On the interrelation between the laryngeal complication and the course and treatment of pulmonary tuberculosis

ON THE IN1'ERRELA'l'ION BETWEEN THE LARYNGEAL COMPIJICATION AN D THE COURSE AND TREA'l'i\IENT OH PULMONARY TUBERCULOSIS. By J .

GRAVESEN,

M.D. (Copenhagen).

Medical Superintendent, Vejlefjord Sanatol'illlll, Denmark, AND

F. W.

GODBEY,

M.D ., D.P.H.Duulin.

OF the complications of phthisis probably laryngeal tuberculosis occupies the most prominent position both in regard to its frequency and its influence on the prognosis, treatment, and the results of treatment. As far as we have been able to trace, there has not been published any account of investigations which show how pulmonary and laryngeal tuberculosis thus mutualIy affect each other. When in this article we seek to illuminate the question from the statistics of Vejlefjord Sanatorium, this is naturally done from a phthisiclogical point of view. The laryngeal conditions, whose detailed description presupposes spec!al training in this tield, are here dealt with according to observations which can be made by the laryngological practice of the sanatorium physician. ~here is much in om' conclusions which emphasises the advantages obtainable from a more intimate co'operation between laryogologist and phthisiologist. On the other hand, the phthisiologist should obtain such practice in diagnosing laryngeal tuberculosis, that he is able to draw fair conclusions from the tables which are presented here, even though these are not based on the observations of a laryngologist. We are concerned with three main problems : (1) The retiology of the complication and its frequency III the different stages of pulmonary tuberculosis, &c. (2) Its influence on the prognosis. (3) Its influence on the treatment. The various investigations are based on a material of 645 cases of laryngeal tuberculosis treated at Vejlefjord Sanatorium in the course of twenty-seven years. This figure does not cover all the cases that have been admitted, as those are excluded who have stayed in the sanatorium leSB than a month. We have also excluded from some of the tables (I III, IV, and V) smaller groups of cases which on admission were d~8ignated "Unfit for Treatment." 'I'he statistics for the years 1900-15 are examined with a view to investigating the permanent results of ordinary sanatOl'ium treatment in laryngeal ~uberclilosis and in equally advanced lung cases without laryngeal involvement. The cases discharged from 1916-26 (inclusive) have been investigated in more detail in order to shoW the results of the more active treatment which has been extensively employed in later years.

30

[July, 1997

TUBERCLE

(1) THE .'E TIO LOGY OF LARY~GEAL TUBERCDLOSIS.

Laryngeal tuberculosis occurs, as one would expect, chiefly in those cases where the pulmonary affection is already in the third stage. Out of the last 281 cases the pulmonary affection was in the third stage in 271 cases, in the second stage in 7 cases, and in the first stage in only 3 cases. It will be seen that this complication is, in our material, practically limited to the third stage of lung affection . Table I shows the frequency of the laryngeal complication in 1,809 patients discharged during the years 1900-17. In this table, as in the following, the third stage cases in which tubercle bacilli were absent from the sputum during the stay in the sanatorium are excluded, as we ha.ve considered these cases mainly to represent inactive disease. The table shows that 31 per cent. of third-stage cases with tubercle bacilli in the sputum are complicated with lar yngeal tuberculosis. The percentage 18. little higher in women than in men (32'3 per cent. against 29'6 per cent.). Medical writers often state that Olen are attacked by laryngeal tuberculosis more often than women. Ulrici [lJ states that men are affected twice as often as women. Our experience is similar to that of Sir StClair Thomson [2J, who finds the affection equally frequent in both sexes. The greater frequency in men observed by others is difficult to explain; it may be due to social circumstances, our patients belonging to more well-to-do classes. Our figures seem to show that smoking does not predispose to laryngeal tuberculosis, for one would then expect to find '. higher percentage in men. TABU;

Th ird."Uli' Ca" t ~ wit1.

Cases complicated with laryngeal

T.B. In spu tum .

Ubchlrged 10CX)-17 incl u...;i\"e

tubercnlosfs

1DO

Men •• Women Total

1.

