40 AFFECTIONS OF THE LARYJsK. 



In rare instances a tuberculous ulcer upon the posterior surface of 

 the epiglottis perforates its entire thickness ; in such cases, however, 

 the contour of the organ is still preserved, thus forming a contrast 

 with syphilitic ulcerations. 



Tuberculosis cf the larynx is very often combined with ossification 

 of its cartilages. If ulceration reach the cartilages, they become carious 

 and necrosed, so that portions of ossified cartilages are often discharged 

 In rare instances, the ulceration has perforated the wall of the larynx, 

 producing laryngeal fistulas and emphysema of the skin. 



SYMPTOMS AND COURSE. When hoarseness supervenes upon symp- 

 toms of tuberculosis of the lungs of long standing, we may confidently 

 infer the coexistence of tubercle of the larynx. (There are cases in 

 which the hoarseness of tuberculous patients depends not upon an alter- 

 ation of texture of the mucous membrane, but upon a paralysis of the 

 muscles of the glottis. To this we shall recur hereafter.) Here, too, 

 hoarseness, at least in most instances, is not the immediate result of a 

 tuberculous ulcer, the latter, as we have seen, being, in the great ma- 

 jority of cases, situated upon the posterior laryngeal wall, and upon 

 the epiglottis. The hoarseness is occasioned by the relaxation and 

 thickening of the vocal chords, and by the secretion which lies upon 

 them. We can thus understand why the hoarseness comes and goes, 

 while the ulcers are always growing and persistent. The mucous mem- 

 brane of a diseased larynx is more vulnerable than that of a healthy 

 one, and far slighter irritants suffice to produce in it a catarrhal 

 affection. 



Nay, just as, without any assignable cause, the parts about every 

 chronic ulcer of the skin become more sensitive, congested, and swollen 

 at one time than at another, so, too, the laryngeal mucous membrane 

 when the seat of ulceration seems always in a state of alternate swelling 

 and detumescence. The nearer the destruction approaches to the vocal 

 chords, so much the more persistent and obstinate does the hoarseness 

 become. If, finally, the ulceration destroys their posterior attachment, 

 it is no longer possible to tighten them, nor to throw them into sonorous 

 vibration. The voice is totally extinguished ; speech becomes whispering 

 and inaudible. 



In other cases, in which the disease runs a more acute course, symp- 

 toms of hypersesthesia of the mucous membrane are more prominent 

 It is characterized by great irritability and violent reflex phenomena. 

 The most distressing fits of coughing, brought on by the most insignifi- 

 cant and often inappreciable causes, paroxysms of choking, which not 

 unfrequently end in retching and vomiting, besides hoarseness or in- 

 audible voice all these very striking and painful symptoms force 

 themselves so prominently into notice that the phenomena of tubercle 



