vein by an exudate or a tumor, 
 in which case the edema is local. The nephritic edema 
 may precede all the other symptoms, and thus determine 
 the diagnosis comj)aratively early in the disease. 
 
 Edema due to vasomotor disturbances, angioneurotic 
 edema, has been observed to occur spontaneously in con- 
 nection with similar cutaneous edema and to disappear 
 again as rapidly. 
 
 Sometimes a similar form of toxic edema aj^pears after 
 the exhibition of potassium iodid. We do not know why 
 this, as well as the apparently ])urely nervous form, 
 occurs only in certain individuals, nor to what the edema 
 is due. 
 
 The treatment in all these forms is primarily concerned 
 with the removal of life-threatening symptoms, if neces- 
 sary, by tracheotomy. In some cases cathartic remedies 
 and cold applications or scarification may suffice. 
 
 VII. SOLUTIONS OF CONTINUITY 
 
 may be produced by insignificant causes if the vulnerabil- 
 ity is abnormal, or by ordinary traumatism. 
 
 The former occur in hemophilia, general arteriosclero- 
 sis, syphilis, tumors, tedious catarrhs of long duration, 
 and in secondary macerations (see p. 60). Com ]ia rati vely 
 slight injuries, such as forcing the voice, violent cough, 
 painting the larynx, may suffice in such cases to bring on 
 hemorrhages in or on the surface of the tissues, or even 
 
SOLUTIONS OF CONTINUITY. 101 
 
 fissures and transverse severing of the vocal cords. In 
 the two first-named diatheses small operations, which 
 ordinarily are attended Avith only very little bleeding, 
 may endanger life by the hemorrhages they occasion. If 
 a severe hemorrhage in the larynx cannot be controlled 
 by making the patient swallow ice, by the application of 
 cocain, a strong alum solution, or the galvanocautery, 
 tracheotomy must be performed immediately without anes- 
 thesia — as blood is aspirated during anesthesia even when 
 the head hangs down — and the larynx packed with tam- 
 pons from above or from below. 
 
 Traumatic lesions of the larynx result from shot- 
 wounds, cuts, and stab-w^ounds, or from contusions. 
 According to situation and intensity, there is more or 
 less division or fracture of the cartilages, or hematomata 
 appear in the mucous membrane, or even free hemor- 
 rhages. The immediate consequence (where asphyxia 
 does not occur at once) is fatal dislocation of the respira- 
 tory path, and this usually demands tracheotomy and 
 eventually intubation. Cut-wounds may heal entirely 
 after removal of the sutures, but usually they leave a 
 membranous or cicatricial stenosis which must be removed 
 by excision or by stretching, either from within or after 
 opening the larynx. 
 
 It is always well, in doubtful cases, to perform this last 
 operation at once, in order to clear up the diagnosis and 
 to remove any possible obstructions (luxated fragments of 
 cartilage, etc.). It is just such injuries as these that give 
 rise to the curious deformities which we meet with in the 
 larynx. 
 
 Thermal or chemical injuries of the larynx result from 
 the aspiration of hot or caustic gases, or from accidental 
 entrance of caustic liquids into the larynx in deglutition. 
 The consequence in light cases is violent catarrh with ero- 
 sions ; in more severe cases, diphtheritic membrane-for- 
 mation, edema, ulcers, and, finally, intense cicatrization. 
 The treatment is purely symptomatic : ice internally and 
 externally ; if necessary, tracheotomy, not intubation. 
 
102 PATHOLOGY AND TREATMENT. 
 
 VIII. FOREIGN BODIES 
 
 frequently find their way into the interior of the larynx, 
 especially in children. Convulsive cough, spasm of the 
 vocal cords, injuries, or direct mechanical suffocation, 
 later irritative inflammations and decubital ulcers, are the 
 consequences. 
 
 Every means must be tried to remove the obstruction 
 on account of the danger of asphyxiation or, at least, 
 aspiration into the bronchi and consequent inspiration- 
 pneumonia. Small, movable bodies are easily coughed up 
 after tracheotomy, especially if no cannula is introduced 
 and the edges of the tracheal wound are sewed to the 
 edges of the skin. In other cases the foreign body must 
 be removed from within or after performing the opera- 
 tion of laryngofissure. 
 
 IX. MALFORMATIONS. 
 
 The development of male larynges may be retarded so 
 that they come to resemble the female larynx in size and 
 shape ; it occurs especially as a part of a general feminism. 
 Imperfect union of the two halves, as in cleft palate, with 
 which it is usually associated, has been observed in the 
 form of longitudinal fission of the epiglottis. Congenital 
 absence of the epiglottis has also been described. 
 
 A kind of atavistic malformation is seen in the lateral 
 expansion of the ventricles of Morgagni, analogous to 
 the resonating-pouches of anthropoid apes, known as 
 laryngocele. In well-developed examples the pouch 
 pushes the hyothyroid membrane before it and becomes 
 visible on the outside of the neck, especially during 
 attacks of coughing. Smaller extensions are more com- 
 mon. 
 
 Congenital mcmhranes have been observed occasionally 
 within the ventricle, dividing it into two compartments. 
 
MALFORMA TIONS. 1 03 
 
 They are more frequent between the vocal cords; the 
 least developed forms appear as a mere broadening of the 
 commissure. 
 
 Ei^tensive membrane-formations, sometimes of the 
 hardness of cartilage and always beginning at the com- 
 missure, produce severe dyspnea in addition to complete 
 aphonia, and often demand radical excision, to be followed 
 by a course of stretching. 
 
 Membranes have even been observed above the vocal 
 cords, completely covering the glottis. 
 
 The treatment is the same. 
 
 We have already referred to the occurrence of dislo- 
 cated tissue from the thyroid gland on p. 81. 
 
Tab. 1 
 
 Fuf.Ji. 
 
 FufJ. 
 
 LUh. Anst /.' Reichhold, Afdiich^i. 
 
PLATE 1. 
 Fig. I 
 
 shows an image of the anterior surface of the epiglottis taken 
 in the Kilhan posture (head bent well forward); the lower 
 border of the cricoid is seen projecting from the trachea, which 
 is exposed to some depth. 
 
 Fig. 2 
 
 is the picture of a very large and wide female larynx, showing 
 the anterior wall of the trachea, the bifurcation, and parts of 
 the main bronchi. 
 
PLATE 2. 
 Fig. I. 
 
 represents the shape of a child's larynx (the " omega " shape). 
 The posterior parts are sometimes even more approximated, so 
 that the aperture of the larynx is entirely covered. 
 
 Fig. 2. 
 
 A gentleman, 65 years old, has an enormously enlarged neck from a 
 struma (circumference, 51* cm.). 
 
 The larynx is displaced to the left about 3 cm. from the middle line ; 
 the upper border of the cricoid is liigher on the right, than on the left 
 side. Marked stridor and cyanosis i)oint to a stenosis. Voice normal. 
 
 The epiglottis and the posterior wall are bent slightly back- 
 ward on the right side. The right true and false vocal cords 
 cannot be seen at all, as the commissure is under the middle 
 of the petiolus, instead of, as usual, at the right angle of the 
 epiglottis. 
 
 In phonation the left vocal cord is drawn far over to the right and 
 the arytenoid cartilage is drawn sharply inward. The peculiar image 
 is therefore due to 
 
 Oblique Position of the Larynx from Struma. 
 
 Fig. 3. 
 
 A woman, 46 years old, complains of difficulty in swallowing for the 
 past year; there is no pain, but inability to swallow any large morsel. 
 There is nothing abnormal in the pharynx. 
 
 Larynx. — There is not much alteration, except a broad red 
 swelling which projects from the posterior wall. 
 
 The tumor does not move in phonation ; on the contrary, the pos- 
 terior wall is seen to glide past it, and it becomes evident that the tumor 
 does not arise from the larynx. 
 
 Digital palpation reveals that it is seated immediately above, but not 
 in relation with the aperture of the larynx, and extends sideways as well 
 as upward and downward on the posterior wall of the pharynx. The 
 tumor is very hard and the mucous membrane is stretched very tight. 
 This tumor must, therefore, originate in the vertebra?, and probably has 
 nothing to do witli the dysphagia, as the finger easily glides past it into 
 the sinus pyriformis. It is, in fact, an old 
 
 Lordosis of the Cervical Vertebrae. 
 
 A sound was introduced, and the dysphagia explained by the finding 
 of a solid obstacle in the esophagus, in the neighborhood of the bifurca- 
 tion. 
 
Tab. 2. 
 
 ru,.i. 
 
 Fiff.S 
 
 w 
 
 FiffJ. 
 
 I.ilh. Ansl F. Reichhold. Miinchen. 
 
Tab. 3 
 
 Fifil 
 
 Fifj. 
 
 ,v» 9 
 
 /Mh. Arusl E Heu'hhoUi, Miinchen. 
 
PLATE 8. 
 Fig. I 
 
 represents a normal larynx of someAvhat unusual appearance, 
 because in respiration the true vocal cords recede more than 
 is normal under the ventricular bands, the latter making a 
 wide curve inward and backward. 
 
 Fig. 3. 
 
 A man, 27 years old, has a deep, rough voice and betrays great exer- 
 tion during phonation. We may mention briefly that anamnesis and 
 examination reveal recently developed tuberculosis of the lungs and 
 larynx (slight infiltration of the posterior wall and pale, relaxed vocal 
 cords). 
 
 In phonation the true vocal cords suddenly disappear under 
 the ventricular bands, which are drawn unusually far toward the 
 middle line ; the edges of the latter are slightly red and form 
 another superior glottis, responding to the current of air by 
 perceptible, coarse vibrations. It is the picture of so-called 
 
 Vicarious Phonation of False Vocal Cords. 
 
Fig. 3. 
 
 A girl, 17 years old, is examined for nose-bleed and headache, which 
 are found to be caused by deep tertiary syphilitic ulcers in the interior 
 of the nose. Deficiencies in the soft palate and uvula show that similar 
 processes have taken place before. The voice has a good sound, but its 
 quality, owing to these deficiencies, is nasal. 
 
 Laryngoscopy at once shows an extensive destruction involv- 
 ing more than half the epiglottis. Of the latter only the an- 
 terior, basal half remains. There are several notches on the 
 left side and a deep incision in the middle. What remains is 
 pale red ; the edge is slightly wavy, and. the surface covered 
 with fairly uniform, flat nodules. 
 
 The other parts are pale but otherwise intact. From the findings in 
 other parts of the body it is evident that these alterations are the 
 
 Remains of Syphilitic Ulcers. 
 
PLATE 4. 
 
 Fig. I. 
 
 A gentleman, 54 years old, with all tlie signs of a viveur, has been 
 hoarse for the past six weeks. Home remedies had no elfect. 
 Nothing abnormal in mouth, nose, or fauces. 
 
 Laryngoscopy shows the right edge of the epiglottis to be 
 hypertrophied and slightly red. The hypertrophy consists of 
 several smooth, round nodules, about the size of a barley-corn. 
 The right true and false vocal cords are slightly red and hyper- 
 trophied. 
 
 No swelling of glands nor abnormalities in the skin or skeleton could 
 be made out; lungs and heart normal. Patient denies any infection 
 but gonorrhea. The nodules on the epiglottis can hardly be regarded as 
 swollen lymph-follicles, though they exist in this region ; the fact that 
 they are limited to one side, and the unilateral inflammation of deeper- 
 lying parts, point either to an infectious or to a malignant process. The 
 latter is excluded by the occurrence of two essentially different eruptions 
 in different localities. There remain tuberculosis and syphilis. The for- 
 mer is improbable in view of the man's general health, whicli is robust, 
 and also on account of the short duration and the marked inflammatory 
 symptoms. Everything is in favor of syphilis ; his denial goes for 
 nothing. We have to deal with the initial stage of a tertiary process 
 with 
 
 Fresh Gummata on tlie Epiglottis and Syphilitic Infiltration of the 
 Right True Vocal Cord. 
 
 Fig. 2. 
 
 A heavy drinker, 32 j'ears old, has been suffering from hoarseness 
 and occasional irritating cough for six months. No expectoration. No 
 family history could be obtained. The voice is entirely without sound. 
 The fauces present nothing unusual ; the mucous membrane is thick- 
 ened and of a dull red, as is frequently the case with drinkers. 
 
 Larynx. — The under surface of the epiglottis is somewhat 
 broad nnd covered with numerous flat, pale red nodules closely 
 packed together. Similar nodules are seen along both true 
 and false vocal cords and on the anterior surface of the aryte- 
 noid cartilages ; in the latter situation they take the form of 
 actual tumors. 
 
 Movement of both cords is only sliglitly impaired. Although ex- 
 amination of the hmgs gives no very abnormal result, the appearance 
 of the chronic, nodular, and diffuse infiltration in various situations per- 
 mits the diagnosis of 
 
 Tuberculosis resembling Lupus. 
 
Tab 4. 
 
 iifjl 
 
 Fig. 
 
 ^ 
 
 FigJ. 
 
 Lith. Anst F. Reichkold, Miinchen. 
 
Tab. 5. 
 
 yi(f.i 
 
 tUf.}i. 
 
 Fiif.y. 
 
 l.Utu Anst F. RjtichJtwld, Mundven . 
 
PLATE 5. 
 
 Fig. I. 
 
 A man, 45 years old, has been suffering for six months with increas- 
 ing lioarseness and, lately, dysjjnea on going up-stairs, etc. He himself 
 attributes his trouble to a cliancre-infection received t'onr years ago. 
 
 The voice is raucous and almost without sound ; the general appear- 
 ance is robust and v^ell nourished ; lungs are sound, only the inguinal 
 glands are slightly swollen. In the nose there is nothing abnormal, but 
 on the posterior wall of the pharynx are seen welt-like scars, and the 
 larynx i)resents extensive changes. 
 
 Tlie epiglottis as a whole is hypertrox^hied ; the edges, es- 
 pecially the anterior, uneven and in parts covered with large 
 nodules. 
 
 The left half presents a deep fissure, so that a superficial 
 fragment can be isolated from, the deeper-lying remainder of 
 the substance. The posterior portion is further defaced by a 
 discolored, dirty-yellow ulcer. 
 
 The left true and false vocal cords are replaced by a thick, 
 wavy strip of dense, dark-red tissue ; the right ventricular band 
 is of a brighter red, and swollen in front and behind to such a 
 degree that it completely covers the true cord, which is also 
 hypertrophied and yellowish-red in color. A thick red projec- 
 tion rises abruptly from the posterior wall on the right side, 
 and a lower ragged excrescence on the left side, as well as the 
 investment of the arytenoid cartilage, is covered by a radiat- 
 ing white scar. 
 
 Without a histological examination of extirpated tissue, or the obser- 
 vation of the subsequent course of the disease, it is impossible to decide 
 between 
 
 Syphilis and Tuberculosis. 
 
 (Later the disease turns out to l)e purely syphilitic in character. The 
 hyperplasia on the posterior wall is due to a latent perichondritis.) 
 
 Fig. 2. 
 
 A man, 32 years old, was treated a year ago for tertiary syphilis of 
 the nose. Now he comy)lains that liis" throat has been troubhng him 
 for several months and he has gradually almost lost his voice. 
 
 Nothing unusual in the fauces. 
 
 In the place of the epiglottis we see a shapeless mass of 
 tissue : a broad, irregular plate, the free edge very much 
 thickened, overhangs the left side of the epiglottis. The upper 
 surface presents two circumscribed inflammatory areas and, in 
 the center of each, an ulcer as large as a pea with well-marked 
 
edges and dirty-yellow floor; the one lying near the middle 
 line has taken part in the destruction of the free edge of the 
 overhanging plate. A deep ragged cleft separates this entire 
 mass from a smaller- fragment on the left, which evidently 
 represents the remains of the left half of the epiglottis. 
 
 Owing to the swollen ventricular band the vocal cord on the 
 right side apjDears to be narrowed, injected, and rough (at the 
 free edge) ; on the left side it is entirely hidden by the ventric- 
 ular band, which is very red and swollen. All that apparently 
 remains of the true cord is a spur projecting from under a 
 similar ulcer to the one just described, and perhaps the re- 
 mains of the processus vocalis. Both aryepiglottidean liga- 
 ments are likewise red and swollen; the right one has a yel- 
 lowish hue. From under the latter a blunt red pyramid about 
 half as large as a pea is seen to project into the lumen. 
 