2 1l i

1.309

It is remarkable to note how frequently laryngeal tuberculosis oceurs in association with cavities in the lungs. On examining the notes of 281 cases discharged during the last eleven years, we find that only 12 (4 per cent.) of these had no signs of cavities in the lungs. With regard to the manner in which the laryngeal process origina.tes, different theories bave been advanced . The most common theory is that the complication arises from direct infection by the sputum, whioh by coughing and other laryngeal movements is supposed to be rubbed into minute lesions in the laryngeal mucous membrane. Lately this theory has been largely abandoned, as the pathologico-anatomical investigations TABL~; lI.-TH~ CONDITION OF THE LARYNGEAL L ESION ON DISCHARGE [Cla.ssified acoordlPl

to the Presence or Absence of Tubercle Bncilli in the Sputum, in 281 Patienu wUla Laryngeal Tub erculosis, Discharged 1916-26 (inclusive)]. Conditio/l of

l"roS" l le, ioll

Healed .. Improved . . Stationary . . Worse .. .. " Only one examination possible

Oisc hal"ged will, tu be rcle ba ctlh

!>" esent

In

sputum

Diocharged with tube1'cl. br.eillI

ab.ent from aputua

29 45

as

7G

l'

11

31

1

41

0

July, 1927J

455

LARYNGEAL AND PULMONARY T"CBERCULOSIS

of recent years seem to show that infection takes place through the lymph, or rather through the blood. The only light which our investigations throw on this problem is to be found in Table II. We have tried to show how far improvement and healing of a laryngeal tuberculosis run parallel with disappearance of tubercle bacilli from the sputum. It is seen that 62 patients were discharged with a clinically healed larynx, but of these ~g still had tubercle bacilli in the sputum. In 5u patients improvement of the laryngeal process was noted, but only 11 of these had become free from bacilli. We may conclude that laryngeal tuberculosis is not maintained by a continued passage of sputum containing tubercle bacilli, and probably is not caused originally in this way. It is remarkable that laryngeal tuberculosis often progresses without causing symptoms. On going carefully through the notes of cases discharged from 1911::-1926, we find that in 90 cases laryngeal tuberculosis was present, although nothing is mentioned in the notes concerning laryngeal symptoms; indeed in many cases it is definitely stated that there were no laryngeal symptoms. In most of these cases the lesion was localised to the posterior glottic area, but in no less than 13 cases the vocal cords were affected. In 48 cases, that is in more than half, there was ulceration, in the rest only infiltration. 'I'he fact that laryngeal tuberculosis often commences without any symptoms emphasises the importance of examining the larynx regularly in every case of pulmonary tuberculosis. It is an invariable rule at Vejlefjord Sanatorium to examine the larynx in all cases, not only on admission, but also every month after this. Thus the complication may often be treated at the early stage, when there is the best possible scope for treatment. (2) THE INFLUENCE OF LARYNGEAL TUBERCULOSIS ON THE PROGNOSIS.

It is usually taught that the prognosis of pulmonary tuberculosis becomes milch more serious when the larynx is affected. Lately this idea has undergone a change, as the tendency is now more and more to lay all emphasis on the activity and extent of the pulmonary affection in determining the prognosis. This change of attitude arises from the fact that the lung is of much greater importance than the larynx in those processes of immunity which determine the reaction of the organism to the tuberculous invasion. Any direct influence which the laryngeal complication may have on the course of the pulmonary affection is probably confined to those relatively few cases where dysphagia is present to IL marked degree. III.-THK STATll: OF HEALTH ON JANUARY 1, 1920 [Four to Nineteen Years after Discharge of 1,167 Patients, all Third-Stage Cases, with T.E. in Sputum during the BtlloY in the Sanatoriu~, Discharged in the Years 1900·15 (inclusive)).

TABLE

Completely or partly fit for work Unfit for work Dead ., Unknown Total

Cases without laryngeal tuberculosis

Cases with l.r~-lIl(o.1 tuborculosta

All cas."

203 = 25'3 per ceut.

50 "" 13'7 per cent.

