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.
On account of the objectionable odor of Iodoform I have tried both Iodol and Aristol, but have been disappointed in the results. Tymonsky [ Monatschrift far Ohrenheilkunde, May, 1891, No. 5, p. 153.] speaks well of a daily application of an 80 per cent. solution of Resorcin. I have had no experience with this remedy, but should regard its effects as similar to those of Carbolic acid. Since the introduction of Pyoktannin (Methyl-violet) as an antiseptic, Masini commends its use as a spray, fifteen drachms to eight ounces of water three times a day. He claims to have found it more useful than Iodoform menthol lactic acid. Sheinman [+ Berlin Klin. Wochenschrift, August 18, 1890, No. 33.] and Bresgen [++ Deutsche Med. Wochenschrift, No. 4, 1890.] apply it directly to the ulcers by means of heated probes dipped in the powder.
From the unsatisfactory results obtained by myself with this remedy in syphilitic ulceration I have never been tempted to resort to it in tuberculous ulceration. Dr. H.F. Ivins [Diseases of the Nose and Throat, p. 432.] makes favorable mention of a spray of a watery solution of Calendula “one to twenty or weaker,” with the addition of two or three drops of Carbolic acid to the ounce, as recommended to him by Dr. A.C. Peterson, of San Francisco. I much prefer Calenduol, a preparation made by macerating under heat the marigold flowers in pure petroleum oil. From a very limited experience I think I may predicate good results from its employment. Among the more recently introduced drugs for the local treatment of this disease, menthol and lactic acid stand pre-eminent in the almost general recognition of their value.
Menthol was first used by Resenberg, in 1885, and since then he was presented several communications attesting its worth. He employed a 10 to 20 per cent. solution in oil, sprayed in the larynx once or twice a day. He claims that, in addition to its analgesic effect, it deterges the ulcers, which soon become of a healthy rose color, and are covered with healthy granulations, and healing in from four to six weeks. The tumefaction gradually diminishes under its influence. Goughenhein and Glover [Jour, Laryngol. and Rhin., 1890, p. 365.] propose the following; One part of menthol added to five parts of Kreosote and five parts of almond oil (mixed in a water-bath) to be painted on the ulcerated surface.
A. B. Thasher [+ Cin. Loncet and Clinic, June 22, 1889.] finds a 10 per cent. solution in liquid vaseline very useful in dysphagia. Solutions as highly concentrated as 40 per cent. have been used, but they are certainly objectionable on account of the intense irritation they cause. Of all the caustics employed in ulcerations of the larynx, lactic acid gives the most hope of successful result. To Krause, of Berlin, belongs the honor of using it for the first time. He was induced to try it through the experiments of Mosetig-Morhof with it in lupus of the skin. Since Krause read his paper before the Laryngological Subsection of the 59th meeting of German naturalists and physicians, many cases have been reported confirming its value.
He commenced with a 10 per cent solution, gradually increasing the strength to 50, 60, 80, or 100 per cent. as the patient becomes more tolerant of the acid. Under its influence, the deep-red tumefied parts become pales and shrivelled. With the stronger solutions firmly adherent eschars are produced, which, in falling, off, leave a healthy- looking granular surface at the bottom of the ulcer. Krause has seen post-mortem evidence of the compete cicatrization of ulcers in a case dying of pulmonary consumption. It acts more promptly on soft than hard infiltrations. When the stronger solutions are used, parts should be anaesthesized with a 4 per cent. solution of cocaine.
Krause used a brush, but the cotton-carrier is cleaner. The part should be thoroughly cleansed by an alkaline spray, and then it should be rubbed in by gentle pressure; when the milder solutions are employed, applications may be made every day, or every other day,. To prevent the spasm of the larynx which sometimes occurs in the use of lactic acid, cocaine may be applied. Dr. Theodore Hering, of Warsaw, in certain cases, those in which there is considerable oedema with pronounced pyriform swellings of the arytenoids, advised sub-mucous injections of lactic acid. They would seem to be especially indicative in hard infiltrations and pseudo-polypoid growths. Hering employed a solution of 10 to 20 per cent. five minims being injected at each sitting. Dr. G.W. Magor [Canada Med. Surg. Jour., December, 1886.] pronounces strongly in favor of this method. This treatment does not preclude the intercurrent use of a mild lactic acid spray or other soothing measures.
Perhaps the most distressing symptom we are called upon to relieve is dysphagia. Before the discovery of cocaine, insufflations of morphia in starch powder, iodoform, or, preferably, gum acacia, from its adhesive qualities, were mainly relied upon for the relief of this symptom. I am commencing to think that far better results are obtained from morphine in painful deglutition than its more recent rival cocaine. The latter is toto evanescent in its effects, and its necessarily repeated use seems to diminish its anaesthetic power. Good-hart [Brit. Med. Jour., December 6, 1884, p. 1133.] has reported a case where this happened.
There are other objections to its continued use. The primary action of cocaine on the muscular fibres of vascular walls is spasmodic, followed by paresis, which, recovering very gradually, leads to diapedesis from the vessels and consequent increased catarrhal inflammation. Dr. Beebe, in an excellent paper, cells attention to the fact that cocaine increases the salivary as well as the mucous secretions. So, while temporarily relieving the odynophagia, it subsequently causes increased disposition to swallow on account of the augmented secretion. This action of cocaine is confirmed by a proving made by Dr. Percy Wide, who gives these two symptoms following its local application “intense salivation and spasm of the abductor muscles.