 The appearance of these sharply eircumscribed ulcers, even without 
 the anamnesia, gives the diagnosis of 
 
 Tertiary Infiltrative and Destructive Syphilis. 
 
 Fig. 3. 
 
 A man, 40 years old, was infected with syphilis seventeen years ago ; 
 since then he has had manifestations of the disease in the skin of the 
 back, on the shins, in the nose, and finally, six years ago, in the larynx. 
 Although the laryngeal affection was relieved by general treatment, as 
 far as the pain was concerned, he now begins to suffer more and more 
 from dyspnea. 
 
 The entire larynx is deformed. The epiglottis consists of 
 a swollen band, thicker on the right side than on the left and 
 approaching the turban-shape. The surface is smooth and red. 
 The ventricular bands are replaced by thick pale-red shreds of 
 tissue ; only one little corner of the vocal cord is seen on the 
 left side, the right does not appear at all (not even in phona- 
 tion). The entire posterior wall is converted into a massive 
 horseshoe, on the anterior surfjxce of which are two broad 
 elevations, the left one marked with a notch. A number of 
 smaller convolutions, resembling a chain of hills, spring from 
 the anterior surface of the cricoid cartilage. The mucous 
 membrane appears to be intact everywhere. 
 
 The voice is feeble and of a deep, grunting quality (false vocal cord 
 phonation). 
 
 The whole picture may be explained as the remains of destructive 
 gummata, although the hypertrophy of the posterior wall is very re- 
 markable. 
 
 The proliferation of the tumors must be restricted in order to relieve 
 the dysj)nea : microscopic examination of tlie extirpated portions reveals 
 onlv harmless connective tissue and epithelial proliferation. (See PI. 
 41, Fig. 1.) 
 
The tumors recur, however, and pain is frequently felt in speaking 
 and in swallowing. 
 
 This state of afiairs continues several years. The long duration with- 
 out material changes in the type, more, even, than the histological 
 picture, excludes malignant growths. Nor have we to deal with syphil- 
 itic manifestations, as there is no reaction to mercury or potassium 
 iodid, and no signs are found elsewhere on the body. We are there- 
 fore inclined to regard the recurring proliferations as the expression of 
 the reaction to a still-existing inflammatory irritation, to which we may 
 also refer the hypertrophy of the posterior wall. 
 
 We assume then, with some sliow of probability, a 
 
 Chronic Secondary (Post-syphilitic) Perichondritis, 
 
 caused by necroses which have not yet been eliminated. 
 
Tab. 7 
 
 IUf.2 
 
 Fuf.M. 
 
 Liih. A fist F. EfiichhvUi. Munch 
 
PLATE 7. 
 
 Fig. I. 
 
 A single woman, 31 years old, has been ill two days with fever, sore- 
 throat, and hoarseness. No dyspnea. The soft palate and both tonsils 
 are slightly red ; the left tonsil slightly enlarged and flecked with pus. 
 The X->osterior pillar on the right side is also slightly enlarged. 
 
 Submaxillary glands on the left side palpable and painful. 
 
 Laryngoscopy. — The entire left half of the epiglottis, as 
 well as the left glosso-epigiottidean ligament, is converted into 
 tense, shiny tumors of a yellowish-gray color. The left ary- 
 epiglotticlean ligament is slightly thickened. The vocal cords, 
 on the other hand, are w'hite. 
 
 Their mobility ls, however, much impaired: both approximation and 
 tension are incomplete in phonation. 
 The picture is interpreted as that of 
 
 Acute Infectious Edema 
 
 originating in tonsillar infection. 
 
 Fig, 2 
 
 is the postmortem picture of the larynx of a very fat man who 
 died suddenly of asphyxia. The entire epiglottis and the 
 mucous memhrane covering the right half of the cricoid car- 
 tilage are puffed out and very red and swollen. In this case a 
 more intense process was at w^ork than in the last illustration — 
 an 
 
 Acute Infectious Phlegmon, 
 
 probably erysipelatous in character. 
 
PLATE 8. 
 
 Fig. I. 
 
 A man with a weak, sighing, high-pitched voice comes with a history 
 of acute catarrh which began ten days ago. 
 
 In this case also the arytenoidean region is especially in- 
 flamed, although the rest of the laryngeal mucous membrane 
 is likewise somewhat injected. During phonation the posterior 
 part of the glottis remains open in the form of a triangle, while 
 the anterior part is spasmodically closed. 
 
 It is therefore an 
 
 Inflammatory Paralysis of the Transverse Arytenoid Muscle. 
 
 Fig. 2. 
 
 A man, 38 years old, caught cold at a ball two days ago and has been 
 hoarse since. His throat is dry and he has a " scratchy " feeling when 
 he swallows. 
 
 The uvula is sHghtly rod ; otherwise the fauces are normal. 
 
 The redness is limited to the internal edges of the true vocal 
 cords, and is especially marked between the two arytenoid car- 
 tilages. There is almost no sound in phonation, the arytenoid 
 cartilages not approximating perfectly; the glottis forms a 
 double ellipse, the point of tangency being at the apices of the 
 two vocal processes. 
 
 Diagnosis : 
 
 Inflammatory Paralysis of the Internal Thyro-arytenoid and of the 
 Transverse Arytenoid Muscles. 
 
Tab. 8. 
 
 Fiff.1, 
 
 Fiff.^. 
 
 lith . Anst /•: ReichhMd. Mimchen . 
 
Fiff.l. 
 
 Fiq. 
 
 Tail 
 
 /,/;, )/,v/ f-' l/i>irhluili} Xfii/it.' 
 
PLATE 9. 
 
 Fig. I. 
 
 A girl, 25 j'-ears old, with a history similar to that of Fig. 2 in PI. 8, 
 presents a somewhat different picture. 
 
 The epiglottis is strongly injected and the mucous membrane 
 over the arytenoid cartilages also appears red, especially the 
 vocal cords. In phonation they exhibit a rather wide eUiptical 
 cleft ; the voice is rough and very feeble. 
 
 We have to deal with a case of 
 
 Acute Laryngeal Catarrh with Inflammatory Paresis of the Internal 
 Thyro-arytenoid Muscles. 
 
 Fig. 2. 
 
 Marked vocal disturbance is the most conspicuous symptom in a man 
 suffering from incipient tuberculous infiltration of both apices. 
 
 The epiglottis is unusually pale ; the outline of the free margin 
 is "interrupted by two small, nodular eminences on the left side. 
 
 The rima giottidis gapes during phonation, because the pars 
 phonatoria of the right vocal cord presents an elliptical con- 
 cavity of the free edge. The left cord is properly stretched, but 
 its middle third shows an area of redness limited externally by 
 a convex boundary. 
 
 This " unilateral catari'h " without any other symptoms is suspicious. 
 The want of tone in the right vocal cord is probably not due to muscular 
 weakness alone, such as occurs in the early stages of tuberculosis, but, 
 from the fact that it is unilateral, also to tuberculous infiltration of the 
 thyro-arytenoid muscle. Besides, the nature of the nodules on the epi- 
 glottis is unmistakable. We must, therefore, diagnose 
 
 Multiple Tuberculous Infiltrations in the Early Stage. 
 
PLATE 10. 
 
 Fig. I. 
 
 A gentleman, 65 years old, is hampered in the discharge of his pro- 
 fessional duties by an intense hoarseness which has been recurring at 
 varying intervals for years. The present attack began six weeks ago. 
 He'also complains of violent "stomach-trouble," which manifests itself 
 in morning retching and vomiting, although the appetite is entirely 
 undisturbed. He has been very temperate in the use of alcohol and 
 tobacco for years. 
 
 Examination of the chest reveals only slight emphysema with traces 
 of bronchial catarrh. 
 
 The fauces are of a dusky red ; the mucous membrane everywhere 
 presents an uneven surface traversed by dilated veins ; even the base of 
 the tongue is hypertrophied and deep red in color. 
 
 In the pharynx some tough mucus. Traces of a similar secretion are 
 seen on the floor of the nose and on the septum in front. 
 
 The anterior exti-emities of the middle turbinated bones are enlarged. 
 
 The larynx, as a whole, is of a dark-red color. A smooth 
 fold of mucous membrane projects from the posterior wall, and 
 similar ones from the lower borders of the vocal processes. On 
 the posterior portions of the vocal cords are seen some irregular 
 dark-red spots, flat and adherent, not movable in coughing. 
 
 This is a general picture of secondary chronic laryngitis, somewhat 
 specialized in this case by 
 
 Inflammatory Hyperplasise and Hemorrliages. 
 
 Fig. 2. 
 
 A girl, 17 years old, has been suffering for six months with hoarse- 
 ness and loss of appetite. Every morning she hawks up and discharges 
 from the nose a great fiuantity of tough, yellow mucus. The act is 
 attended with much difficulty and often followed by complete aphonia. 
 Tlie father has tuberculosis of the larynx. The voice is very rough and 
 croaking, and often changes suddenly to a different rt^cister. The 
 general condition is reduced ("flaccid"); complexion a dirty yellow, 
 although the mucous membrane of the mouth is not much discolored. 
 Lungs and heart normal. Urine free from albumin. 
 
 The posterior wall of the pharynx and the arch of the palate are 
 covered with tough masses of mucus; also the anterior extremities of 
 both middle and turl)inatod bones. (Upon closer examination a puru- 
 lent f(K;us is found on both sides of the septum in front.) 
 
 Larynx. — General anemia. Both vocal cords are of a yellow- 
 ish-gray, covered with spots; the surface uneven and giving the 
 effect of maceration ; the free edges are rough, so that closure 
 is incomplete during phonation (Fig. 2a). 
 
 Tbo diatrnosis of secondary maceration of the true vocal cords by 
 pus from the nose, wliifh was made from the objoctivc signs, is confirmed 
 by the subsequent course, inasmuch as all tlie phenomena were made to 
 disappear by treati-ng the purulent focus in the nose. 
 
Tab. 10. 
 
 Tig.l. 
 
 Fig.S 
 
 i \ 
 
 \ 
 
 Fxg.3. 
 
 Lith.Arist H Reichhoid . Miincheii. 
 
Fiffl. 
 
 Fiff.^. 
 
 Tab. 11. 
 
 l.ilft An.sl I. Rpuhhniil Xtiiiirhcn 
 
PLATE 11. 
 
 Fig. I. 
 
 A gentleman, in his 56th year, seeks advice for hoarseness which began 
 about six months ago. The voice is deep, toneless, and rough ; some- 
 times it is lost entirely. The man has a well-nourished appearance; is 
 not too fat for his years ; his face is somewhat red. There is a little 
 cough, weak and noiseless and sometimes painful. He complains chiefly 
 of dryness and occasional stabbing-pains in the throat ; the patient has 
 been a heavy smoker, but a moderate drinker. Physical examination 
 reveals some enlargement of the lung-area, otherwise nothing abnormal. 
 
 The entire larynx, and especially the vocal cords, are very 
 red. The latter also exhibit a yellow discoloration in the neigh- 
 borhood of the apices of the vocal processes, circumscribed in 
 character and not affected by cough, extending over the upper 
 surface and along the inner margin. 
 
 They are, therefore, not depositions of secretions, but alterations of 
 the epithelium itself — erosions. As there are no grounds for suspecting 
 any other cause than the evident catarrhal condition, they may be re- 
 garded as 
 
 Catarrhal Erosive Ulcers 
 
 of decubital origin (from compression of the processus vocales). 
 
 Fig. 2. 
 
 An appparently healthy man, 62 years of age, lost his voice three 
 weeks ago ; it had been growing weaker and weaker for some time. He 
 says he has never been sick. Nothing abnormal in nose and throat. 
 Aphonia. 
 
 The posterior half of each vocal cord is apparently narrowed, 
 while the anterior portion is thrust forward in the form of a 
 flabby irregular lobule. These lobules are of a dull-white color, 
 while the remaining visible portions of the vocal cords and the 
 median borders of the ventricular bands are intensely red. The 
 apparent narrowing of the vocal cords is due to the inflamma- 
 tory swelling of the ventricular bands. 
 
 These alterations, from their acute onset, permit of but one interpre- 
 tation ; they are 
 
 Syphilitic Papillomata. 
 
 Neither the patient's age nor his denial should affect the diagnosis. 
 
PLATE 12. 
 
 Fig. I. 
 
 A young man who was affected with syphiHs ten weeks ago com- 
 plains of pain in the mouth and throat ; he took cold two weeks ago and 
 has since become hoarse. 
 
 In the mouth conspicuous condylomata are seen on the 
 mucous membranes of the cheek. The entire larynx is some- 
 what injected. Both vocal cords are red, the right more than 
 the left. Over the right vocal process there is a whitish-yellow 
 prominence with sharply defined red base reposing on the 
 somewhat swollen background — a true 
 
 SypMlitic Papilloma. 
 
 Fig. 2. 
 
 A man, 30 years old, who has been under treatment for pulmonary 
 tuberculosis for years and has been much benefited by climatic cures, 
 seeks relief for chronic hoarseness. 
 
 The voice is raucous but loud. 
 
 There is some dulness at the apices of both lungs, with circumscribed 
 bronchial breathing and a few rales. 
 
 The larynx as a whole is rather pale. The posterior wall, 
 which is hypertrophied, presents on its anterior surface several 
 rows of flat, wavy elevations merging into one another. The 
 left vocal cord is reduced to a narrow strip ; the right, which is 
 broader and has an uneven edge, presents about the middle a 
 whitish eminence surrounded l)y a narrow, pale-red zone of in- 
 flammatory tissue ; behind the hitter two other nodules are 
 seen, pale red in color and about the size of a millet-seed. The 
 right ventricular band appears to blend with these nodules, and 
 for the rest is also swollen and convohited. 
 
 On the left side we i)robably have the remains of a destructive process ; 
 cicfitrizatlon is now complete, as is shown by the absence of proliferation 
 or inflammation. On tlie right side the i)rocess is evidently still going 
 on, while the hypertrophy of the posterior wall appears to depend on 
 deeper-lying alterations, since the superficial })roliferations still persist. 
 The entire picture, viewed in connection with the anamnesis, represents 
 therefore a 
 
 Mixture of Destructive and Retrogressive Tuberculous Infiltrations. 
 
Tab. 12. 
 
 Figl. 
 
 Fuf.^ 
 
 J? 
 
 LUh. Aixst F. Reirhhold Miinrhen . 
 
Tab. l:S. 
 
 ri„.i. 
 
 Fig.a. 
 
 Fig.,i. 
 
 LUh: Anst /.' fietrAhold, Miiiichei 
 
PLATE 13. 
 
 Fig. I. 
 
 A woman, 28 years old, has been sutfering for the past week with pain 
 in the left side of tlie throat radiating toward the ear. The voice was 
 entirely without sound ; sometimes the patient could not speak above a 
 whisper. Now the voice is croaking, and small in volume almost to 
 aphonia. The woman is well nourished and shows no signs of illness. 
 She says she has always been well. 
 
 In the larynx everything is normal but the left vocal cord. 
 It is almost twice as broad as its fellow, of a rounded form and 
 strongly injected. 
 
 •Mobility is only slightly impaired. 
 
 These phenomena are apparently purely catarrhal in character, but 
 there is no such thing as unilateral catarrh ; such affections always de- 
 pend upon a deeper lesion, iLsually of an infectious nature. That it is 
 infectious in this case is proved by the short duration, which, together 
 with the intense inflammation, leads us to decide in favor of syphilis. 
 Although the anamnesis furnishes no positive data, we nevertheless 
 abide by this diagnosis and conclude that we have to deal with the ter- 
 tiary period. It is, therefore, a 
 
 Gummatous Infiltration of the Vocal Cord. 
 
 Fig, 2. 
 
 A girl, 16 years old, has been hoarse ever since she had diphtheria, 
 nine years ago. Although she is slender and delicate, and rather pale, 
 heart- and lung-examination reveals notliing abnormal ; the slight 
 degree of anemia may perhaps be explained by her previous residence 
 in an educational institution. The voice is almost without sound; air- 
 waste during phonation is plainly pei'ceptible. 
 
