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518 Mr. FALLOWS (London) read a paper on (1) a case of Polypoid Growth from a Meibomian Gland, and (2) the Use of Fluorescin in the Form of Tabloids in the Diagnosis of Corneal Abrasions. Mr. H. E. JONES (Liverpool) read a paper on Irrigation for the Nasal Duct. Mr. JuLER and Dr. GEORGE MACKAY remarked on the instrument. Mr. JONES replied that he used boric solution. He did not use corrosive sublimate owing to its effect upon the canaliculus. Mr. CHARLES WRAY (London) read a paper on Extraction of Transparent Lens in High Myopia. Up to August last over 2000 patients with myopia over 10 D. had been submitted to operation. The immediate results were good but the ultimate results were bad. Mr. JOHN GRIFFITHS related particulars of a case of Acute Exophthalmic Goitre. Dr. GEORGE MACKAY described a case upon which he had operated. Dr. A. HILL GRIFFITH mentioned a similar case in which he had used thymus extract. Mr. MARCUS GUNN stated that electricity had been found useful. Dr. A. BRONNER read a paper on Crystals of Cocaine in preference to Solution. - LARYNGOLOGY AND OTOLOGY. FRIDAY, JULY 29TH. Dr. JOBSON HORNE (London) read a paper upon The Pathogenesis and Earlier Clinical Evidence of Laryngeal Tuberculosis. He said that it would not be possible for him to do more than touch upon the threshold of the disease and endeavour to demonstrate what appeared to him to be the portal of infection, the beginning and progress of tuberculous destruc- tion, the origin and formation of the giant cell, and briefly indicate the clinical counterparts of the early pathological changes which he had learnt to regard as the earliest signs and symptoms, not only of laryngeal tuberculosis, but also of pulmonary tuberculosis. A lantern demonstration was given of photographs of microscopic sections on which the con- clusions were based and some of the more important sections were shown under microscopes. The pathogenesis of the disease had been studied in larynges which post mortem presented to the naked eye none of the usual signs of laryngeal tuberculosis, but which had been removed from bodies of persons who had died undoubtedly from tubercu- losis. In the examination of these larynges films were first prepared from the contents of the ventricles and stained for tubercle bacilli and the larynx was afterwards examined microscopically throughout. Dr. Horne dwelt upon the importance of the ventricle as a harbour for tubercle bacilli. The earliest changes noted in the lymphatics were a pro- liferation of the parenchyma of the acini and efferent ducts and the formation of masses of small round cells distending and choking the ducts and obliterating the glands, the adjacent and superficial structures remaining intact. These changes had been noted in the lymphatics situated in the walls of the ventricles when a careful microscopic examina- tion of the entire larynx had failed to reveal changes in the lymphatics in other parts. The nature of this cell prolifera- tion was next considered. Was it to be regarded as nothing more than an outcome of a traumatism or of some simple catarrhal process perhaps peculiar to tuberculous subjects ? or was it to be attributed to one specific cause- namely, the presence of the tubercle bacillus ? Dr. Horne said that although he was not prepared altogether to accept or reject the theory that these lymphoid masses were due to a simple catarrhal process, he was now able to demonstrate the tubercle bacilli in the midst of some of them and was of the opinion that once having gained an entry into the lymphatic ducts they acted as an irritant and caused a cell pro- liferation. Thefons et origo of the giant cell in tuberculosis next came under consideration and by a series of lantern photographs of microscopic specimens its development from the wall of a lymph space was demonstrated. The series showed first the tubercle bacilli lying amongst the endo- thelial cells forming the wall of the lymph space ; secondly, the division and fusion of the adjacent and divided cells; and thirdly, the separation off of this plasmodial mass as a giant cell. Reference was made to the researches on lepra laryngis by Dr. Paul Bergengrun of Riga, in which he had shown that the so-called ’’ globi were bacillary thrombi lying in dilated lymphatics and that the lepra giant cell developed from the lymphatic endothelium. If, then, ae would appear to be the case from the foregoing, the tuber- culous process commenced in the lymphatics it would be natural to suppose that those parts