Kyle, M. D., D. Braddon.—Initial Forms of Tubercular Laryngitis.—Inter. Med. Mag., March, 1900.
The enumeration and exact description of these prodromal symptoms are so important that we copy them in full.
The following, which is a translation of an article by Monsarrat of Paris (Rev. Hebdom. Laryngol., d’Otol., et de Rhinol., No. 43, October 28, 1899), covers the ground so thoroughly that it is worthy of repetition:
“Laryngeal phthisis completely developed presents multiple and varied symptoms, some more characteristic than others. In one patient are found symptoms functionally grave, out of proportion to the lesions relatively benign. In another, physical signs take first place; there may be an ulceration completely obliterating one cord, or considerable œdema of the arytenoids and vestibule, which closes the opening of the glottis. Having reached the period when tuberculosis is easily recognized, the various patients are able to date their laryngitis from diverse pathologic beginnings. This one will present solely the history of a cough, the other a raucous voice, in another pain will take precedence. In mentioning these various modes of commencement we insist on the connection which may exist between each of them and the localization at the beginning of tuberculosis, on one or the other parts of that complex organ known as the larynx. Let us divide the symptoms into the functional and the laryngoscopic. The connection or antithesis between them will be noticed.
“An initial symptom, quite frequent in tubercular laryngitis, is, without a doubt, cough. This symptom, common to all maladies of the respiratory tract, would have no diagnostic value, except that it is characteristic. On it alone the diagnosis of laryngeal phthisis could never be based. At the beginning, cough puts us on our guard, especially when it is causeless; that is to say, when auscultation of the chest fails to reveal anything abnormal. This cough is always persistent, sometimes violent, hawking, and provoking.
“The physical signs of the chest do not correspond to the tenacity of the cough; it is therefore possible for the larynx to be accused. As regards this cough, the ‘hemming’ so often described, and which draws attention most often to a possible rhinopharyngitis, may cause us to think at the beginning of tuberculosis, but only after examination of the rhinopharynx has established its integrity. There is a cough, well known at the beginning of tubercular laryngitis, a little dry cough, commencing insidiously, often at the moment when the patient is about to speak, which the individual himself does not notice, but to which his friends attach an importance too often justified by the outcome. The cough may be hacking, followed or not by expectoration, and often accompanied by vomiting. It is certainly right to consider it as a symptom of the beginning of the disease.
“The speaking voice is often altered, dysphonia appears, and the patient who is attacked presents little alteration in his larynx; no ulceration, the cords accurately approximate, and they are very slightly congested; the laryngeal image does not reveal anything by which this profound alteration in the voice can be explained. There is no cough. There will come a time in the disease, however, which will cause us to see that this, too, is an initial form, and oblige us to give a prognosis exceedingly guarded.
“The voice may be eunuchoid. Castex has noted it among the tuberculous. The raucosity of the voice should also recall the statistics which demonstrate the fact that a fifth of the cases of this condition are tubercular. But these three symptoms, dysphonia, raucosity, eunuchoid voice, are also found in other maladies of the larynx; conditions, however, easily diagnosticated by the laryngoscope. If nothing justifies these affections of the voice, one should think of tuberculosis. It is these initial forms, apparently paradoxical, but analogous to that, which we are going to mention under the subject of pulmonary lesion not sufficient to provoke cough in the beginning if the larynx has not been initially affected. The forms that are recognized in the mirror are evidently very numerous. We will mention some: Congestion of the cords, monocorditis, recurrent laryngitis, and a nodular form at the free border of the vocal cords. We do not take into consideration any variety of ulceration, no matter how insignificant, as for the most part the velvety aspect of the cords leads us to think at once of laryngeal phthisis. But this has not appeared at the beginning, and we are only considering initial forms. The symptoms which we are attempting to describe are those suggestive of tuberculosis, and we only say that tuberculosis of the larynx may begin by a nodule, by a congestion, by a monocorditis, etc.
“Congestion of the vocal cords, whose ætiology is difficult to explain, often coincides with slight dysphonia, with cough. This congestion, fugacious, if not tuberculous, disappears with rest, if it is not aggravated by a chronic rhinopharyngitis. In the majority of cases the patient returns. Despite a treatment, properly instituted, the congestion persists; it extends on the cords; it may remain there, or it may reach over the ventricular bands to the arytenoidal apophyses; this is a form of commencing laryngeal phthisis, especially if, after a period of calm, there is found in a patient a new congestion. It is recurrent laryngitis, another form of initial tuberculosis more grave than the first. Against laryngitis of this form treatment is of no avail.
“Another variety of initial tuberculosis is monocorditis. The patient becomes suddenly aphonic; laryngoscopic examination shows a cord perfectly red, congestion of which is evident, not only by the color, but by its altered volume. Contrast with the sound cord is often striking. Movements of the affected cord may be observed, but it is generally paretic. Acute monocorditis should cause us to think that it is an initial form of tuberculosis. This monocorditis often corresponds to the side of the lungs which is afterward or at that time attacked by the bacillus. Certain authors admit that this relation is absolutely constant, and their statistics allow no exception to the rule. On the other hand, Bayle’s theory, setting forth the direct penetration of the tubercular infection, becomes less often justified. It is the lymphatic route which most often produces bacillary infection.