 On examining the larynx (\vhich is oblique) we are at once 
 struck by the cadaver position of the left vocal cord. It is^also 
 much narrower and somewhat paler than its fellow. The free 
 edge is slightly concave and curves outward. 
 
 During phonation it remains immovable, while the right is 
 approximated. At the same time the right vocal process is 
 seen to spring forward. On the left side the upper part of the 
 posterior wall appears somewhat narrowed. 
 
 The picture is unmistakable : 
 
 Paralysis of the Left Recurrent Nerve, with Secondary Atrophy of 
 the Paralyzed Muscles. 
 
 Fig. 3. 
 
 A gentleman, 47 years old, was infected with syphilis twenty-one 
 years ago, and has since had depositions in the testicles, in the muscles 
 of the upper arm, and in the palm, which always yielded to potassium 
 iodid. 
 
Five months ago he caught a bad cold and became suddenly hoarse. 
 He also had pains radiating toward the right ear ; the pains disappeared 
 under potassium iodid and local application of mercurial ointment to 
 the throat ; the hoarseness, however, remained. 
 
 At the present time there are at both angles of the mouth white, 
 wrinkled condylomata, raised above the surface, not detachable, which 
 do not bleed on being touched. On the inner aspect of the right thigh, 
 over a vein, which can be seen and felt to be slightly thickened, there is 
 a stripe-like, slightly abraded sore. 
 
 In the larynx the right vocal cord appears not a little nar- 
 rowed from the overlianging, hypertrophied ventricular band, 
 The latter is rough and yellowish-gray at the edge and on the 
 surface, especially in its posterior haff. 
 
 The movements of the vocal cords are uniform and sufficient. 
 
 The nature of the disease is not easy to determine. The patient's age 
 and the persistence of infiltration-phenomena in spite of antiluetic 
 treatment arouse a suspicion of malignant growth. But the fact that 
 other sypliilitic or postsyphilitic symptoms on the body (leukoplakia 
 and psoriasis) have resisted the treatment argues against this theory. 
 As it sometimes happens that just such chronic forms only heal a long 
 time after the treatment has been discontinued, the diagnosis will 
 depend on the subsequent course of the disease. 
 
 Two months later the larynx had practicallj'^ regained its normal 
 appearance. We therefore had to deal with 
 
 Remains of Syphilitic Ulcers. 
 
PLATE 14. 
 
 Fig. I. 
 
 A man, 34 years of age, had a chancre four years ago, the nature of 
 which was abundantly explained by a subsequent exanthema. Ten 
 months ago the skin affection broke out afresh, and since then he has 
 had pain in the throat and hoarseness, with occasional aphonia. 
 
 The voice is raucous. 
 
 The fauces present a diffuse redness. 
 
 The larynx as a whole is also injected. The ventricular bands 
 are so swollen that the vocal cords appear to be narrowed. 
 The latter are also red throughout their whole extent, and on 
 the anterior third of their inner margins -are smooth, flap-like 
 prominences. 
 
 The latter become still more prominent in phonation. The disease is 
 unquestionably of a syphilitic natui^e, and the only question that re- 
 mains is : To what pathological category does this picture belong? We 
 evidently have here not mere swellings, but true hyperplasite. They 
 are distinguished from ordinary condylomata by their absolutely smooth 
 surface without epithelial alterations. Remembering that such inflam- 
 matory neoplasms may develop in the soil of a chronic catarrhal irrita- 
 tion, although usually found in other situations, we describe these for- 
 mations as 
 
 Connective-tissue Hyperplasise from Protracted Syphilitic Catarrh; 
 
 that is to say, as postsyphilitic. 
 
 Fig. 2. 
 
 A lady, 32 years old, presents herself with a feeble, very hoarse, tone- 
 less voice. 
 
 This hoarseness has lasted for six months, according to the patient's 
 statement, since a local application to the larynx ; before that event 
 there had been occasional improvement in the voice. For several years 
 she has had frequent coughing-spells without apparent cause and with- 
 out being able to expectorate. 
 
 Patient is apparently in a flourishing state of health. The posterior 
 wall of the pharynx is granulated and the pillars are hypertrophied. 
 Irritation of these parts with a sound is immediately followed by spas- 
 modic cough. 
 
 Larynx, — The left vocal cord is smooth and somewhat red- 
 dened, the anterior two-thirds of the inner edge slightly curved 
 outward. The right cord is pale yellow, the entire surface 
 slightly granulated, and at the boundary between the anterior 
 and middle thirds of the free border there is a flat, rounded, 
 double eminence about the size of a millet-seed. 
 
During phonation this eminence interferes with the approximation 
 of the cords, so that a gap remains at the rear. If the hand is held 
 before the mouth during phonation, the outgoing current of air can be 
 felt (phonatory air- waste). The diagnosis is 
 
 Benign Neoplasm of the Vocal Cord. 
 
 The microscopic picture after extirpation confirms the diagnosis. 
 
 Fig. 3. 
 
 A man, 59 years old, has been hoarse for the past two years, but has 
 never had any pain or dyspnea. The voice, besides being hoarse, easily 
 breaks into a falsetto. 
 
 The larynx is pale. On the left side, above and below the 
 vocal cords, of which only a narrow strip is visible, are two 
 nodular tumors of fairly uniform thickness and pale, grayish- 
 red color. 
 
 During phonation the left true vocal cord remains immovable in 
 cadaveric position. 
 
 The middle of the left plate of the thyroid cartilage is slightly rough 
 to the touch. No glands can be felt. 
 
 Heart and lungs show no changes but those due to age. 
 
 Infection is denied. 
 
 The age of the patient, the appearance of the tumor, the sound por- 
 tion surrounded by proliferations, the infiltrations of the deeper parts 
 about the joint as proved by the fixation of the true vocal cord, and the 
 evident participation of the thyroid cartilage itself on the one hand and, 
 on the other, the absence of any symptoms or data pointing to a syphil- 
 itic or a tuberculous infection, induce us to describe the tumor as a 
 malignant one, most probably 
 
 Carcinoma. 
 
 Experimental excision with a view to operation was not permitted. 
 
Tab. 14. 
 
 riff.i. 
 
 <Mmm 
 
 Fin ? 
 
 Fixf,J. 
 
Tab. 15. 
 
 Fw.l. 
 
 Fi(f.'-i 
 
 I ,il, i//v/ !■ Nri'iil,,,!,! \fiinilirn 
 
PLATE 15. 
 
 Fig. I. 
 
 A man, oQ years of age, presents himself for examination on account 
 of dyspnea and asthmatic attacks. Although a well-developed emphy- 
 sema with chronic bronchial catarrh is recognized as a sufficient cause 
 for these symptoms, the patient's voice is so rough and discordant that 
 the disturbance cannot be wholly attributed to the accompanying 
 chronic hyperemia of the upper air-passages. 
 
 Laryngoscopy reveals the cause in a round, shining, white 
 tumor, as hirge as the head of a pin, situated on the free border 
 of the rigiit vocal cord, at the boundary between tlie anterior 
 and middle thirds. Tlie cord is rather inflamed and, on the 
 whole, somewhat broader than its fellow. 
 
 The movements are not affected, the disturbance being due to en- 
 croachment by the tumor on the rima glottidis. Its peculiar appear- 
 ance, the patient's age, and the comparatively short duration — six 
 months — of the hoarseness, lead us to suspect a malignant growth. A 
 trial extirpation, penetrating to apparently healthy tissue, proves quite 
 reassuring, as shown in PI. 33, Fig. 3. It is, therefore, a 
 
 Hard Wart. 
 
 The future course of the disease must, however, be carefully watched. 
 
 Fig. 2. 
 
 A robu&t man, 32 years of age, has noticed an alteration in his voice 
 for the past year. At the present time it is deep, rough, and vibrating, 
 sometimes almost toneless. 
 
 The larynx is normal except for a grayish-white, shining 
 eminence on each vocal cord. The tumors are exactly equal 
 in size, about half as large as a lentil, and placed exactly 
 opposite each other, partly on the free border and partly on the 
 upper surface of the respective vocal cord, at the boundary 
 between the middle and anterior thirds. The remaining por- 
 tions of the cords are slightly inflamed. 
 
 During phonation the posterior part of the glottis, of course, stands 
 wide open, as complete approximation is prevented by the intervening 
 tumors. 
 
 In the entire absence of other symptoms of disease, and in view of the 
 bilateral distribution of the tumors, -^-e are justified in pronouncing 
 them innocent connective-tissue neoplasms ; that is to say, 
 
 Edematous Fibromata. 
 
 Microscopic examination later showed that the edema had progressed 
 to complete cyst- formation (PI. 39, Fig. 1). 
 
PLATE 16. 
 Fig. I. 
 
 A man, 24 years old, complains of hoarseness and aphonia. After 
 much laborious coughing he sometimes succeeds in expectorating small, 
 dried masses of secretion. 
 
 The mucous membranes of the fauces are hypertrophied and of a 
 dusky-red color. 
 
 Behind the pillars and in the posterior nares some grayish-yellow, 
 mucous secretion is seen. The isthmus is tilled up by the hypertrophied 
 tonsils. A similar thick secretion covei*s the floor of the nose ; the pos- 
 terior extremities of both inferior turbinate bones are enlarged. 
 
 A dusky-red discoloration pervades the entire interior of the 
 larynx, especially the vocal cords. The latter are thickened 
 and of a rounded form, the left more so than the right. A re- 
 ceding fold of mucous membrane rises high above the left vocal 
 process in such a way as to make it appear double. It is the 
 typical picture of 
 
 Pachydermatous Swelling. 
 
 The inflammation which produced the condition was evidently caused 
 by pus from the nose and fauces. 
 
 Fig. 2. 
 
 A woman, 36 years old, lost her voice six weeks ago. On being closely 
 questioned she admits that she had been hoarse for some time previous. 
 No expectoration, but a good deal of irritative cough and pain in the 
 right ear on swallowing. The mother died of some throat-trouble and 
 a sister was " scrofulous " when she was young. The patient herself had 
 an attack of pleurisy two years ago. She is of rather slight build, but 
 not especially thin. Examination of tlie chest gives markedly impaired 
 resonance over the right base, and the right apex is somewhat depressed. 
 At this point there is a slight friction-sound in both inspiration and ex- 
 piration, which does not appear after coughing; the respiratory murmur 
 over the lower area of impaired resonance is weak, but vesicular. 
 
 Larynx. — The color of the epiglottis and of the aperture 
 appears somewhat darker than normal. The left ventricular 
 band is irregularly swollen and inflamed. The vocal cord of the 
 same side presents similar alterations, except that the process 
 has gone on to distinct nodule-formation. The right vocal cord 
 appears divided into two parts by a discolored ulcer running 
 lengthwise of the cord and especially marked on the surface. 
 The edges are also hypertrophied and covered with nodules. 
 
 This ulcer, the origin of which can easily be traced to decu- 
 bital softening of a former infiltration, associated with the 
 nodular form of the latter, is very characteristic of 
 
 Infiltrative and Ulcerative Tuberculosis. 
 
Tab. 16. 
 
 Tig.l 
 
 Fie,. 3. 
 
 Lull . Ansf /•: Reuhhold. Mimchgn . 
 
Tab. 17 
 
 Fifj.l 
 
 b. /Ai ( jk 
 
 Fiff.Ji. 
 
 Rf*ir/ihi>[tl Miijii! 
 
PLATE 17. 
 
 Fig. I. 
 
 A man, 45 years old, has had dyspnea for the past few months ; 
 his voice became rough before the dyspnea, which has been growing 
 steadily worse, developed. The patient appears strong, although thin, 
 with slight cyanosis of nose, ears, chin, and fingers. There is audible 
 inspiratory stridor after violent exercise. The voice is rough and rumb- 
 ling. No areas of dulness in the lungs; some emphysema and dry 
 catarrh. Arterial sclerosis ; heart somewhat enlarged. The mucous 
 membranes are pale and slightly livid. 
 
 The same pallor in the larynx. The rima glottidis is ex- 
 tremely narrow, the vocal cords almost meeting in the middle 
 line. A pale strip of tissue projects from under the left cord, 
 along the processus vocalis. Behind this a broad, pale, rather 
 shiny eminence is seen projecting from the posterior wall. (In 
 phonation the right cord is drawn over to the left, which is com- 
 pletely immovable ; the same thing happens with the arytenoid 
 cartilages. Palpation of the larynx gives nothing abnormal.) 
 
 That this is not a palsy appears from the mobility of the right cord 
 and the position of the left ; we have to deal, therefore, with an abnor- 
 mal fixation of both vocal cords, which must be due to inflammatory or 
 swelling-infiltration ; in other words, to destruction of the articular sur- 
 faces. The arytenoid cartilages are probably not involved, as there is no 
 swelUng over them ; we therefore assume disease of the cricoid car- 
 tilage, preferably of the left side. The superficial wheals do not re- 
 semble neoplastic formations, but point rather to a chronic inflammatory 
 process. 
 
 The choice lies between tuberculosis and syphilis, and we decide in 
 favor of the former ; it is evident from the steady development of the 
 symptoms that the process is still going on, while, if it were syphilitic, 
 it would have produced more marked signs of inflammation and de- 
 struction. While awaiting further developments we are, therefore, justi- 
 fied in assuming 
 
 Tuberculous FericlioiLdritis of the Cricoid Cartilage. 
 
 Fig. 2. 
 
 An unmarried woman, 38 years old, has been troubled with shortness 
 of breath on going up stairs for the past two years, and lately the 
 dyspnea has become very severe. 
 
 Five years ago she had typhoid fever, and her voice was bad for a long 
 time afterward. 
 
 Loud stridor is heard during inspiration, a somewhat softer breathing- 
 sound during expiration. The face is somewhat bloated, not cyanotic, but 
 pale. The voice is loud and pure, and only occa.sionally a little hoarse. 
 The larynx moves up and down during respiration ; the posture of the 
 Jiead is normal. 
 
The base of the tongue is crossed by bluish-red, dilated 
 vessels; the mucous membrane of the larynx as a whole is pale. 
 The vocal cords are slightly injected and in the cadaver-position. 
 Two pale-red bands, of the same width as the vocal cords, project 
 from under them, curving a little outward in the back part 
 of the glottis. These bands have thin, uneven edges and a 
 smooth surface, and extend almost continuously to the anterior 
 portion of the cricoid cartilage. 
 
 During phonation tlie cords are perfectly approximated, while the 
 subcordal bands remain immovable. 
 
 The lungs present only a little enlargement; heart, etc., normal. No 
 swollen glands, nothing suspicious in the anamnesis. The neoplasm 
 may be either malignant in character or it may be due to chronic 
 plastic inflammation. Although the bilateral distribution does not 
 exclude the former, yet the movabihty of the vocal cords, at least 
 toward the middle line, argues against it. Further observation showed 
 no increase in size. It was a 
 
 Stenosis from Chronic Perichondritis of the Cricoid following 
 Typhoid Fever. 
 
PLATE 18. 
 
 Fig. I. 
 
 A roDUst man, 28 years old, has been hoarse for six months. No 
 other symptoms. Syphilis denied. Lungs and heart normal. 
 
 The entire larynx presents the picture of chronic infiamma- 
 tion. The vocal cords in particular are thickened and of a 
 dark-red color. The center of the left cord is covered by a 
 smooth, dark-red, spindle-shaped tumor which extends to the 
 ventricular band. The tumor appears to be seated imme- 
 diately upon the vocal cord, like an extinguisher. 
 
 It is small and can easily be pushed aside with a sound, so that it 
 almost disappears under the ventricular band in the ventricle of Mor- 
 gagni. Everything points to an inflammatory origin. It is the relaxed 
 and hypertrophied mucous membrane of the under surface of the ven- 
 tricular band which has prolapsed, presenting the picture of 
 
 Prolapse of the Ventricle of Morgagni. 
 
 Fig. 2. 
 
 A woman, 58 years old, has been hoarse for eight years ; often she 
 loses her voice entirely. No other symptoms. 
 
 The voice is rough and low, easily breaks into falsetto, and is produced 
 with great difficulty. 
 