253 "" 21'7 per cant,

R =

23 "" 2-9 513 = 63-S 64 = S'O

\l79 = 7u'7 27 ~ 7·4

808

364

2'2

31 = 2'6 7(/2 "" 67'9 91 "" 7'S 1,167

"

456

[July, 1927

'J'OB~ROLE

When in Table III the cases with laryngeal tuberculosis show a worse prognosis than the rest, this must be interpreted to mean that the pulmonary affection in these cases has shown. so much grea.ter activity that the percentage fit for work 4 to 19 years after discharge is reduced to nearly half, whilst there is a corresponding increase in the percentage of deaths. Tables IV, V and VI are drawn up to shew that it is the course of the pulmonary affection which is decisive for the prognosis. In the first two of these tables is shown the condition of cases two to nine years after discharge. The results in these tables are almost identical, and in both these tables the results are connected chiefly with simple sanatorium treatment. FOl: comparison we have drawn up Table VI, which deals with 107 TABLE

IY.-THE STATE OF HEALTH ON JANUARY I, 1910 [Two to Nine Years a.lter Discharge, of 612 Patients (Third Stage, T.H. +). Discharged 1901-07 (incluaivej]. Case, without laryngeal tuberculosts

Completely or partly fit for work Unfit for work Dead Unknown .. Total TAsr.E

140 = 33'2 per cent. 32 ="C 'i' u :J44 = b7'8

"

Case. with laryngeal tuberculosis

39 =~ 20'5 per cent.

= 29'2 per cent.

14 =;'4 187 =' 72'1

46 = 7'5 381 = 62'3 6 = 1'0

190

612

6 . = 1'4 422

All eases

179

"

Y.-THE STATR. m' HEALTH ON JANUARY], ]920 [Two to Nine Years after Discharge, of 470 Patients (Third Stage, T .B. +) Discharged, 1!J1l-17 (inclusivel]. • C:lSI'~

Completely or partly fit for work Unfit lor work Dead " Unknown Total

107

witllout

I :U Y Il~I'nl

Cases with laryngenl

tllll~l'Ct,los i '\

=0=

27 - -'

34'3 per cen t. 8'G

145 ,

4(;' 5

::l~

10'6

312

All

tuberculoxi s

32 = 20'2 per cent .

139

==

ca~"s

29'6 per oent.

o 5 '7 102 - 64 '6 15 9 ·5

:lG '-' c 7 '7 247 co,. 52 '5 48 :..-: 10'l!

158

470

" "

"

TABLE Yr.-THE STATE OF HEALTH ON MARCH I, 1926 [Two to Nine Years after Discharge, of 107 Patients (Third Stage, T.n. +), on whom Thoracoplasty bas been performed. Discharged between Mareh I, 1917, and I1hrch I, 1924). C3.!(e~

Completely or partly fit for work Unfit for work Dead Total

wnho ut laryngeal

tub ercul osts

Ca,,~~

= 45 '5 per cent. 7 = 10 .G 2:) = 43' 9

1 = 2'4 26 = G3'4

66

41

30

14

=

with

IRryn;.:~ al

subereuloets

34 '2 per cent.

44

=

8=

41'1 per oent.

7'5

55 = 51'4

"

107

third-stage sputum-positive patients on whom thoracoplasty has been per formed within more recent years. The condition of these patients has also been determined two to nine years after discharge, and it has been ascertained that the average extent of the lung disease was larger in these cases than in those belonging to the two former tables. In addition to the improvement in the permanent result for all cases, there is a much s1114ller difference between laryngeal and other cases than in the previous tables. That there is also some difference here is 1Io natural consequence of the fact that the cases complicated with laryngeal tuberculosis are generally cases of more active disease.

July, 1927J

457

L AH YNGE AL AN D P UL MON ARY T UBERC ULOSI S

(3 ) TH E I NPf, uE N CE OF L A HYN<;EAT, T TT BER CI' J, OS IS ll~ THE T HE Al'M E N'l'.