“I think morphine combined with tannic acid and glycerine, and applied with the applicator, will give for more satisfactory and lasting results in painful deglutition than cocaine, whether used as a spray or painted on in oily solution. Sainte-Hilaire recommends a 30 per cent. solution of antipyrine as an aesthetic. Its effect last from one to two hours. Milder solutions have no effect. It causes some transient pain, however. Caffeine has been used as an analgesic, but it is only very slightly sedative, and is very uncertain. The acetamide of engenol, made form cloves, has recently been found to possess anaesthetic power. It is an aesthetic as well, but is not caustic. It may possibly have a future.
In laryngeal, as well as pulmonary cases, a suitable and sufficient diet is necessary. Experience has shown that food of a semi-solid consistency is swallowed with less pain than in a liquid or solid form. Food should be taken with a gulp and not sipped.
Egg swallowed en bloc, milk enriched with cream, and nutritious broth thickened with backed flour, rice flour, or oatmeal, raw oysters and custards, form the dietary to which the patient is often restricted. Dr. D.G. Woodvine [Jour. of Opth., Oto., and Laryngol., vol. ii., 1890, p. 303.] found this method very useful: “A small pitcher is placed upon the floor at the foot of a lounge; the patient procures a place of rubber tubing eighteen inches long; he lies down with his feet over the arm of the lounge, his face and head extending over the foot, his left check toward the flour,. he then places one end of the tubing in then pitcher, the other in his mouth, and by suction draws the fluid into the mouth, letting it flow along the inside of the check and the lower jaw until it reaches the oesophagus and then swallowed.”
This is a slight improvement of Wolfenden’s method.[+ Jour. of Laryngol, and Rhin., vol. i., p. 317.] A patient of Dr. Woodvine’s [++ Trans. Am. Med. Inst. Hom. 1885.] discovered that the springing of the shoulders simultaneously with the swallowing would facilitate the act. With the occurrence of aphagia our only course is lavage and nutrient enemata. Bryson Delevans [Trans. Am. Laryngol. Asso., 1884, p. 81.] advised that a tube of small calibre about the size of a large catheter, be introduced into the oesophagus just below the inferior constrictor of the pharynx. He devised a special apparatus for thus introducing the food. Owing to the size of the of the tube, great care should be exercised not to pass it into the larynx. I prefer a tube about half an inch in diameter. There are cases in which the tube will not be tolerated; nutrient enemata must then be given. The rectum should be thoroughly washed out preceding the enema. A few drops of tincture of opium added will often assist its retention.
The following recipe of Morrel McKenzie makes a very nourishing injection. Cooked beef, mutton or chicken three ounces seven drachms; sweat-bread, one ounce seven drachms; fat,,six drachms; brandy, two drachms; water, two ounces. “These ingredients mixed well together will make nine ounces. The most, sweet-bread and fat must first be passed through a fine mincing machine and then rubbed up with water gradually added to make a very thick paste. It should be injected at a temperature of ninety-five degrees, and ought not to be administered more than twice in twenty-four hours.” Feeding by rectum, however, should not be persisted in for a long time on account of the intolerance often produced, but should be alternated by attempts per oram.
The surgical treatment of laryngeal phthisis commenced with the introduction by Schmidt, of Frankfort, of puncturing and incising. To my mind this procedure only furnishes fresh foci for infection. Hering [Deutsche Med. Wochenschrift, Leipsic, 1887, Bd. 13, p. 136.] observing that the deep ulcers were not reached in every part by Lactic acid advised curetting to be followed by cauterization with the acid. Krause afterward adopted the same treatment in selected cases. But from the reports I have read it seems to me that where there were good results they might fairly be attributed to the action of the acid, and curetting was superfluous. As to the use of the galvano-cautery I regard it as productive of much more harm than good.
When laryngitis assumes a form, which in the earlier part of this paper has been designated as polypoid, that is, the formation of circumscribed tumors without ulceration, and in the papillomatous vegetations sometimes, though rarely, found in the tuberculous larynx, and when sessile, their destruction by the galvano-cautery is to be preferred to their evulsion by the cutting forceps, the only objection to this method being the repeated seances which its use requires. When pedunculated the removal by forceps is more desirable.
Tracheotomy, in my judgment, is only justifiable in threatened death from suffocation. Beverly Robinson [+ Am.Jour. Med. Sciences, 1879, p. 416.] advises it as a directly curative measure!.
“1. Because it is certainly a palliative procedure of much value.
“2. It may ultimately be found a direct curative means yielding favorable results. To obtain these latter it seems indicated not to delay the operation to a late date.” My objections to the operation, except in cases of apnoea, are, that the larynx does not receive the necessary amount of air, and mucous more readily accumulates. The dry cool air coming into almost immediate contact with the pulmonary surface is apt to cause complications. Again, the wound may become infected.
The complete physiological rest which this operation is supposed to give I do not think is obtained. Mckenzie [++ Diseases of the Throat and Nose, vol. i., p. 377.] says. ” during the last twenty years I have performed tracheotomy in a few cases of laryngeal phthisis perhaps, a dozen. Although it has often relieved urgent dyspnoea, I cannot recall a single instance in which the operation delayed the pathological process. Far from giving rest to the larynx, the wearing of the canula, in my opinion, tends to irritate the windpipe.” Resort has been had to intubation. F.E. Hopkins [N.Y. Med. jour., 1892. p. 234.] reports a case.