 The larynx is very large. A very red, smooth, semi-elliptical 
 tumor, with blood-vessels ramifying over its surface, projects 
 from the right ventricle of Morgagni and covers the greater 
 part of the vocal cord. 
 
 In phonation the tumor is held against the left ventricular band. 
 Examination with a sound reveals a broad base, seated upon the upper 
 surface of the vocal cord. 
 
 Both the appearance and the seat of the neoplasm, as well as the ex- 
 ternal conditions, attest its innocent nature. It is a 
 
 Soft Fibroma. 
 
 Subsequent microscopical examination confirms the diagnosis. 
 
 Fig. 3. 
 
 A gentleman, 38 years old, who has been treated for syphihtic ulcers 
 in the throat, complains of hoarseness and a feeling of dryness in the 
 throat for some weeks. 
 
 The epiglottis is slightly, the right vocal cord intensely in- 
 flamed ; the surface of the latter also exhibits areas of j'ellow- 
 ish discoloration. The most anterior portion of the vocal cords, 
 
and epecially the anterior half of the ventricular bands, are 
 overshadowed by a smooth, dark-red, semi-elliptical tumor, 
 which apparently springs from the posterior surface of the 
 epiglottis. 
 
 Although tlie tumor looks very much like an innocent neoplasm, yet 
 the unilateral character of the inflammation and the destruction of 
 epithelium show tliat a more complicated process is going on— first infil- 
 trative, then destructive — and the diagnosis of 
 
 Tertiary SypMlitic Depositions 
 
 finds further support in the anamnesis. 
 
Tab. 18. 
 
 Fi(^.l 
 
 Fig.Ji. 
 
 tiff.'i. 
 
 Uth.Anst F. Reidihold, Miindien. 
 
Tab. 19. 
 
 F,f,.l 
 
 Fig.S. 
 
 Fig.,3. 
 
 LUh^ Anst F. Retrhhxtld, Miinchen 
 
PLATE 19. 
 Fig. I. 
 
 A gentleman, 30 years old, complains of stabbing-pains in the right 
 side of the throat, felt on swallowing and when he wakes up. No cough 
 or fever. The symptoms began a week ago, when the patient took cold 
 after dancing. He also remembers that he swallowed a large piece of 
 candy whole. 
 
 The region of the right crico-arytenoidean articulation is painful to 
 pressure from the outside. The throat shows no swelling or inflamma- 
 tion. 
 
 Larynx. — A broad, red eminence, capped with a yellowish 
 discoloration, protrudes over the posterior extremity of the right 
 vocal cord in the region of the upper surface of the right car- 
 tilage of Wrisberg. 
 
 The probe meets with no abnormal resistance, nor does anything else 
 point to the presence of a foreign body. The mobility of the right vocal 
 cord and the voice itself are unimpaired. All the symptoms disappeared 
 within a week with no other treatment than rest. The only possible 
 diagnosis, therefore, is 
 
 Circumscribed Inflammation with Abscess-formation 
 
 of unknown origin, probably of a traumatic nature. 
 
 Fig. 2. 
 
 A strongly built man, 27 years old, has had attacks of convulsive 
 cough for a week ; no expectoration, or at most a trace of gray mucus. 
 Nothing abnormal in nose, throat, or lungs. 
 
 The entire larynx is slightly inflamed. The redness of the 
 posterior wall is particularly noticeable ; on it are seen two flat 
 prominences more intensely colored than the surrounding 
 surface. 
 
 The patient was examined a short time ago and nothing of the kind 
 was visible, so that these formations must be of acute origin. The con- 
 vulsive cough is also very characteristic of 
 
 Acute Interarytenoid Laryngitis. 
 
 Fig. 3. 
 
 A pale, thin girl of 23 says she has noticed a loss of tone in her voice 
 for the past three months ; she has also lost strength and perspires very 
 easily. Little cough and no expectoration. The mother died of some 
 lung-disease. 
 
 Conjunctivse, mouth, and throat are very pale. Chest narrow, with 
 slight respiratory movement ; auscultation reveals no areas of impaired 
 
resonance or other abnormal signs, only the breath-sounds are very faint. 
 Heart-dulness a little smaller than normal ; pulse 85, and weak. 
 Nothing abnormal in nose or fauces. 
 
 The larynx in general is rather pale ; the posterior wall ex- 
 hibits a slight jagged dentation ; to the left of the petiolus of the 
 epiglottis the tissues are slightly inflamed and hypertrophied. 
 
 It is only by great eflbrt that an apjDroximate closure of the 
 glottis is brought about. 
 
 Tliis want of tone in the muscles shows that the inflammation of the 
 epiglottis and the formation of the posterior wall are not due to mere 
 irritation of the mucous membrane from external causes, but correspond 
 to the 
 
 First Stage of Tuberculous Infiltration. 
 
 The positive value of these findings is not diminished by the failure 
 to determine the presence of lung-disease, and is furthermore supported 
 by the general decline of the entire body. 
 
PLATE 20. 
 
 Figs. I and 2. 
 
 The patient mentioned in the preceding history died soon afterward 
 of hemorrhage from the lungs. 
 
 Fig. 1. — The larynx is opened from the front ; in the middle 
 of the posterior wall is a small ulcer, hardly as large as a lentil, 
 with raised, slightly nodular edges ; the floor is of a grayish- 
 green. (The edges appear flatter in the cadaver than in the 
 living subject.) After making two lateral incisions it is found 
 that the destruction is much more extensive than was supposed. 
 
 Fig. 2. — The mucous membrane is extensively undermined 
 beyond the domain of the arytenoid cartilages. The floor of 
 the ulcer presents a grayish-green discoloration and is covered 
 with a scanty, thin, purulent secretion. 
 
 Palpation with the finger and with the sound shows that the floor of 
 the ulcer is hard and rough ; the cartilage is therefore exposed and 
 eroded and at tlie same time converted into bone. It is the usual process 
 in tuberculosis — 
 
 Ossifying and Rarefying Fericliondritis and Chondritis. 
 
o 
 
 si 
 Eh 
 
 I 
 
 =^-^ 
 •^ 
 
 
Tab. 21 
 
 Firj.l. 
 
 Fiff.. 
 
 Fuf.'i. 
 
 I 111, ;/,./ F T}pirhhi)hl \ 
 
PLATE 21. 
 Fig. I. 
 
 A man, 35 years old, has had cough for the past three months ; in the 
 last two weeks he has also had pain, both spontaneous and on swallow- 
 ing. No expectoration. 
 
 There is marked pallor and impaired nutrition. The chest is flat; 
 the right apex is depressed, resonance is impaired, and there is accen- 
 tuated, prolonged expiration. 
 
 The heart is small and its action weak. On the breast are several 
 radiating scars. 
 
 A rough, sharp-pointed eminence with a broad base springs 
 from the center of the posterior wall. The mucous membrane 
 at the back of the epiglottis over the petiolus is intensely in- 
 flamed ; in the center of this zone is a yellowisli-gray discolored 
 ulcer with smooth, straight edges. 
 
 Although the general condition of the entire body and of the lungs is 
 in perfect accord with the lesion in the posterior wall, which exhibits 
 the typical appearance of tuberculous hyperplasia, the ver>' acute course 
 of the ulcer, without infiltration of the surrounding tissue, argues against 
 tuberculosis. 
 
 Upon being more closely questioned the patient admits that he was 
 infected a year ago, and had a rash and pustules on the breast, so that 
 our suspicion of syphilis is confirmed. At the same time this does not 
 influence our judgment as to the nature of the infiltration in the pos- 
 terior wall. We have two processes going on side by side, 
 
 Tuberculosis and Active Tertiary Syphilis. 
 
 The diagnosis is confirmed by the subsequent course of the disease. 
 
 Fig. 2. 
 
 A woman, 25 years old, seeks relief for entire aphonia. She says she 
 is not sick otherwise except for "a slight cough," which, she thinks, 
 amounts to nothing. It appears, however, that this "slight cough" 
 brings up yellow mucus in considerable quantities. The father died 
 of " inflammation of the lungs." "How long was he ill?" "Only a 
 year and a half." The husband is well ; two children always sickly. 
 
 The patient is strongly built but decidedly emaciated. Breathing' is 
 superficial. Respiratory movement impaired on the right side. A 
 somewhat shortened note over both apices, more on the right side than 
 on the left. Over the right base behind, a little inside of the scapular 
 line, is a zone of high-pitched tympanitic note. In the same situation 
 loud sonorous rales and bronchial breathing. Over the apices accentu- 
 ated inspiration and interrupted expiration. The fauces are very pale; 
 the gums retracted. 
 
 Larynx. — The anterior surface of the right arytenoid cartil- 
 age is converted into two small, pale prominences. A thickish, 
 
PLATE 22. 
 
 Fig. I. 
 
 A woman, 47 years old, afflicted with advanced tuberculosis of the 
 lungs, comes to be treated for dyspnea and total loss of voice. The 
 dyspnea can hardly be explained by the lung-disease alone. She does 
 not complain of pain on swallowing, but the epiglottis frequentlj' fails 
 to protect the larynx from the entrance of foreign matters. 
 
 The larynx in general is rather pale — a yellowish -gray. A 
 rough, brownish-yellow tumor springs from the free edge of the 
 right vocal cord ; it is rather flat and apparently very dense, 
 and the line of demarcation from the surrounding healthy 
 tissue is indistinct. A similar, though much larger tumor, in 
 shape like a blunt pyramid, arises between the two arytenoid 
 cartilages. The posterior wall is uniformly hypertrophied, its 
 left outline being somewhat irregular. 
 
 The movements are very slow in phonation, as if all the parts were 
 rigid, showing that the infiltration is tough. The appearance of the 
 alterations alone, without regard to the condition of the lungs, tells the 
 experienced observer that he has to deal with 
 
 Tuberculous Tumors and Tuberculous Infiltration. 
 
 Fig. 2. 
 
 A man, 28 years old, seeks relief for constant hoarseness. Three 
 months ago he went through an antisyphilitic cure for indurated ulcer. 
 Mouth and throat are free from symptoms. 
 
 In the larynx there is a smooth, dark-red tumor, shaped like 
 the segment of a sphere, bulging out from the posterior w^all 
 far down under the glottis. 
 
 The tumor may immediately be pronounced a 
 
 Gumma on the Anterior Plate of the Cricoid Cartilage, 
 
 for it is evident from the hoarseness that the infiltration must extend 
 deeply. 
 
 The diagnosis is confirmed by the rapid disappearance of the tumor 
 with the use of potassium iodid. 
 
 Fig. 3. 
 
 A man, 32 years old, was treated a year ago for syphilis of the palate 
 and nose. The ulceration was followed by a tedious secondary sup- 
 puration of the no.se, tl)e secretion pouring itself into the throat ex- 
 clusively. The voice, which had been fairly good, has become very 
 rough in the last three months. 
 
Tab. 22. 
 
 Fiff.l. 
 
 Fig. 2. 
 
 Fi-f/.J. 
 
Tab. 23. 
 
 Figl. 
 
 Fifi 
 
 LlJh..yn.>i . >'-'-r>>hnhl Munrlu'U. 
 
PLATE 23. 
 
 Fig. I. 
 
 A man, 40 years old, comes to us in the Spring with a history of dry- 
 ness in the throat and roughened voice, which, he says, began with the 
 cold weather and persist obstinately. Occasionally he is troubled with 
 convulsive cough. The throat is slightly inflamed. 
 
 The larynx is rather pale. Tlie region below the apex of the 
 left arytenoid cartilage is somewhat hypertrophied ; in front 
 the hypertrophy merges into a red, granular tumor with a broad 
 base and apparently of a dense consistence, ending in a fairly 
 sharp point. 
 
 The movement of the left cord is imperfect and the closure of the 
 glottis is not complete. Exploration with a sound shows that the tumor 
 is very" hard. The lungs are apparently normal. Nothing suspicions in 
 the family history, but the patient says he has lost strength considerably. 
 
 The last-mentioned circumstances confirm the suspicion, based on the 
 granular appearance and dense consistence of the tumor and on the 
 probability that the infiltration extends more deeply, that the disease is 
 
 Hyperplastic Tuberculosis. 
 
 Further confirmation is furnished by trial curettage and microscopic 
 examination. 
 
 Fig. 2. 
 
 A woman, 26 years old, has been hoarse for the past six weeks, and in 
 the course of the last few days severe dyspnea has been superadded. She 
 also has pains radiating to the left ear. 
 
 The body appears badly nourished ; the color of the skin is a dirty 
 white. Inspiratory stridor. Great tenderness on pressure at the upper 
 and back part of the left thyroid cartilage. The glands under the angle 
 of the jaw and in the neck are swollen on both sides, but only the left 
 cervical glands are painful. The speech is entirely aphonic. The hair 
 has been dropping out fast lately. Xo birth, no abortion. The patient 
 cannot recall any personal or family disease. 
 
 Only the (posterior) margin of the epiglottis retains its 
 normal yellow color ; from that point to the line of version the 
 injection of the tissues becomes more and more marked and 
 culminates in. a deep, dark-red discoloration. The mucous 
 membrane of the posterior wall is red and swollen on the right 
 side ; on the left the swelling has resulted in the formation of a 
 grayish-red, shiny sac (edema). The left vocal cord is in the 
 cadaver-position and immovable during phonation, as is the 
 entire region of the arytenoid cartilage. 
 
 We have all the signs of an acute, far-reaching inflammatory^ process, 
 showing that the immobility of the left side, which is considerably more 
 
Lungs are intact ; glands not swollen ; syphilis denied. The process 
 is evidently a chronic one, dependent anatomically on some grave dis- 
 turbance of the motile apparatus, as the posture of the vocal cords shows. 
 Whether this disturbance is in the muscles or in the cartilages, is hard 
 to decide, as the posture corresponds to paralysis of the posterior crico- 
 arytenoid muscles. Nor is it quite clear if inflammation or a new 
 growth is at the bottom of the trouble. The appearances are more in 
 favor of the former (inflammatory edema) ; on the other hand, the 
 irregular surface and angular form of the tumor are rather suspicious of 
 the latter. The ulcer also has no typical character. In any case, the 
 disease is not tuberculosis. As we are in doubt, we resort to antiluetic 
 treatment. 
 
 At first this treatment is apparently effective, for after six weeks the 
 breathing is so much improved that the advisability of removing the 
 cannula? is considered. Meanwhile, however, the appearance of the 
 picture is so much changed that there is no further doubt as to its true 
 nature. 
 
 (Fig. 3.) During respiration the right vocal cord still occupies 
 a median position, while the left is abducted. The latter is of 
 a pale red. The tumor on the posterior wall has diminished, 
 but is still quite marked. 
 
 Close to the ulcer, which is now reduced in size one-half (?), 
 on the median side is a pale-red, w^avy tumor as large as a 
 lentil, irregular in outline, and merging into the larger tumor. 
 
 This formation occurs only in 
 
 Malignant Growtli. 
 
 Microscopic examination of an extirpated portion shows it to be an 
 alveolar sarcoma. (See PI. 37, Figs. 1 and 2.) 
 
Tab. 24. 
 
 >. 
 
 Tig.l. 
 
 Fiq. 3, 
 
 Fi(f.,3. 
 
 Lilh. Anut t'. HejjCh/iold, Miinchejt 
 
Tab. 25. 
 
 Fi(ll. 
 
 Fiff.Ji. 
 
 Fiii-fJ. 
 
 L((h. Afi.sf /•: HjeidOwUI. Miinci 
 
PLATE 25. 
 Fig. I. 
 
 A girl, 16 years old, has been ill for two days with headache, fever, 
 and violent pain on swallowing. This morning hoarseness and some 
 dyspnea set in. Bowels constipated. 
 
 The patient is weak, cheeks very red, respiration short, and the sen- 
 sorium is reduced. Pulse 110, temperature 39.5° C. In the pharynx 
 there is nothing abnormal except a slight redness of the posterior wall. 
 The voice is toneless ; even the whispered sounds are very weak. 
 
 Larynx. — The exnglottis is inflamed. The vocal cords are a 
 very little hyperemic and in the cadaver-position. But the 
 posterior wall consists of two enormously swollen, glistening, 
 blood-red masses which prevent all motion. 
 