We have already considered the influence of laryngeal tuberculosis on the results obt ained after thoracoplasty. The results obtained with this operation, as well as our exp er ien ce of individua l cases, leads us to disregard a : a rul e the laryn geal complication as a contra-indication to collapse th erapy. Laryngeal tuber culosis has also suggested other t reatm ent in many of the cases treated with th oracoplast y. L ight treatment, especially, has been extensively used . We may here state a practice which has been acted on at the Sanatorium, of directing the treatment chiefly against the primary pulmonary focus, and m ore over, of COUI bining this with other methods indica ted by the complications presen t. Wi th r eference to laryngeal tuber culosis, the work of lat er yea rs , and not lea st that done at the Finsen Inst itute, has brough t light t reatmen t st rongly into the fore ground . In Table VII we have collected th ose cases of laryngeal t uberculosis which belong to the last eleven years (l HlG -215 inclusive), as this period TAB~

VIJ. -TIII': C ONDI T IO N. OF THI:: L A ItY~ ~a: AL L E S I? N ON Il I SCII ARGg [ i n 281 Patien t s D isch a rged fr om HllG-26 (i u cl u stv e), Cla ssified accordin g to the Various Tr eatmeo t s) .

L" r ~ ng r" 1 lexiou

~o

:o-I ,el' ial t rca t me n t

J.i;:h t t rea t III{'JlL on ly

1"°1 r ('1I1.

H ea.led Improvcd . . Sta.tionary .. Worse Only on e exaUlilla t ion possib le Tot ,~1

..

Colla).>," tr-eat . me n t on ly

P f':"I " (O' oHl .

+

('ollaps(>; t I f'Htrn eJlt

1Ii 12 , 24 23 "'"' .Jfi 7 .:..-:. 1-1 0

21 11

!J4

50

64

17

32 'S 17' '; -

.

see

4

G'2

11

17"2

AlI l'll S t'S

I'er cou t .

P('r r"lI t .

P c.."1' ( ' \ ' 111.

:J .::.: 3 '2 1Ii= 17 '0 :3 ~ '. .. 41'5 15 __ l()(l 2 1 _ - 22 ')

8~

L ig b t

20 R .

t. --

5 . 1 '-

39

51 ', l 20' 5 12'8 128 2' 6

()2 _co 2:J-l 5fi zi: 1O'!J tlO c .' 3:2'0 32 -0; ' 11 '4 41 .- 14 ' 6 281

covers the yea rs in wh ich the sanatorium has owned an operating theatre and a light hall, and in wh ich more active pulmonary and laryngeal treatment has been possible. The table sh ows the effect of various methods of treatment on the lar yngeal affection. It deals wit h 281 cases in which the condition of the laryn geal affect ion has been recorded on discharge. The re sults are shown for all cases in the last column, and in the other columns after some of the var ious methods of treatment. The first column deals with t hose who rec eived ord inary san atorium treatm ent onl y. A positive re sult has been obtained in only '20 pe r cent. of these cases . After light treatment there is a favourable result in 40 per cent., and after collapse t reatment in 50 per cent. A combinat ion of light and collapse treatments h us given a posi tiv e result in about 70 per cent. of cases. It is seen that these treatments can be combined with great advantage. The pulmonary affection is also favourably influenced by these treatments, but here we ha ve recorded the results of the laryngeal findings in order to be able to compare our resul ts with those published by laryngologists . Table VIII is an example of such comparison. We have taken the cases treate~ with light only, and compared the re~ults on di~charge with those of sim ilur cases treated by Dr. Strandberg (F'insen Institute, Copenhagen). The cond it ion of the lungs in th ird-stage cases , and the condition

458

[July. 1927

TUBERCLE

of the lar ynx in all cases is compared. The table shows that the laryngologist has far the best results fOL' the larynx, and the phthisiologist the best results for the lungs. There are several different circumstances to be taken into account. The great majority of Dr. Strandberg's patients have been treated ambulantly, many carrying on with their work in the intervals of treatment. They have, therefore, been under conditions which were less favourable for improvement of the pulmonary affection. The reason why our laryngeal results are not so good may be due partly to the shorter period of observation. It has not been possible, in most cases, to follow the progress of the laryngeal affection after the discharge of the patient, and many have been discharged on the und erstanding that treatment of the larynx should be continued at home or in the light department of a hospital. At the Finsen Institute, on the other hand, as most of the patients reside in Copenhagen, it is possible to follow the progress of the majority of cases for as long as may be considered necessary. TULII:

VIII. -LIQHT TREATMENT [A Com pa rison between the Results Obtained by Dr. Strandberg, Finsen In stitute. a n d those obtained at Vejl efjord Sanatorium).

