I KNOW of no disease that is attended with more intense, constant and often intolerable suffering than the one, the treatment of which, is the subject of this paper. To palliate pain, to prevent a lingering death from starvation, and to save life from suffocation are the problems that often require all the surgical skill and medical acumen of the physician. As statistics prove that laryngeal phthisis is present in the majority of consumptives, cases more or less numerous will come to us all sooner or later. It is therefore most important that we have at command the means experience has demonstrated to be of value in the abatement of its manifestations or its possible cure.
Heinze in his classical work on laryngeal phthisis published in 1879, in his third and final conclusion says,” a cure of laryngeal consumption will most probably never be made.” Although since this was written the progress of fourteen years has introduced new methods and new remedies, but few cures have been reported, and some of these must be taken sub judice as sufficient time from the apparent recovery had not been allowed to provide for the occurrence of relapses. Others have undoubtedly been merely cases of follicular catarrhal laryngitis complicating pulmonary tuberculosis.
Much may be done, however, in the way of prevention. Repeated laryngeal inflammations occurring in those of a strumous diathesis impair the vitality of the mucous membrane with consequent defective function. The capillary walls lose their elasticity, thus favoring stasis of the circulation. The products of inflammation, which in those of sound constitution are easily absorbed, in the scrofulous and debilitated form a nidus for the development of tubercle. A timely recognition of this predisposition followed by prompt and suitable treatment will often prevent tuberculosis. The progress of laryngeal phthisis may be divided into the following stages:.
1. Stage of Anaemia.
2. Stage of Tumefaction.
3. Stage of Ulceration.
4. Necrosis or Caries of the Cartilages.
The second stage, as to form, may be regarded as hypertrophic or polypoid. The treatment should be both general and local. The constitutional treatment is necessarily the same as that of pulmonary consumption. Especially in those rare cases where the physical signs of lung invasion are wanting, and where the larynx seems to be the focus of the disease, too exclusive reliance on topical medication should be guarded against; for it is in these very cases that hygienic and general medical measures should be adopted with reference to the predisposing cause. If the causa excitans can be traced with a certainty, as is sometimes possible, the pursuance of the causal avocation should be interdicted.
Of the general treatment I have but little to say, as it is still as varied and manifold as the theories of the aetiology of the disease were before the discovery of Koch. Now while the general treatment, as has already been said, is referable to that of consumption in its most extended sense, I would not be understood as limiting the therapeutics of the larynx to purely local medication; for fortunately we possess remedies whose specific power, when administered internally, seem to be exerted upon the larynx. The local treatment may be divided into palliative and curative. The office of the first is to alleviate pain, mitigate cough, diminish dysphagia, and calm the laryngeal dyspnoea.
The second is employed in primary cases or cases in which the lungs are but slightly involved, and where the disease the has not become so extensive as to banish all hope of success. The anaemic stage seldom presents itself for treatment; when it does the laryngeal membrane is livid, stained with dirty- looking spots and marked by the velvety projections which presage coming ulcerations; I know of no better topical application than ten drops Liquor sodae arsenitis to the ounce of water used as a spray.
In a paper read by me before the New York State Homoeopathic Medical Society in 1879 I advocated this treatment, and have had, as yet, no reason to abandon it. It is in this stage that I have used the Perchloride of iron (ten drops to the ounce), especially if the above named velvety projections are present, as recommended by Sir Morrel McKenzie. .
Palliative Treatment.-One of the first symptoms met with is the hacking cough, which most patient quite definitely locate as rising from the superior part of the larynx-what might be called an interarytenoideal cough. Laryngoscopic examination will usually disclose some tumefaction of the arytenoids, a swelling of the arytenoidean space, bathed with a secretion more or less rich in cellular elements.
If there is a disposition to excessive secretion, a through cleansing of the part is essential. A simple spray of Carbonate of soda, five grains to the ounce, will answer quite as well as then Polypharmic solution of Dobell, though if the secretion is offensive, then the latter is better. This solution consists of.
Acidi carbolici, grains 8.
Soda biboraci, grains 2.