 Such phenomena are produced only by 
 
 Laryngeal Erysipelas. 
 
 Fig. 2. 
 
 A gentleman, 67 years old, who had formerly always enjoyed good 
 health, became very ill nine months ago after an attack of influenza: 
 fever in the evening, sweats, loss of flesh, copious yellowish-gray expec- 
 toration, and, in the last few months, hoarseness and shortness of breath. 
 
 The body is still fairly robust, but the flabby skin testifies to the loss 
 of substance. On percussion : above and behind on both sides almost 
 complete dulness ; on the right side under the clavicle, from the second 
 to the fourth rib, dull tj^mpanitic note, increased at the point where it is 
 best heard when the mouth is opened. Numerous rales over the entire 
 lung; over the right apex loud bronchial breathing with tinkling rales. 
 Posteriorly above, bronchial breathing on both sides with crackling 
 rales. 
 
 Piespiration short, accelerated, and faintly audible. 
 
 The entire larynx is bright red. The posterior wall is hyper- 
 trophied and resembles a sausage. On the left side a smooth, 
 thick swelling rises from its anterior surface. The right vocal 
 cord is entirely hidden by the swollen ventricular band ; in the 
 region of the vocal process the left appears to be split in two; 
 in reality, however, it is a doubling of the fold of mucous mem- 
 brane; for the reason mentioned above (the thickening of the 
 ventricular band) it also appears narrower. Abduction is evi- 
 dently incomplete, as neither cord moves beyond the cadaver- 
 position in its outward excursion. 
 
 The larjmx is not sensitive to pressure from the outside. The voice 
 is discordant, deep, rough, almost aphonic, and often changes to a 
 whisper. 
 
PLATE 26. 
 
 Fig. I. 
 
 A patient, 36 years old (male), afflicted with pulmonary and laryn- 
 geal phthisis, is treated with a Koch injection. On the following day 
 this picture is seen. 
 
 Both aryteno-epiglottidean folds, as well as the entire upper 
 border of the posterior wall of the larynx, especially on the left 
 side, are converted into a smooth, glistening, balloon-like swell- 
 ing. The ventricular bands also appear hypertrophied. In 
 respiration both vocal cords are very near the middle line, 
 between cadaveric and phonation-posture ; they are discolored 
 and harder than normal, with rough, uneven edges. A small 
 spur projects in front of the left vocal process. 
 
 The tumors must all be attributed to 
 
 Acute Inflammatory Edema 
 
 over the tuberculous portions. 
 
 Fig. 2. 
 
 An extremely emaciated woman, 24 years old, with hectic flush, 
 copious purulent expectoration, extreme debility — in short, all the signs 
 of advanced pulmonary phthisis, which is furllier confirmed by the 
 physical examination — is suffering, in addition, from intense dyspnea. 
 Orthopnea and stridor are also present in a marked degree. 
 
 With the exception of the epiglottis, the entire larynx is 
 diseased. The right vocal cord is not visible at all ; of the left, 
 only a small strip near the vocal process is to be seen. Every- 
 thing else is hidden by the ventricular bands, which are con- 
 verted into pale, rigid, somew^hat uneven tumors. The aryteno- 
 epiglottidean folds are also very much hypertrophied, grayish- 
 yellow in color, and glistening (edematous). On the right side 
 is a broad, club-shaped tumor as large as a bean and slightly 
 nodular, blocking up the back t)art of the already narrowed 
 lumen. 
 
 No signs of degeneration, at least on the surfaces exposed to 
 view. 
 
 The presence of edema in the posterior portion proves that, in addi- 
 tion to the more superficial lesions which are at once recognized, a 
 deeper morbid process is at work, probably in the cartilaginous frame- 
 work ; it is, tlierefore, 
 
 Diffuse Tuberculous Infiltration of the Entire Larynx and Tubercu- 
 lous Tumor-formation. 
 
Tab. 26. 
 
 Fig.!. 
 
 FigJi. 
 
 LUh.An.^i /'' RpirhhnlfJ Wirirfwri 
 
Tab. 27. 
 
 FMfl. 
 
 X^Itp^ 
 
 Fiff.Ji. 
 
 LUh. Aruil F. Reichhjold, Miinchf/t 
 
PLATE 27. 
 Fig. I. 
 
 A gentleman, 47 years old, of robust appearance, has been sufifering 
 from increasing dyspnea for the past year; occasionally he also experi- 
 ences diflficulty in swallowing solid food. 
 
 The voice is raucous and easily breaks into another register ; respira- 
 tion someW'hat stenotic. 
 
 A tumor as large as a walnut blocks up the entrance to the 
 larynx, so that only a part of the ventricular band and the ary- 
 epiglottidean fold on the right side are visible. 
 
 The tumor is yellowish-gray in color; the surface lumpy and 
 irregular, and crossed by numerous blood-vessels. 
 
 There is still some mobility, most marked in the anterior portion, so 
 that the origin of the tumor may be in the left arytenoid region. Its 
 nature cannot be determined with any degree of certainty ; in the 
 absence of swelling of the cervical glands and of metastastes, the rapid 
 development perhaps points to malignancy. 
 
 Microscopic examination of the excised tumor shows it to be a 
 
 Squamons Epithelioma. 
 
 (See PI. 39, Fig. 3.) 
 
 Fig. 2. 
 
 A woman, 62 years old, has experienced increasing difficulty in swal- 
 lowing during the past six months, and latterly has been able to take 
 only liquid nourishment. She never had pain. Has lost strength a 
 good deal. 
 
 Pale, emaciated subject ; no discoloration of the skin or mucous mem- 
 branes. No glands can be felt in the neck ; nothing abnormal on palpa- 
 tion. 
 
 The throat and larynx are very pale ; the posterior half of 
 the latter is concealed by a pale, bluish-red, slightly uneven 
 tumor, which gradually disappears in the posterior wall of the 
 pharynx. The base of the tumor is continuous with the upper 
 margin of the larynx. 
 
 Phonation is not impeded ; the voice is weak, but pure. The tumor 
 can be easily moved and lifted away from the posterior wall of the 
 pharynx with a sound. Respiration is free ; heart and lungs present 
 only alterations incident to age. 
 
 Owing to the curious seat of the tumor and the age of the patient, no 
 diagnosis could be made until after the extirpation. The tumor was 
 found to have a broad base, resting on the posterior wall of the cricoid 
 cartilage. Microscopic examination revealed an 
 
 Innocent Connective-tissue Neoplasm. 
 
 (See PI. 40, Fig. 1.) 
 
PLATE 28. 
 Fig. I. 
 
 After suffering for a year with "throat-catarrh " and extreme hoarse- 
 ness, a gentleman, 56 years old, would like to have his throat examined. 
 He can barely produce a feeble, rough sound, and also has diflficulty in 
 swallowing. 
 
 The general habit is vigorous, but somewhat anemic. The neck 
 hangs in folds ; is not swollen. On palpation the left plate of the thyroid 
 is found to be hypertrophied and lumpy, and more or less adherent to the 
 surrounding connective tissue. Two small glands can be felt under the 
 chin. 
 
 Larynx. — The epiglottis alone is normal ; it leans far back- 
 ward, obstructing the view into the interior (more so than is 
 represented in the picture). The right vocal cord is slightly in- 
 flamed ; the left is replaced by a rather red, granular tumor re- 
 sembling a raspberry, which fades away gradually into the ven- 
 tricular band. Both aryteno-epiglottidean folds are very much 
 hypertrophied, especially the left, which is swollen to about 
 double its natural size and presents a shapeless, irregular mass. 
 On the upper and anterior surface is an ulcer of irregular, sinu- 
 ous outline, becoming deeper as it sweeps backward, with raised 
 edges surrounding it like a rampart and grayish-green, discolored 
 floor. 
 
 During phonation the left side is immovable, from which we may de- 
 duce that the infiltration extends deeply and has involved the joint. 
 
 The infiltration is evidently extensive, and the true nature of the 
 tumor is clearly shown by its appearance and by the duration of the 
 process. It is evidently a true neoplasm which, judging by its extent, 
 degeneration, invasion of surrounding tissues, and the glandular metas- 
 tases, can only be a 
 
 Carcinoma. 
 
 Fig. 2. 
 
 A man, 47 years old, calls in the physician for imminent asphyxia. 
 Dyspnea has existed for some months, also a good deal of cough nnthout 
 expectoration. For several weeks the patient has been able to swallow 
 only liquid food. 
 
 Extreme emaciation, explained by the last point in the anamnesis. 
 Intense inspiratory stridor; expiration very much prolonged, all the 
 accessory muscles being called into action. Although the patient is very 
 weak, he sits up straight all the time, with head retracted. 
 
 Percussion gives marked increase in lung-area ; no dulness anywhere. 
 Auscultation impossible on account of the stenotic respiration, which 
 drowns all other sounds. 
 
 The temperature has been taken for several days, and there is no fever. 
 
The larynx as a whole is anemic and leaves only a narrow 
 cleft for the passage of air. The right vocal cord is yellowish- 
 white. A smooth, red band, nearly as broad as the cord, lies 
 directly underneath and gradually fades away in the commis- 
 sure, the anterior part being slightly swollen at the edge. The 
 left vocal cord at its middle third is converted into a rough, 
 red tumor, while the posterior third is hidden by another thick, 
 pale-red growth as large as a bean, its broad base resting on the 
 posterior wall, which is very much hypertrophied. 
 
 The cervical glands are not swollen. The left ala of the thyroid is 
 somewhat thick and uneven to the touch, but not sensitive. 
 
 During phonation the left side is immovable. 
 
 It is clear from the anatomical alterations that the left half of the 
 cricoid cartilage is the principal seat of the disease. The subcdrdal band, 
 however, shows that the right half has also become secondarily in- 
 volved. The predominant character of the lesion is tliat of a tumor ; the 
 only inflammatory features appear in the subcordal band, which is prob- 
 ably an inflammatory edema overlying a perichondritis. As the tumor 
 is associated with extensive infiltration of the deeper parts, and has also 
 attacked the cartilaginous structure, to judge from the fixation of the 
 joint, the process must be a destructive one. There are three possibilities : 
 malignant growth, syphilis, and tuberculosis. 
 
 There are many points in favor of the first : the unilateral character 
 of the disease, the patient's age, the gradual development, the absence of 
 general and pulmonary symptoms. There is nothing either in the anam- 
 nesis or in the results of physical examination to suggest syphilis; slow, 
 gradual development is not characteristic of that disease. Tuberculosis 
 might produce a similar picture, — in fact, the pale, uneven tumor simu- 
 lates that disease very closely ; but, on the other hand, the intact condi- 
 tion of one vocal cord is very unusual in such an advanced stage; be- 
 sides there is no expectoration and no fever (the patient has been under 
 observation for several weeks). 
 
 As even the microscopic examination of part of the tumor on the 
 true vocal cord gives no positive result, we must be content with a pro- 
 visional diagnosis of 
 
 Carcinoma ? 
 
 (See following plate.) 
 
Tab. 28. 
 
 Ji,,.l. 
 
 Fiff.. 
 
 Lith. AnM E Reichhold. Munchen. 
 
Tab. 29. 
 
 Fiff.l. 
 
 LUh.Atist KReiJchhotd. Miinchen. 
 
PLATE 29. 
 
 To the foregoing historj^ must be added that, a few weeks after traohe- 
 otomy was perforraed, high hectic fever set in, the patient expectorated 
 copiouslj'-, and the sputum contained tubercle bacilh. Thus the 
 diagnosis of 
 
 Tuberculous Perichondritis of the Cricoid 
 
 was at last established. 
 
 How extensive it was is seen by the result of the autopsy, held six 
 weeks after the patient first came under observation. 
 
 The cut surfaces of the cricoid cartilages exhibit a uniform 
 green discoloration ; the left side contains a large ulcerated 
 cavity, in which a large (ossified) sequestrum is freely movable. 
 
 In the trachea is seen the wound of the tracheotomy-tube, 
 very much enlarged by suppuration of the edges. 
 
These data are too meager for us to form an opinion of the true nature 
 of the disease, and for the present we must be content with an anatomi- 
 cal diagnosis. 
 
 The process is evidently an inflammatory one, involving the greater 
 part of the mucous membrane of the larynx. That its action is also 
 deeper than this, is shown by the motile disturbances in the vocal cords, 
 which correspond exactly with paralysis of the crico-arytenoidei postici; 
 that is. of the abduction-fibers in the recurrent laryngeal nerve. But 
 such disturbances may be of a purely mechanical nature, produced by 
 any obstruction in or about the joint, in this case the crico-arytenoidean 
 articulation. The latter theory is supported by the diffuse character of 
 the inflammation. We assume, then, an arthritic process, associated 
 with inflammation of the cartilage or rather of the matrix. This view 
 is further confirmed by the marked swelling and inflammation of the 
 aryepiglottidean fcjlds. 
 
 Without further hesitation we may, therefore, make the diagnosis of 
 
 Crico-arytenoidean Perichondritis and Inflammatory Ankylosis of the 
 Crico-ar3rtenoidean Articulation. 
 
 Tlie subsequent course of the case revealed the cause. After per- 
 forming tracheotomy and putting the patient on an active potassium- 
 iodid treatment we see the following picture. 
 
 Fig. 3. 
 
 The swelling has disappeared in the entire larynx, except in 
 the posterior wall. Over the left cuneiform cartilage is a 
 spherical, grayish-yellow, glistening eminence in the mucous 
 membrane (edema), between which and the cartilage of Wris- 
 berg a notch is seen. 
 
 The right vocal cord is white and smooth ; the left is still 
 inflamed and somewhat rough at the edge. The glottis is per- 
 fectly widened during respiration. A smooth, red, horizontal 
 band of tissue projects from under the commissure and covers 
 half the lumen, ending behind in a convex margin. The un- 
 covered part of the trachea exhibits a bright luminous line. 
 
 The latter evidently corresponds with the tracheotomy-tube, which 
 is still in position. The band of tissue, on being examined with a 
 sound, is found to be smooth, of the hardness of cartilage, and about 3 
 mm. in thickness. Taking everything into consideration we may pro- 
 nounce it a 
 
 Syphilitic Cicatricial Diaphragm. 
 
 Our earlier supposition, that the impeded abduction was due 
 to an inflammatory, ankylotic condition, also proves correct, 
 for the mechanical alterations disappeared at the same time 
 and in the same measure as the inflammatory symptoms; 
 remains of them arc still found in the edema over the apex of 
 the left arytenoid cartilage and in the secondary inflammation 
 of the corresponding vocal cord. 
 
Tab. 30. 
 
 X "<•- 
 
 Fuf.l. 
 
 Fig/J. 
 
 LUh. Anst F. Heichiwld, Miifichen 
 
Tab 31 
 
 X 
 
 Hio 
 
 r^ 
 
 Fiffi 
 
 fiif.Z. 
 
 t'ig.,i. 
 
 Ulh. ArLst /■: Hfidlholil. Mulirli 
 
PLATE 31. 
 
 Fig. I. 
 
 A strongly built man, 63 years old, otherwise quite healthy, has suf- 
 fered for the last two j^ears with disturbance of the voice and great 
 hoarseness ; the symptoms have become more marked in the past two 
 months. No pain, no cough. The voice is rough and toneless. 
 
 Larynx. — In front, under the epiglottis, the petiolus of which 
 it hides completely, is a rounded, somewhat uneven tumor, a 
 Uttle larger than a pea. The surface is covered with red and 
 white spots. The rest of the larynx presents no marked altera- 
 tions, except that the left vocal cord and the posterior margin 
 of the epiglottis are slightly more injected. The movements 
 of the true and false vocal cords are unimpaired. 
 
 The patient's age and the irregular appearance of the tumor lead us 
 to suspect a malignant growth, but the disease has lasted a long time (at 
 least two years) without invading the surrounding tissues or giving rise 
 to disturbances of motility, so that we are justified in assuming an 
 
 Innocent Neoplasm. 
 
 To be conscientious, however, we must make a histological examina- 
 tion of the extirpated tumor (the result is illustrated on PI. 34, Fig. 1) 
 and watch the patient for some time after. (The tumor did not recur.) 
 