which were rich iu lymphatics would be the more common sites for infiltra- tion and ulceration, while such parts as were without glands would escape ulceration except by continuity. This was clinically verified. The inter-arytenoid region, the’ posterior third of the cord, the ventricular band, and the epiglottis, especially the petiolus, were the parts more richly endowed with glands and these were the parts more commonly ulcerated in laryngeal tuberculosis. The cord, the functionally more important part of the cord,-namely, that part lying between the two small cartilaginous bodies-being free from glands escaped ulceration excepting superficial erosion and by continuity. A proliferation of the sub- epithelial blood-vessels was described as taking place side by side with this cell proliferation. With regard to the muscles, changes were described as occurring at an early stage in the fibres and as being clinically brought into evidence’ by an early functional failure which was mainly myopathic, The earlier clinical evidence of laryngeal tuberculosis, thE’: clinical counterparts of these early pathological changes,. were next described. Whilst clinically investigating these it!. was necessary, inasmuch as only slight departures from the normal were being looked for, to retain a control mental image of a normal larynx. This was done by constantly examining a large number-some hundreds in all were examined-of larynges in healthy subjects or at least pre- sumably free from tuberculosis. And it was whilst in search of normal larynges that some important aids two the present research were stumbled upon. The larynx had been examined in 359 consecutive cases of pul- monary tuberculosis or cases in which there were reasons for suspecting pulmonary disease. The points to which attention was mainly directed were the following a (1) disturbances of sensation, hypæsthesia, hyperasstbesia, paræsthesia; (2) colour changes, anæmia, hyperasmia; x (3) functional disturbances ; (4) impaired movements of vocal cords apart from paralysis ; and (5) changes in the contour of the larynx due to slight cedema. Inasmuch as disturbances of sensation were subjective too much signifi- cance could readily be attached to them if taken alone as a clue to pulmonary tuberculosis, but in regarding them only as evidence of I hysteria" " one was apt to miss important clues to pulmonary tuberculosis. Hypagsthesia, was not infrequently associated with anæmia of the soft palate,, and it might be stated that unless the subject was wilfully hostile to laryngoscopy the more pallid the soft palate the greater the tolerance to laryngoscopy. And when in the course of the pulmonary condition the anaemia passed off the tolerance often went with it. Anagmia of the laryngeal mucosa was noted as present in varying; degrees in 157 out of 359 cases. At times it was universal ; p when patchy it was confined to points where the mucosa. was more easily exposed to tension, occasioned by a slight, oedema in association with the proliferation of subepithelial vessels. It was as frequently met with in men as in women- Hyperasmia was noted in 117 out of 359 cases and rather more frequently in males. This hyperæmia must be regarded) as a feature distinct from and not amounting to acute laryngitis. Acute laryngitis did not occur so frequently as one might previously have anticipated. The hyperasmia was. often transient, within a few days giving way to pallor ; but, at times it was most persistent. These phenomena were. also attributed to the proliferation of subepithelial vessel’s. Disturbances in the vocal function were most frequently met with, often transient, not amounting to more than a weakness of voice or loss of tone. The production of voice called for a greater effort, there was a forgetfulness of office, a sluggishness of one or both cords to act, so that there was phonatory waste before voice was produced, and in connexion with this required effort might be mentioned that in early tuberculosis when the speaking voice was weak the singing voice was quite clear. Then the singing voice might suddenly go; this caused the patient to seek advice, and the possi- bility of commeneing tuberculosis should not be forgotten. Transient dysphonia. was more commonly met with amongst women, and especially young married women, during pregnancy. Not infrequently in cases of so-called " hys- terical aphonia" thoracic signs of pulmonary tuberculosis had been subsequently made out, and it was as well to bear in mind the possibility of diagnosing "hysterical aphoiaia "’