Sodae bicarb, grains 2.
Glycerinae, ounce 1.
Aquae dest., ad. q.s. ounces 8.
M. et. ft. lot.
A favorable spray of mine, after cleaning, is Glycerinae, ounce one-half; Aquae dest., ounce one-half; Acidi tannici, grains 40; Acidi carbolici; grains 4; Tincture olei menthe pip., minims 3. For home use, Compound tincture of benzoin, a teaspoonful to a pint of water at 140 degree, in a Martingale inhaler, is of great service. Or two drachms of Succus conium, with a pint of water, when the cough is very aggravating. Schmidt recommends steam inhalations-to a pint of hot water, Balsam of Peru, half an ounces; Alcohol, 2 drachms; but I believe whatever efficiency it may possess depends upon a Benzoic acid which the Balsam contains. The following is advised by Dr. E.L. Sherley: Kreosote, I drachm; Compound tincture of benzoin, 4 drachms; Tincture of lupulin, 4 drachms-one drachm of this mixture to a pint of hot water.
Kreosote alone may be used us a spray. One and a half ounces of Kreosote in the presence of one ounce of Glycerine, add to fifteen ounces of water. (English Beech-wood Kreosote, prepared by Morsen, is the best preparation.) The atomization of Glycerine by a Codman & Shurtleft atomizer will often prove serviceable. Sacubash speaks highly of inhalations of Pine-needle oil, two or three times a day, for the irritating cough. Oil made from the fresh needles is preferable. A Davidson’s oil atomizer will severe well the purpose of administration.
I have found a maceration of powdered Hydrastis root in Albolene very serviceable in those cases characterized by a tough, gluey secretion. Lefferts has found Terebene, five to forty minims, added to an ounce of water, in the presence of twenty grains of Magnesium carbonate, a teaspoonful mixed with a pint of water and inhaled at 140 degree for ten minutes night and morning, very useful in allaying the irritative cough.
Eucalyptol, half a drachm to the ounce of Albolene, makes a useful spray Solis-Cohen [N.Y. Med. Jour., March 6, 1886.] recommends Ethyl iodide, ten minims, dropped on the sponge of a respirator and inhaled for an hour. Iodine has long been used to relieve the infiltration, but I have never observed that it exerted the slightest influence in checking the progress of the disease. Should its application be thought advisable, however, great care should be taken not to employ too concentrated solutions, for cases of oedema are on record which have been produced and proven fatal through its indiscreet employment.
With the advent of ulceration we have much graver conditions to meet. Since Horace Green recommended Nitrate of silver, of a strength varying from 20 to 60 per cent., no remedy in the entire range of topical application has excited more controversy than this agent. Although it is still used by a few laryngologists, the majority have consigned it to its proper place among “the things that were.” Nitrate of silver does not penetrate sufficiently deep into the tissues. It has been experimentally proven that when s solid or saturated solution is applied to a denuded mucous surface, it combines with the albumen and protein of the granular cells, forming a thin pellicle.
Its action on the intact membrane is first a combination of a portion of the silver with the albumen, mucine and chlorides of the secretion; the remainder of the silver penetrates the epithelial interstices and is deposited as granules of Oxide of silver, which act as foreign bodies, giving rise to congestion and inflammation. When the ulcerations are superficial, and especially on the arytenoids, applications of Iodoform seem to have a retarding effect. But I think our best results from Iodoform are in those cases of combined syphilitic and tuberculous laryngitis.
Schnitzler’s excellent paper, read at the International Congress of 1890, has called attention to the comparative frequency of the coexistence of tuberculosis with syphilitic ulceration of the larynx. In these cases, Iodoform has an almost magical effect. I prefer the saturated ethereal solution diluted with twice the quantity of Almond oil sprayed through a tube with about thirty pounds pressure. It is often used in powder, but my preference has long been in favor of the spray with this, as with other remedies, unless it be necessary to limit the extent of the medicament. I then prefer cotton on a laryngeal applicator. The insufflation of powders I have found badly borne by the tuberculous larynx, frequently causing cough, and suffocating attacks.