A.-The Lungs (Third .stage Cases). 8t ~tho.copic

8t mn dh..g

Improved Unaltered Worse, .

5 = 20 13= 52

~1~1l"

P er-cent .

Total

7

=

\!8

Vejl.fjord Sallat llri um Pe rcen t.

24 =54 '5 12 =27 '3 8

=

18'2

B .-The Larynx (All Cases). La r yn geal lesi on

~ t rand berg

Per cent .

H ealed Improved .' Unaltered . . Worse

25

113 59

= 55 '7 .s:

:29'0

15 -:: 7'4 16 = 7 '9 203

Vejleljord

Sanatortum

Percent. S::::: 16 12::::: 24 28 46 7=14

==

50

The impression obtained by this comparison is that the phthisiologist can obtain good results in cases compl icated with laryngeal tuberculosis, but that still better results may be obtained at a sanatorium with the assistance of a laryngologist specially experienced in the treatment of this complication. The realisation of the truth of this observation has a.t Vejlefjord Sanatoriuru led to the institution of regular visits of the laryngologist from the Finsen Institute (Dr. Strandberg). SCMM ARY ,

Our investigations show that i-> (1) The laryngeal complication occurs chiefly in cases of third-stage pulmonary tuberculosis with cavitation . (2) The frequency of the lar yngealcomplication, in cases of third stage pulmonary tuberculosis with tubercle bacilli in the sputum, is about the same in both sexes. (3) Improvement or healing of the laryngeal lesion occurs frequently, despite the continued pre sence of tubercle bacilli in the sputum. This fact supports the view that laryngeal tuberculosis is not of bronchogenic origin . (4) Many cases of laryngeal tuberculosis commence without symptoms. It is therefore necessary to examine the larynx regularly in every case

July, 1927]

LARYNGEAL AND PULMONARY TUBERCULOSIS

459

of pulmonary tuberculosis , so that suitable treatment may be commenced as early as possible. (5) Thoracoplasty improves the prognosis of cases complicated with laryngeal tuberculosis relatively more than of cases not so complicated. This observation supports the view that the prognosis of laryngeal tuberculosis depends on the activity and extent of the accompanying pulmonary disease. (G) Healing of the laryngeal lesion depends on the adoption of suitable treatment. The best results have been obtained by a combination of light and collapse treatments . .This is what one would expect, as by this means the laryngeal and pulmonary affections are simultaneously attacked. (7) Table VIII shows that close co-operation between phthisiologist and laryngologist may be expected to lead to results which will be even better than those already obtained. REFERENCES. [1J

H. "Diagnostik und Therapie del' Lungen, und Kehlkopf. Tuberkulose." [2] Sir STOLAIR THOMSO~ . Medical Research Council Report No. 83, 1924. ULRICI

THE

BOVINE TUBERCLE

BACILLUS IN

IMMUNISATION.

r' By Professor S . L. C UMMINGS, C.B., C.M.G. , M.D. David Davies Pr ofessor of Tub erculoeis, Welsh National School of Medicine. OPINION on the question of immunisation by the bovine tubercle bacillus seems to vary considerably, and to be influenced by certain factors unconnected with the mere search after truth for its own sake. On the one hand, there are those who hold that to attribute immunising powers to the bovine tubercle bacillus m ight encourage the farmers to neglect milk precautions. On the other, there are the fanatical few . who claim, or perhaps merely hint, t~at the drinking of tuber.cle-in~ected milk is ?f such immunising value against subsequent human infection that the risk may advantageously be ignored . And finally, there are those who believe in an " antagonism" between" bovine" and" human" infection-a word which implies th~t infection with the one is inconsistent with simultaneous infectIOn WIth the other.

As for the first of these" views, " it makes no appeal to serious students of tuberculosis. What we want is truth. As for the second, a study of the findings of A. Stanley Griffith, together with a visit to a ho~pital for surgical tuberculosis, will suffice to dis ose of it. When we rea.llse. ~hat roughly ~ quarte~ of su~erers. from tu~rculoBis of the bones and joints ?we their IDfe~tlOn, their crl~pled lim bs, their loss of useful and happy hf~: .to the. bO~lDe"tube~cle ba:clllus, we cannot seriously advocate a form of immunisation so impossible to