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.
“The presence of the tube excited violent paroxysms of coughing, and was later expelled. The dyspnoea was relieved and the relief continued.” This is explained by the force exerted in introducing the tube; it tore away a portion of the posterior commissural thickening, and doubtless the remainder subsided somewhat from contraction and relief to the engorgement from bleeding. Dr. Massei [+ jour. Laryngol. and Rhin. Jour., July, 1891, p. 265.] reports three cases relieved by this operation.
Therapeutics.-The dominant school of medicine place but little reliance on the internal administration of medicine with distinctive reference to their special action upon the air passage, but largely limit their internal treatment to the general dyscrasia, and to local applications. So, it is to Homoeopathic literature that we are obliged to seek for this means of encountering the pathological conditions in question.
Arsenic, as mentioned before, is indicated where the laryngeal membrane is anaemic, stained with dirty-looking spots, and marked by the velvety projections which presage coming ulceration. Cough is absent or entirely out of proportion to the progressive emaciation. Accompanying the objective signs is a peculiar sensation of burning, which is referred to the region of the cricoid and thyroid cartilages. The same remedy is also serviceable in a later stage, when extensive ulceration has taken place and an indolent and acrid sero-purulent discharge comes form the ulcers. I formerly used Arsenicum album, but of late years have preferred the second trituration. The late Dr. Nichol in a study of this sort commends it highly in throat consumption. Dr. Beebe reports three cases greatly benefited by its use.
Aurum Iodatum 3x.-Meyerhofer has found it useful “in torpid ulcerations of the larynx.”.
Drosera.-Is nearly always useful for the spasmodic cough of the early stages. I agree with Jousset in giving material doses of 15 to 20 drops of the tincture three times a day. .
Kali Bichrom is only useful in the follicular catarrh with muco-purulent, stringy expectoration which often precedes the development of tubercle.
Hepar Sulphur.-The posterior wall of the larynx is abundantly supplied with racemose glands, from this fact suppurating ulcerations in this portion of the larynx are quite frequent and especially indicate the use of this classical drug.
Phosphorus.-Often indicated in irritative cough which seems to arise from the posterior commissure.
Seleniate of Sada.-In my paper on “Laryngeal Phthisis,” to which allusion has been made, favorable notice was given no this salt of Selenium, but since then I have not found it at all satisfactory. The following is an extract of a letter written to Dr. Ivins [Diseases of the Throat and Nose., p. 436.] by Meyerhofer in 1889: “In my work you will find (page 48, per. 148) a case of recovery of phthisis laryngis under the influence of the seleniate. Since then this salt, though useful in many other respects, has disappointed me in this disease. Many other remedies are prescribed, but their sphere is mainly found in the concomitant lung diseases.