 Fig. 2. 
 
 A vigorous man, 56 years old, has suffered with dysphonia for ten 
 years. No other symptoms to complain of; no pain, no dyspnea. 
 
 The voice is all but aphonic — a mere rough whisper; i)honation is 
 always preceded by a long, audible inspiration, and the first expiratory 
 sound is accompanied by a distant rattling sound. The larynx does not 
 move during inspiration and is thrown into strong vibration by phona- 
 tion. Otherwise there is nothing abnormal on palpation. The face and 
 the mucous membrane of the back of the mouth are highly colored, but 
 not cyanotic. 
 
 At the first glance into the larynx the entire interval be- 
 tween the epiglottis and the posterior wall is seen to be filled by 
 a mass which is moved by the expiratory blast ; the surface is 
 somewhat rough, white in front, more of a reddish hue beliind. 
 The parts which are still visible (arytenoid cartilages, small 
 portions of the ventricular bands and of the right vocal cord) 
 do not deviate from the norm. The mass is intimately adherent 
 to the anterior portions of the aperture, but its origin cannot 
 be made out very clearly. 
 
The absence of any signs of destruction at or about the seat of the 
 tumor, its duration, and general apj)earance permit the diagnosis of 
 
 Innocent Tumor. 
 
 Histological examination shows it to be a hard fibroma. 
 
 Fig. 3. 
 
 A woman, 40 years old, is in imminent danger of asphyxiation. The 
 dyspnea, which had existed occasionally in a slight degree, has de- 
 veloped rapidly in the last few hours. 
 
 The patient sits upright, breathing slowly and painfully, and using all 
 the muscles of the neck ; a loud noise is heard both in inspiration and 
 in expiration. The voice is rough, almost aphonic. As soon as the 
 tongue is drawn forward a greenish-yellow, half-dried bolus of muco-j^us 
 is seen on the posterior wall of the pharynx, extending upward. 
 
 The entire entrance to the larynx is covered by a thick, gray- 
 ish-green, dry mass, the back part of which, judging from the 
 more uniformly glistening appearance, is a little more moist. 
 It is everywhere raised above the level of the surrounding, in- 
 flamed mucous membrane. 
 
 This crust is immovable even during phonation. 
 
 Nose and fauces are filled with a mass of liquid and solid pus, the 
 source of which is found in a diseased condition of the cribriform plate 
 of the ethmoid bone. 
 
 The foreign body in the larynx is, therefore, also a crust of pus ; it is 
 simply an 
 
 Obstruction by a Foreign Body. 
 
PLATE 32. 
 
 Fig. I. 
 
 A boy, 3i years old, comes to be examined for complete aphonia 
 and intense dyspnea. Inspiration especially is labored and very pro- 
 longed ; all the accessory muscles are plainly seen to assist in the act, 
 which is also accompanied bj^ loud stridor. At the same time the larynx 
 is deeply depressed. Expiration is somewhat less difficult. Face and 
 extremities are markedly cyanotic. The condition developed in the last 
 two years after an attack of whooping-cough. 
 
 Laryngoscopy. — The mucous membrane of the epiglottis, 
 which is displaced forward, shows a faint bluish-red discolora- 
 tion. Under the epiglottis and covering the entire aperture of 
 the larynx is a bright, brick-red tumor, the surface of which 
 exactly resembles that of a mulberry. On palpation with the 
 finger the tumor is found to be soft and very slightly movable. 
 It is evidently a 
 
 Papilloma, 
 
 a form of laryngeal tumor very characteristic of childhood. 
 
 Fig. 2. 
 
 A woman, 30 years old, complains of hoarseness and dyspnea. The 
 hoarseness has existed three or four years ; the dyspnea has increased 
 lately. She has lost strength, has night-sweats and cough, but no ex- 
 pectoration. Her fatlier died of pulmonary phthisis. The woman is 
 slender and delicate ; she has lost her voice entirely, and there is audible 
 laryngeal stridor when she breathes ; the thyroid cartilage at the same 
 time moves up and down. Under the angle of the jaw on each side is a 
 gland as large as a pigeon's egg. There is resonance all over the lungs, 
 but the right apex is somewhat depressed ; under the riglit clavi(.*le 
 accentuated, prolonged expiration is heanl. Accentuated breath-sounds 
 and dry rales are heard all over the lung. Heart-action is weak, dul- 
 ness .small, heart-sounds pure. 
 
 The larynx as a whole is rather anemic (as is the mucous 
 membrane of the mouth); the interior is cornpk^tely filled 
 with slightly pa[)illary, raspberry-colored tumors, which grow 
 out from the ventri(ailar l)ands and the posterior wall, so that 
 only the posterior third of each vocal cord is visible. These 
 latter are rough and grayish in color. No iilceration is seen 
 anywhere. The tumors, when touched with a sound, are found 
 to be very hard. 
 
 The wide, diffuse distribution and the appearance of the tumors, 
 together with the general conditiijn, permit a provisional diagnosis of 
 
 Tuberculous Tumors. 
 
 Diagnosis confirmed by microscopic examination. 
 
Flff.l 
 
 Tab. 32. 
 
 tr 
 
 Fiff. ^. 
 
 Ulh. Anst F. Retchhold. Miuudhen . 
 
-^->::^-c^ 
 
 Tab. 33. 
 
 Jig.l. Vergn^o/i 
 
 '■.^k 
 
 - - - - :s-------^-Z'i^^W 
 
 G 
 
 ~3^?<Ef C'.- - '.' ' 
 
 Lilh.AriM t: Keichhold. Munrhen . 
 
PLATE 33. 
 Fig. I. 
 
 The nodules on the true vocal cord, shown in Plate 14, Fig. 
 2, were removed and a horizontal section was made. 
 
 The base consists of fairly dense connective tissue, the lymph- 
 spaces of which are surrounded by slight accumulations of 
 round cells. Some of the vessels are much dilated and filled 
 with blood. On the right, the tissue is filled with blood from a 
 profuse hemorrhage, evidently traumatic in origin. 
 
 The surface is formed by two elevations consisting chiefly of 
 epithelium, divided by a deep vertical incision. The epithe- 
 lium exhibits great proliferation ; toward the left a thick, club- 
 shaped mass extends as far as a greatly dilated vessel, curved 
 like an S. This mass is surrounded by a band of round-celled 
 infiltration as by a cordon. The superficial layers are horny. 
 
 The inflammatory origin of the neoplasm is at once evident 
 from the alterations in the vessels ; the epithelium probably 
 proliferated secondarily, chiefly in consequence of the pressure 
 from the other vocal cord during phonation. 
 
 The tumor is, therefore, an 
 
 Inflammatory Hyperplasia. 
 
 Fig. 2. 
 
 In its essential features this preparation is similar to the pre- 
 ceding. 
 
 The epithelial proliferation is more active, and has resulted 
 in the formation of villous processes which tend to coalesce. 
 The same band of round-celled infiltration appears along the 
 upper boundary. The grouping of the round-celled infiltration 
 about the blood-vessels is very conspicuous, and the cornifica- 
 tion of the superficial layers has gone on to the formation of 
 lamellae. Like the preceding, this tumor, which grew like a 
 wart on the posterior wall of the chronically inflamed larynx 
 of a man, 46 years old, is an 
 
 , Inflammatory Fibro-epithelioma. 
 
 Fig. 3. 
 
 The preparation is a vertical transverse section of the tumor 
 shown in Plate 15, Fig. 1. 
 
 The root of connective tissue almost disappears between the 
 two layers of epithelium which enclose it above and below, 
 
The upper layer, which corresponds to the httle whitish tumor 
 seen macroscopically, forms an enormous epithelial mass. It 
 is chiefly made up of very large polygonous squamous cells ; 
 at the base some stratified squamous epithelium is seen, while 
 the surface consists of numerous horizontal lamellae, the original 
 epithelial character of which is shown by the few remaining 
 nuclei. The enormous thickness of this zone of horny epithe- 
 lium explains the white color of the living tumor. 
 
 The connective tissue is filled with blood and presents numer- 
 ous clefts, due, no doubt, to edematous swelling of the tissue, 
 which was but poorly nourished through its slender pedicle. 
 
 (With a higher power numerous elastic fibers are seen at " a," 
 representing proliferations of the media of blood-vessels, show- 
 ing that all the tissues were involved.) 
 
 Innocent Homy Epithelioma. 
 
PLATE 34. 
 Figs. I and 2. 
 
 A sagittal section was made of the tumor shown in Plate 31, 
 Fig. 1. 
 
 This preparation shows, even better than any of the preced- 
 ing ones, the round-celled infiltration of chronic inflammation 
 associated with the highest degree of epithelial hyperplasia. 
 The villous j^rocesses of the latter extend almost to the 
 boundary of the healthy tissue. The superficial laj-ers present 
 a very curious picture : the large polygonal cells with vesicular 
 nuclei are replaced by a network, the meshes of which corre- 
 spond approximately with the cell-areas, but contain only a few 
 scattered nuclei. Instead of these, niunerous large masses of a 
 homogeneous color are scattered through the network, and in 
 many places the meshes are larger than the adjoining cells. 
 
 This difference is emphasized in the peripheral portion 
 (marked R), shown under a higher power (Fig. 2). The altera- 
 tions manifest themselves as extensive fatty degeneration of 
 the epithelium ; the fjit has collected to form the lumps at '*a," 
 Avhile at "b " some cells are still to be seen, though their con- 
 tents are disintegrated and granular. This mixture of fatty 
 and of partially intact areas is resjjonsible for the peculiar, 
 mottled (macroscopic) appearance of the surface. 
 
 Inflammatory Hyperplasia, with Epithelial Degeneration. 
 
 Fig. 3. 
 
 This illustration presents a similar form of degeneration. 
 
 The flat, sui)erficial growth (taken from the vocal cord of a 
 lady, 42 years old) consists almost exclusively of epithelial pro- 
 liferations, undergoing degeneration not only at the surface,, 
 but clear through to the bottom. The protoplasm is on the 
 verge of absorption, as the numerous bright spaces in it show ; 
 in places it is swollen, and the nuclei have disappeared for the 
 most part. As in the preceding case, the outlines of the cells 
 have remained substantially the same, instead of becoming 
 flattened and forming lamellae, as in cornification. 
 
 Epithelial Hyperplasia in Process of Degeneration. 
 
Tab. 34. 
 
 a 
 
 MM 
 
 a 
 
 '^^m^ 
 
 ^'0^^^^ 
 
 
 >«%>^- 
 
 Tiff.l. Vergr.^04 
 
 *V^% 
 
 ^-^::::# 
 
 'I 
 
 Mi 
 
 :3^i >7: 
 
 
 a 
 
 
 . r© 
 
 z-^.^. Ver^rr.y 
 
 A^. J. Vercjr. 25/i 
 
 Lith. Anst F. RetcMwld, Miinchen. 
 
Tab. 35. 
 
 Fig.l. Vergn^o/i 
 
 I 
 
 Fiff.^. Vergr. 25/1 
 
 Lilh.Anst F ReichhoLd, MiUiche/i. 
 
PLATE 35. 
 Fig. I. 
 
 A dense, pale-red, uneven tumor was removed from the left 
 ventricular band of a man 40 years old. 
 
 In a horizontal section the core of dense, fibrous connective 
 tissue appears in the form of an elevation, partly covered over, 
 and partly traversed by numerous layers of squamous epi- 
 thelium, so that several isolated islands of connective tissue, 
 " a," are seen in its substance. These islands, as well as other 
 areas near the epithelium, especially the portions surrounding 
 the blood-vessels, exhibit profuse round-celled infiltration. The 
 surface is horny and covered at " Bl " by a thick layer of clotted 
 blood, which shows beginning metamorphosis into comiective 
 tissue. 
 
 Inflammatory Hyperplasia. 
 
 Fig. 2. 
 
 The mulberry-shaped tumor, light pink in color, was removed 
 from the left vocal cord of a man 50 years old. The cold-wire 
 snare was used. The tumor had a very narrow, smooth pedicle, 
 surrounded on all sides by wavy masses of proliferated epi- 
 thelium from the surface. A vertical section down to the base 
 does not, therefore, include the center, but only lateral portions 
 of the tumor, and is bounded on all sides by epithelium. The 
 real framework consists of dense, fibrous connective tissue, con- 
 taining dilated blood-vessels (G), the walls of which are in part 
 hypertrophied. On the free surface the epithelium is arranged 
 in numerous horizontal layers, while further down the layers 
 of epithelium occupy a plane at right angles to that of the base, 
 the transition between the two directions being effected grad- 
 ually. The similarity of the tissue to epidermis is unmistak- 
 able. The boundary-line between epithelium and connective 
 tissue is fairly even in some parts, in others it is more or less 
 deeply indented, wherever the connective tissue sends out pro- 
 jections into the epithelial layer. On the left there is a very 
 extensive projection of this kind (B), enclosed on both sides by 
 a thick shell of epithelium, which in turn shows numerous 
 indentations. Several large islands of epithelial tissue are 
 grouped about the surface of the tumor without any apparent 
 connection with it. Each of these islands contains a central 
 core of connective tissue, and many similar cores are also seen 
 in the substance of the thick epithelial zone itself, showing 
 
that it is not a homogeneous formation, but rather the result of 
 fusion of contiguous processes. The islands are, in fact, only 
 peninsulas ; their isthmuses are to be found in deeper, or in 
 more superficial sections. The whole formation might be com- 
 pared to a tree with a rich network of interlacing branches. 
 
 It is to be noted that each of the larger outgrowths of con- 
 nective tissue has its own vascular supply ; this does not appear 
 everywhere in the picture, owing to the low power used, but is 
 quite plainly seen at G. 
 
 Papillary Fibro- epithelioma. 
 
PLATE 36. 
 Fig. I. 
 
 This preparation was taken from the epiglottis of a httle girl, 
 9 years old, who died of multiple recurrent tumors, resembling 
 cauliflower, in the larynx and trachea. 
 
 At the base of the sagittal section the cut surfaces of the car- 
 tilage are seen. Next is a broad layer of loosely arranged fibers 
 (G), and tissue-islands in process of hyaline degeneration (d); 
 above this is a dense layer of connective tissue, surrounded at 
 its upper boundary by round-celled infiltration. As in the pre- 
 ceding case, the epithelial layer in some places is enormously 
 hypertrophied ; the boundary-line between it and the basal 
 tissue is marked by undulations and indentations correspond- 
 ing to outgrowths from the connective tissue. At certain 
 points we see the evidences of connective-tissue processes 
 growing in from different planes. But, whereas in the preced- 
 ing case the changes in outline were produced exclusively by 
 hyperplasia of the basal tissue — in other words the growth was 
 chiefly eccentric (centrifugal) in character — we here see, in 
 addition, an active proliferation of the epithelium itself at one 
 sj^ot, resulting in the formation of a process which extends 
 almost to th« deeper tissue-layers. The epithelial proliferation 
 has, therefore, begun to absorb the normal tissue, and this gives 
 the growth a malignant character. We are accordingly justified 
 in pronouncing it a 
 
 Destructive Papillary Epithelioma. 
 
 The diagnosis is confirmed when, under a higher power, the 
 dividing-line between epithelium and round-celled infiltration, 
 at the projections marked b, appears so indistinct that the epi- 
 thelium may be assumed to be migrating directly into the con- 
 nective tissue. 
 
 Fig. 2. 
 
 Four years ago aman, 42 years old, had a number of multiple 
 raspberry -like tumors removed from his larynx. Two years 
 afterward there was no sign of recurrence ; now, two years after 
 the last examination, the entire larynx is again filled with pale- 
 red, papillary tumors. The preparation was taken from one 
 of the vocal cords after death. It shows numerous projections 
 of connective tissue covered with a thin layer of epithelium. 
 Some thicker strands of epithelium have even penetrated as 
 far as the glandular layer, displacing normal tissue in their 
 
atypical, eccentric growth. Still, the general direction of these 
 processes is more or less parallel to the surface, so that we can 
 hardly pronounce the growth a carcinoma ; rather, in view of 
 the uniform proliferation of the surface, is it to be regarded as a 
 
 Destructive Papillary Epithelioma. 
 
