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.