 Fig. 3. 
 
 Vertical transverse section of the free border of the vocal 
 cord ; the upper portion is shown at O, the lower at U. The 
 fibers are found chiefly in the lower half of the cord, and run 
 parallel with each other from before backward. The prepara- 
 tion also shows the appearances of chronic catarrh in the accum- 
 ulations of round-cell infiltrations about the blood-vessels G. 
 
Tab. 36. 
 
 G 
 
 
 Fig.^. Vergr. is/ 
 
 Lith. Arist F. Raidihold. Miinchen . 
 
Tab. 37. 
 
 D 
 
 lig.l. Vergr.16/, 
 
 Ficf.Ji. Vercjr. 300/^ 
 
 Fiy.'J. Vergr. Wi 
 
 LUh.Ansl F. Reidihold, Mdndi 
 
PLATE 37. 
 Figs. I and 2. 
 
 This is a section of the tumor shown in PI. 24, Fig. 3. Only 
 the central portion of the surlace is covered with proliferating 
 epithelium sending down numerous thick processes; imme- 
 diately beneath is a layer of soft connective tissue containing 
 dense areas of round-celled infiltration and groups of glands 
 (D), wedged in between the two lateral portions. The latter 
 consist almost entirely of an irregular network of epithelioid 
 cells in chains, with here and there a narrow strip of connective 
 tissue — a tumor of alveolar character. 
 
 The higher amplification in Fig. 2 reveals the nature of the 
 cells forming the parenchyma of the tumor. They resemble 
 the epithelial elements found in the pelvis of the kidney, hav- 
 ing irregular round bodies with sharp processes. Some of them 
 are multinuclear and probably engaged in reproduction. The 
 individual cells, however, are not in immediate contact with 
 each other, being separated by slender interstitial fibers of con- 
 nective tissue, so that even this epithelioid structure is really a 
 connective-tissue formation. Judging from the situation and 
 appearance of the cells, we are inclined to regard them as 
 degenerated endothelium from the lymph-spaces. It is there- 
 fore an 
 
 Alveolar Sarcoma. 
 
 Fig. 3. 
 
 At first sight, this picture appears very similar to the pre- 
 ceding : numerous large spherical and club-shaped masses re- 
 sembling epithelium, separated by small quantities of connec- 
 tive tissue. The part of the surface on the left is not covered 
 by epithelium ; it consists largely of naked connective tissue, 
 lined on the free edge by a narrow border of densely packed 
 round cells, so closely simulating true epithelium that their 
 real nature is only recognized with a very high power — a pseudo- 
 epithelium. 
 
 The cells of the tumor itself prove to be true epithelial cells 
 in close contact with each other (without any intervening 
 spaces). 
 
 The tumor, which is seen macroscopically in PI. 27, Fig. 1, is 
 therefore a 
 
 Carcinoma. 
 
PLATE 38. 
 
 Fig. I. 
 
 A thick, smooth tumor from the left vocal process of a man, 
 26 years old. The outer covermg, which is fairly uniform in 
 thickness, consists of several layers of sciuamous epithelium ; 
 next comes a layer of dense tissue of about the same thickness, 
 containing spindle-shaped cells. The interior consists of loose 
 connective tissue poorly supplied with cells and broken up into 
 large cavities with thin walls ; the latter are lined with a single 
 layer of endothelium (En), and correspond to dilated lymph- 
 spaces or lymphatic ducts. Part of the supporting tissue (a), 
 even when seen under a high power, shows no nuclei and 
 appears to be made up of structureless debris ; it is, therefore, 
 engaged in retrogressive metamorphosis. This, as well as the 
 lymph-spaces, must be regarded as a manifestation of an edem- 
 atous process. The tumor is an 
 
 Edematous Lymphangiofibroma. 
 
 Fig. 2. 
 
 This smooth, pale-red tumor, from the right vocal cord of an 
 elderly man, presents a similar formation on the surface as well 
 as in the deeper parts. The proliferation of epithelium (E) 
 toward the base is more active and shows the characteristic 
 villous formation ; the cells are more abundant in the body of 
 the tumor, and there are large clefts not lined with endo- 
 thelium. The latter are, therefore, not lymph-spaces, but 
 simple mechanical dilatations of the tissues by edema. Signs 
 of edema are also seen at "0," where the tissue is still con- 
 tinuous, and of impaired nutrition in the form of structural 
 loss at "a." 
 
 As the lymph-spaces themselves are but little involved, the 
 tumor is practically an 
 
 Edematous Fibroma. 
 
 Fig. 2. 
 
 The accompanying cut represents a part of the epithelial 
 covering of the above preparation. The upper half is engaged 
 in complete metamorphosis. The cells, which are quite small 
 in the deeper layers, gradually increase in size, and their pro- 
 toplasm becomes more and more granular as they approach 
 
the surface. At last the cell-boundaries are lost entirely, the 
 nuclei disappear, and only a few " shadow " cells are dis- 
 tinguishable. The latter are enlarged to forty-five times their 
 
 m 
 
 Fig. 24. 
 
 normal size and completely filled with granular material. The 
 whole is covered by several layers of dense lamellae without 
 nuclei— the results of cornification. 
 
Tab. 38. 
 
 Tiff.l. Vergr. ^fi 
 
 S^^^mS 
 
 
 •r^^;'\k 
 
 ^^u^ 'fy 
 
 o & 
 
 Fig. 2. Vergr. 25/i 
 
 lUh. Anst F. Retchhold, Mdnjchen. 
 
Tab. 
 
 'A( 
 
 /vv/..y. Vercjr. ^f/ 
 
 c 
 
 Lilh: Arts I F. Retdihold, Mmidijen . 
 
PLATE 39. 
 Fig. I. 
 
 This preparation is a sagittal section of one of the two small 
 symmetrical tumors shown in PI. 15, Fig. 2. The growth con- 
 sists of a hollow sac filled with a clear mucoid substance; the 
 cavity occupies almost the entire body of the tumor and 
 merges, without any clearly defined line of demarcation, into a 
 delicate connective tissue moderately rich in cells and thick 
 blood-vessels. The whole is covered by a layer of squamous 
 epithelium of varying thickness, which sends down villous 
 Xjrocesses here and there toward the center of the tumor. The 
 cavity is evidently due to loss of substance. In order to get a 
 clearer understanding of the way in which this cavity was 
 formed let us compare it with Fig. 25. 
 
 Fig. 25. 
 
 The interior of this preparation is almost homogeneous, with 
 only a few groups of round cells scattered here and there ; if 
 we imagine this area to have undergone the same degenera- 
 tion (by colliquation and absorption of the broken-down cells) 
 that is seen in the first preparation, we shall obtain an almost 
 exactly similar picture, the only difference being the narrow 
 peripheral zone of denser connective tissue. It is therefore an 
 
 Absorption-cyst within a Soft Fibroma. 
 
PLATE 40. 
 Fig. I. 
 
 This cut also exhibits marked changes in the blood-vessels, 
 although somewhat different in character from the preceding. 
 It is taken from the tumor shown in PI. 27, Fig. 2. 
 
 The hyperplastic, horny epithelial covering encloses a core 
 of connective tissue filled with numerous dilated lymph-spaces, 
 in accord with the gelatinous nature of the edematous infiltra- 
 tion described macroscopically. There is only a very light 
 sprinkling of cells. On the right is seen a rich network of 
 small arteries with hypertrophied and thickly infiltrated w^alls, 
 but without dilatation. The condition is, therefore, not an 
 inflammatory, but a purely hyperplastic one. The concentric 
 mode of the hypertrophy has led to obliteration of the lumen 
 in many situations, and hence, by stasis, to edema. We have 
 before us, therefore, an 
 
 Edematous Angiofibroma. 
 
 Fig. 2. 
 
 Again the most striking feature, after the enormous prolifera- 
 tion of squamous epithelium, is the diseased condition of the 
 blood-vessels. The section corresponds to the excrescence on 
 the posterior wall of the larynx shown in PL 5, Fig. 1. Numer- 
 ous small lumina of blood-vessels, some of them dilated, are 
 seen at G. Some present only a slight uniform hypertrophy 
 of the media, while others are surrounded by huge masses of 
 round cells. In places the round cells have even filled up the 
 lumen, and in the upper right-hand portion they are on the 
 point of attacking the epithelium. This is not a simple inflam- 
 mation of the vessel-walls ; the uniform character of the densely 
 packed cells imbedded in loose areolar tissue (as seen with a 
 higher power), and disposed in spherical masses, characterizes 
 the process even macroscopically as 
 
 Syphilitic Meso- and Peri- arteritis, changing to Gumma-formation. 
 
Tab. 40. 
 
 ■•^• 
 
 'l^§^(ii 
 
 f^>--:m 
 
 W 
 
 /Mk 
 
 
 ■^m 
 
 
 Bl 
 
 Fig.l. Vergn^o/i 
 
 ^^f'- 
 
 i^^y.^. Vergn Wi 
 
 Lith. Arist F. ReicMwld, Munchen. 
 
Tab. 41. 
 
 a 
 
 Fig.l. Vergr.^^i 
 
 c 
 
 a 
 
 Fig.^. Vergr. 25/i 
 
 LUh-Anst F. ReiJChhoUl.Munjchjen. 
 
PLATE 41. 
 
 Fig. I. 
 
 One of the convolutions on the posterior wall, represented in 
 PL 5, Fig. 3, was removed with the galvanocautery ; it was 
 found to be exceedingly hard. In horizontal section the 
 growth appears as a roundish elevation of connective tissue 
 covered by an epithelial layer of varying thickness. ^ At certain 
 points the epithelium is very abundant and, especially on the 
 left side, sends down long ramifications into the basal tissue. 
 That the proliferation proceeds downward is also proved by 
 the smooth outline of the free surface. Here and there we see 
 open spaces which probably correspond to the transverse sec- 
 tions of invaginated portions of the epithelial layer. The 
 central portion of the base is occupied by numerous glands, 
 some of which exhibit considerable uniform enlargement, 
 while in others the hypertrophy of the walls betrays itself in 
 the irregular outline of the transverse section. A zone of 
 round-celled infiltration of varying density surrounds this area 
 of gland- tissue and the blood-vessels which are seen at G. In 
 some of the latter the lumen is considerably narrowed from 
 hypertrophy of the inner wall, which at one point (a) forms a 
 mushroom-like elevation ; this pronounced form of hyperplastic 
 endarteritis, as well as the peri-arteritis, accords perfectly with 
 the syphilitic nature of the tumor. It does not, however, 
 possess any distinctive syphilitic features ; it is a general hyper- 
 plasia of all the elements composing the mucous membrane, 
 without any typical characters, so that the tumor cannot be 
 regarded as syphilitic. It is simply a 
 
 Postsyphilitic Inflammatory Hyperplasia. 
 
 The probable cause of the growth has already been discussed 
 in connection with PI. 5. 
 
 Fig. 2. 
 
 This preparation is taken from PI. 18, Fig. 3 ; it is a vertical, 
 transverse section of the tumor on the ventricular band. At 
 first sight, it seems to be a hard wart, for we observe a very 
 heavy epithelial covering, the upper layers of which, being flat 
 and showing no nuclear stain, have, therefore, become horny. 
 On the right the epithelium is seen to dip down into the basal 
 tissue. The core of the tumor, however, is anything but nor- 
 mal : there are three distinct areas of infiltration, a small one 
 in the lower right-hand portion (b), and two larger adjoining 
 
groups (c, d), which occupy almost the whole of the center and 
 are in turn made up of smaller, round aggregations of cells, 
 lighter at the center than at the periphery, where the cells 
 are massed in heavier layers. In addition, we see a dense in- 
 filtration along the course of small blood-vessels — a sign of peri- 
 arteritis. 
 
 With a higher power we note that the round cells are fairly 
 uniform in size and disposed in groups of varying density, but 
 no giant-cells can be made out. The cells are imbedded in a 
 delicate areolar stroma ; at the center of the large group on the 
 left they appear more scattered and are not stained so deeply. 
 
 We know from the anamnesis that syphilis is present; but 
 the histological appearances alone would suffice for the diag- 
 nosis. They are 
 
 Confluent Gummata in the Deeper Tissues, witli Hyperplasia of the 
 
 Superficial Elements. 
 
PLATE 42. 
 Fig. I. 
 
 This is a vertical section of the ulcer on the epiglottis shown 
 in PL 5, Fig. 1. 
 
 The dense ground-tissue (G) shows numerous sclerotic arte- 
 ries ; overlying this is a layer of tubular glands (D), the most 
 superficial of which are already being absorbed by numerous 
 small masses of round cells. The latter are in direct relation 
 with the free surface, the epitheUum being entirely lost ; hence 
 the ulceration extends almost to the glandular tissue. The 
 uniform (areolar) infiltration is of a gummatous nature; we 
 have before us a 
 
 Syphilitic Ulcer. 
 
 Fig. 2. 
 
 A horizontal section of the larynx taken from a tuberculous 
 subject; only a slight fold had been visible on the anterior sur- 
 face of the posterior wall. The section shows even in this slight 
 alteration the signs of beginning infection. KK, the arytenoid 
 cartilages in transverse section; M, muscle-bundles; D, glands. 
 Exactly in the centre (E) the epithelium is much hypertro- 
 phied and forms a small wart-like elevation which corresponds 
 to the ominous interarytenoidal spur seen macroscopically. 
 Immediately beneath we see small aggregations of round cells 
 (T), which under a higher power reveal themselves as a true 
 tuberculous infiltration. The (reactive) epithelial proliferation 
 extends some distance laterally over the surface. 
 
Tab. 42. 
 
 Lith. Anst F. ReiMwld, Miindim. 
 
Tab. 43. 
 
 Fig.l. Vergr.n/i 
 
 rfSX:? 
 
 
 Ti . 
 
 ^2s^Sf' 
 
 
 ^K'%^^ 
 
 
 
 
 c^ 
 
 :^- 
 
 
 D 
 
 fs. 
 
 Fig.^. Vergp. 104 
 
 LUh.Anst P ReicMwld, Miinchen. 
 
 /' 
 
PLATE 43. 
 Fig. I. 
 
 This preparation was removed with a curet from a tubercu- 
 lous infiltration on the posterior wall of the larynx. 
 
 The figure shows principally a conglomeration of tuberculous 
 proliferations merging into one another. These overlie a cen- 
 tral mass of dense connective tissue (in the lower left-hand 
 portion) which forms the boundary of the cut surface, showing 
 that it was made within the limits of healthy tissue. (The 
 yellow portions are not tissue, but portions of the imbedding- 
 material.) 
 
 Fig. 2. 
 
 A horizontal section of the larjTix of a tuberculous cadaver 
 which showed prominent, pale, rigid infiltration of the posterior 
 wall. 
 
 We see two large areas of infiltration separated by a deep 
 fissure, lined with a thin layer of epithelium. At the bottom 
 of the fissure the infiltration has invaded the epithelium and in 
 part crowded it out entirely, so that it appears completely 
 naked. The infiltration possesses a pronounced tuberculous 
 character, even under the low power. The cells exhibit a 
 circular arrangement with a lighter area in the center, poor in 
 nuclei, showing that degeneration has begun. Even the peri- 
 chondrium of the upper cross-section of the (left) arytenoid 
 cartilage shows infiltration. 
 
 The (non-specific) reaction manifests itself in this case not in 
 the epithelium, but in the vessels, whose w^alls are much hyper- 
 trophied : the beginning of sclerosis so common in tuberculosis. 
 
PLATE 44. 
 Fig. I. 
 
 A section of a club-shaped tumor on the left ventricular band 
 of a man 44 years old. Macroscopically the tumor presented the 
 appearance of a pale, uneven papilloma, about f cm. in length, 
 6 mm. in breadth, and ^ cm. in thickness. Three other similar 
 tumors were seated in the same situation. The remaining 
 parts of the larynx and the lungs were normal. The epithelium 
 (E) presents numerous villous processes which descend quite 
 deeply into the basal tissue. Just as in true papillary tumors, 
 we see a part of the growth diverging from the main body to 
 such an extent that in transverse section it appears as an 
 isolated mass (Fig. 1^). But whereas such isolated portions 
 usually consist entirely of epithelium, wdth only a slender 
 pedicle (PI. 30, Fig. 2), in this case the external epithelial layer 
 is very thin and encloses an ovoid kernel consisting chiefly of 
 round cells with only a narrow ring of connective tissue (T). 
 Many such masses or kernels are seen in the tumor itself, the 
 cells being more densely packed near the peripher}' than at the 
 center. 
 
 With a higher power we find that the center contains also 
 epithelioid and giant-cells, revealing the true nature of the 
 growth. It is a 
 
 Papillary Tuberculous Tumor. 
 
 Fig. 2. 
 
 This preparation corresponds to the tumor shown in PI. 32, 
 
 Fig. 2. The general appearance is that of a connective-tissue 
 growth with al)undant round-celled infiltration. The surface is 
 enclosed in a cellular band of varying thickness, which imder a 
 higher power is also found to consist of round cells — another 
 example of pseudo-epithelium (P) (see PI. 37, Fig. 3). In the 
 center the infiltration al)Out the vessels varies much in density, 
 without, however, forming typical tubercles. Only at one spot 
 on the surface is there anything approaching in appearance a 
 tubercle. We must call the tumor a 
 
 Diffuse Tuberculous Hyperplasia. 
 
Tab. 44. 
 
 T.: 
 
 T 
 
 Fig1 
 
 E^.V 
 
 
 
 Fig. 
 
 ? 
 
 Vergr. 
 
 i5A 
 
 I'.'r 
 
 G 
 
 LWx.Anst F. Rei£hJtwld,Mimjdmv. 
 
Fig. 15, 
 
 A woman, 43 years old, seeks relief for increasing dyspnea and diffi- 
 culty in swallowing. The cyanosis of the face is very striking, and 
 there is rough, audible stridor in inspiration. The voice is rough and 
 sometimes aphonic. 
 
 The larynx is entirely concealed by a dark-red tumor as large 
 as a walnut, with a slightly wavy surface traversed by a few 
 large vessels. The tumor is free behind and on the left side, 
 while on the right it is continuous with the lateral wall of the 
 pharynx. In front nothing is visible but the epiglottis and the 
 commissure. 
 
 A slight goiter is noticeable on the outside of the throat. On palpa- 
 tion the right lobe is found to extend more deeply than the left. Press- 
 ure on this part causes the internal tumor to move slightly toward the 
 left. On bimanual palpation (right index finger on the tumor inside, 
 left hand on the goiter outside) the effect of pressure on one side is even 
 more plainly felt. The tumor is, therefore, beyond doubt a 
 
 Struma Retropharyngea Dextra. 
 
Fig. i6. 
 
 A young lady, 23 years old, has lost her voice entirely ; she cannot 
 speak above a whisper, l)ut from time to time slie coughs loudly. This 
 condition has lasted two weeks; at the same time she complains of 
 violent pain in the region of the right cornu of the hyoid bone. The 
 larynx as a whole is rather pale. 
 
 During respiration the vocal cords exhibit a slight twitching move- 
 ment toward the middle line. 
 
 When the patient tries to phonate the vocal cords approach 
 only to the cadaveric position. 
 
 Occasionally, however, w^hen she coughs, the arytenoid cartilages are 
 seen to move more distinctly inward. 
 
 The fact that the closers of the glottis are insufficient when a volun- 
 tary attempt at innervation is made, yet respond to an involuntary act 
 of "the same character (loud cough), and the absence of inflammatory 
 signs, at once establish the diagnosis as 
 
 Hysterical Aphonia. 
 
 Later it appears that the hysteria was caused by a great psychical ex- 
 citement. 
 
Fig. 17. 
 
 A woman, 40 years old, has been hoarse since she was operated on Tor 
 struma. 
 
 The right vocal cord is widely abducted during respiration, 
 the left remains midway between respiration and phonation- 
 posture. The left arytenoid region is thrust somewhat farther 
 forward than the right. During phonation (dotted lines) the 
 right cord moves to the middle line, while the left is immova- 
 ble. The cartilages on the right side move forward and inward, 
 as usual ; those on the left also, but not to the same extent ; at 
 the same time the left aryteno-epiglottidean ligament is slightly 
 put on the stretch. 
 
 From the anamnesis and from the absence of any mechanical obstacle 
 we must diagnosticate 
 
 Traumatic Paralysis of the Left Recurrent Nerve, with Marked 
 Vicarious Function of the Transverse Ar3rtenoid Muscle. 
 
Fig. i8. 
 
 In another patient the right vocal cord is also fixed in the 
 cadaveric position both in respiration and in phonation. In 
 respiration (a) the right arytenoid cartilage stands a little farther 
 toward the front than the left, while in phonation (b) the oppo- 
 site occurs. 
 
 It is another case of 
 
 Paralysis of the Right Recurrent, 
 but without function of the arytsenoideus transversus. 
 
Fig. 19. 
 
 In a third case of this kind the paralyzed left vocal cord and 
 its cartilage are immovable during phonation. The right ary- 
 tenoid cartilage, however, passes underneath the left; the right 
 vocal cord moves farther over, and almost perfect closure of the 
 glottis is efltected during j^honation. The voice is accordingly 
 good, only a slight hoarseness being noticeable. 
 
Fig. 20. 
 
 A male singer, 23 years old, suddenly lost his voice eight months ago. 
 It gradually returned, but since that time he occasionally becomes 
 almost aphonic for one or two days at a time. During the intervals 
 between the attacks he is able to sing well and loud. 
 
 Both vocal cords are grayish-yellow and somewhat succulent. 
 
 Both vocal C'ord.s move during phonation.but the right moves 
 so far V)eyond the middle line that the left does not get beyond 
 the cadaveric position. At tlie same time the right arytenoid 
 cartilage comes in front of the left. 
 
 During respiration both vocal cords are perfectly abducted. This 
 irregularity, which formerly was. without good reason, designated by the 
 special name of asjfinmetrm arytxnoidea cruciata, is very suggestive of 
 the posture seen in paralysis of the recurrent. In view of the anamnesis, 
 it may be regarded as the 
 
 Remnant of an Old Paralysis of the Left Recurrent. 
 
Fig. 21. 
 
 A woman, 36 years old. has had dyspnea for years; it has been 
 gradually getting worse, and in the last few days suddenly became in- 
 tense. The cause is a goiter, not very extensive, but easily felt on deep 
 palpation ; it is on the left side of the throat. 
 
 With the laryngoscope the trachea is seen to be pushed to one side. 
 
 In the larynx the position of the left vocal cord is striking. 
 During phonation it stands exactly in the middle line, and 
 during respiration it maintains the same position, only the free 
 edge, which was stretched taut before, becomes slightly concave. 
 
 It is the typical position of 
 
 Paralysis of the Left Posterior Arytenoid Muscle. 
 
 As usual, it represents the first stage of pressure-paralysis of the left 
 recurrent by the struma. 
 
Fig. 22. 
 
 A man, 45 years old, who is found to have been suffering with tabes 
 dorsaHs for three or four years, began to be troubled with dyspnea about 
 a week ago, so that any active exercise has Ijecome impossible. The 
 voice is loud and has a good tone. 
 
 Instead of separating, the vocal cords remain immovable 
 during respiration, at a short distance from the middle line. 
 
 As there is nothing to indicate a mechanical obstacle to abduction of 
 the cords, it must be that the abductor nuiscles are paralyzed. 
 
 Tabetic Paralysis of the Posterior Crico- arytenoid Muscles. 
 
Fig. 23. 
 
 A -woman, 63 years old, has been hoarse for some time. The voice is 
 feeble, rough, and toneless. 
 
 The only abnormality in the larjTix is observed during phona- 
 tion, which presents the following curious picture. The edges 
 of the vocal cords present in the resting position, as usual, a 
 smooth, slightly concave outline ; but as soon as the glottis is 
 closed the edges become wavy, so that closure is not complete. 
 
 A soimd can be introduced without causing the patient to cough ; in 
 fact, she does not feel it when she closes her eyes. Even the tinger 
 elicits no reflex either from the epiglottis or from the superior aperture 
 of tlie larynx. 
 
 If the finger is held on the cricothyroid ligament during phonation, 
 no tension or movement of the two arytenoid cartilages can be felt. AVe, 
 therefore,, have to deal with paralysis of the cricothyroid muscle and of 
 the sensory nerves of the larynx. 
 
 As these constitute the entire domain of the superior laryngeal nerves, 
 we have before us a 
 
 Paralysis of the Superior Laryngeal Nerves. 
 
 As no other abnormal condition can be found in the body, it is im- 
 possible to determine the cause. 
 
INDEX. 
 
 (Fig. indicates Figure; PI. indicates Plate.) 
 
 AxGiOFiBEOMA, PI. 39, Fig. 3 ; PL 
 
 40, Fig. 1 
 Angioma, PL 21, Fig. 3; PL 39, 
 
 Fig. 2 
 Aphonia, hysterical. Fig. 16 
 
 Caecixoma, PL 14, Fig. 3; PL 27, 
 Fig. 1 ; PL 28, Figs. 1 and 
 2 ; PL 29 ; PI. 37, Fig. 3 
 
 Cartilages of larynx, 9, 10 
 
 Catarrh, PL 9, Fig. 1; PL 11, Fig. 
 1; PL 14, Fig. 1; PL 36, 
 Fig. 3 
 
 Cauterization, 33 
 
 Chondritis, PL 20 
 
 Cortical center for movements of 
 larynx, 19 
 
 Crepitation, 26 
 
 Croup, pseudo-, 38 
 
 Cyst, absorption, PL 39, Fig. 1 
 
 Diphtheria, 39 
 
 Edema, acute inflammatory, PL 7, 
 
 Fig. 1 ; PL 26, Fig. 1 
 Electrolysis, .33 
 Epiglottis, 10 
 
 n shape, 21, PL 2, Fig. 1 
 Epithelioma, PL 36, Figs. 1 and 2 
 Epithelium, distribution of, 18 
 Erysipelas, PL 25, Fig. 1 
 
 Falsetto voice production, 22 
 Fibro-epithelioma, PL 33, Fig. 2 ; 
 
 PL 35, Fig. 2 ; PL 45, Fig. 2 
 Fibroma. PL 15, Fig. 2 ; PL 18, Fig. 
 
 2; PL 38, Fig. 2; PL 39, 
 
 Fig. 1 
 Foreign-body stenosis, PL 31, Fig. 3 
 
 Galvanocautery, 34 
 
 Herpes, 57, PI. 6, Fig. 1 
 Hyperplasia, connective-tissue, PI. 
 14, Fig. 1 
 
 epithelial, PL 34, Fig. 3 
 
 inflammatory, PI. 10, Fig. 1 ; PL 
 
 22, Fig. 3; PL 33, Fig. 1; 
 PL 35, Fig. 1 
 
 pachydermatous, PL 16, Fig. 1 
 post-syphilitic, PL 41, Fig. 1 
 tuberculous, PL 21, Fig. 2; PI. 
 
 23, Fig. 1 ; PL 44. Fig. 2 
 Hysterical aphonia, Fig. 16 
 
 Ixflammatiox, PL 19, Fig. 1 
 Influenza, laryngitis in, 56 
 Innervation of larynx, 18 
 
 false, 27 
 Intubation, 35 
 
 Killian's posture, 
 Fig.l 
 
 22, PI. 1, 
 
INDEX. 
 
 Kirsteiu's method of direct laryu- 
 goscopy, 24, 29 
 
 Laryngitis, acute, PI. 19, Fig, 2 
 secondary chrouic, PI. 10, Fig. 1 
 Ligaments of larynx, 10, 11 
 Light in laryngoscopy, 24 
 Lordosis of cervical vertebrge, PI. 2, 
 
 Fig. 3 
 Lymphangiofibroma, PI. 38, Fig. 1 
 Lymph-follicles, distinguished from 
 miliary tubercles, 17 
 
 Maceeation by pus, PI. 10, 
 
 Fig. 2 
 Measles, laryngitis in, 54 
 Muscles of larynx, extrinsic, 10 
 
 intrinsic, 12 et seq. 
 Muscular process, 12 
 
 Papilloma, PI. 32, Fig. 1 
 Perichondritis, syphilitic, PI. 5, 
 Fig. 3 ; PI. 24. Fig. 1 
 tuberculous. 29, PI. 17, Fig. 1; 
 PI. 20 
 after typhoid, PI. 17, Fig. 2 
 Phlegmon, PI. 7, Fig. 2 
 Phonation, 22 
 
 false vocal cord, 23, PI. 3, 
 Fig. 2 
 Process, muscular, 12, 15 
 vocal, 12, 15 
 
 Rheumatism, 59 
 
 Sabcoma, alveolar, pi. 24, Figs. 2 
 and 3; Pl. .37, Figs. 1 and 2 
 Scarlet fever, laryngitis in, 55 
 Sinuses, pyriform, 11 
 Small-pox, laryngitis in, .55 
 Stenosis, by foreign body, PI. 31, 
 
 Fig. 3 
 Stridor, 27 
 
 Struma, Fig. 15 
 Syphilis, catarrh, PI. 14, Fig. 1 
 gumma, PI. 4, Fig. 1 ; PI. 5, Fig. 
 1; PI. 13, Fig. 1; PI. 22, 
 Fig. 2 ; PI. 40, Fig. 2 ; PI. 
 41, Fig. 2 
 membrane, PI. 30, Fig. 3 
 meso- and peri arteritis, PI. 40, 
 
 Fig. 2 
 papules, PI. 11, Fig. 2; PI. 12. 
 
 Fig. 1 
 perichondritis, PL 5, Fig. 3; Pi. 
 
 24, Fig. 1 
 tertiary, PI. 5, Fig. 2; PI. 21, 
 Fig. 1 
 depositions, PI. 18, Fig. 3 
 infiltrate, PI. 23, Fig. 2 
 ulcers, PI. 13, Fig. 3 ; PI. 42 
 
 Tuberculosis in fibro-epithelioma, 
 
 PI. 45, Fig. 2 
 hyperplastic, PI. 21, Figs. 1 and 
 
 2; PI. 23, Fig. 1: PI. 44, 
 
 Fig. 2 
 infiltrative, PI. 5, Fig. 1; PI. 6 
 
 Fig. 2; PI. 9, Fig. 2; PI 
 
 12, Fig. 2 ; PI. 16, Fig. 2 
 
 PI. 19, Fig. 3; PI. 22, Fig 
 
 1; PI. 25, Fig-s. 2 and 3 
 
 PI. 26, Fig. 2 ; PI. 43, Figs. 
 
 1 and 2 
 lupous form, PI. 4, Fig. 2 
 perichondritis, PI. 17, Fig. 1 ; PI. 
 
 29 
 tumors, PI. 22. Fig. 1; PI. 31, 
 
 Fig. 2 ; PI. 44, Fig. 1 ; PI. 
 
 4.5, Fig. 1 
 ulcerative, PI. 16, Fig. 2 
 Tumors, benign, PI. 14, Fig. 2 ; PI. 
 
 16, Fig. 1; PI. 27, Fig. 2; 
 
 PI. 31, Figs. 1 and 2; PI. 
 
 33, Fig. 3 
 tuberculous, see Tuberculosis, 
 
INDEX. 
 
 Typhoid fever, laryngitis in, 56 
 
 Ventricle of Morgagni, prolapse 
 
 of, PI. 18, Fig. 1 
 Ventricular bands, 14 
 Ventriloquy, 23 
 Vocal cords, 13 
 color of, 21 
 position of, in cadaver, PI. 13, 
 
 Fig. 2; PL 17, Fig. 2; PI. 
 
 23, Fig. 2 ; PI. 25, Fig. 1 ; 
 
 Figs. 16, 18, 22 
 
 Vocal cords, position of, in phuna 
 tion, 22 
 in respiration, PI. 3, Fig. 1 
 paralyses. Figs. 16 to 23; PI. 8; 
 
 PI. 13, Fig. 2 
 IH'ocess, 12 
 Voice, character of, 27 
 production, 13, 22 
 
 Wart, hard, PI. 15, Fig. 1 
 Whooping-cough, 57 
 
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