TREATMENT.—Whatever the grade or stage of a chronic laryngitis, the constitutional condition or proclivity of the patient always requires suitable hygienic, dietetic, and therapeutic management. The repair of regional or local morbid conditions may often be confidently entrusted to such constitutional measures; and it is only when these morbid conditions resist the influence of systemic treatment, or are of some special character obviously insusceptible to such influence, that topical medication or actual surgical procedure becomes requisite in addition. The accessibility of the interior of the larynx to instrumental manipulation under laryngoscopic guidance offers great temptations for topical interference. The result is, that the diseased larynx is sometimes submitted to unnecessary, and even injurious, direct attack at the hands of a dexterous manipulator untrained in general practice, and consequently ignorant of the beneficial influence of purely constitutional measures upon many local morbid conditions. While it is highly proper, therefore, to utter a few words of caution, it is equally proper to assert that many local conditions are entirely beyond the control of systemic measures, and require topical treatment.
Constitutional Treatment.—Simple or catarrhal chronic laryngitis, unassociated with special diathesis, is often admirably influenced by the prolonged administration of some preparation of cubeb; the oleoresin being preferred by the writer in doses of from fifteen to twenty-five minims for the adult, three times a day on crushed sugar. This drug being eliminated in part by the bronchial tract, it seems especially adapted to exert upon chronic inflammatory conditions of the aërial mucous membrane that healing process which it is known to exert on mucous membrane elsewhere. Among other useful constitutional remedies from which similar service can be expected may be enumerated compound tincture of benzoin in doses of from thirty to sixty minims for the adult, three or more times daily; fermented infusion of tar or tar beer, several ounces daily; and petroleum mass, one to two grains for the adult, three or four times daily, with pulverized extract of glycyrrhiza in pill or capsule. In cases with deficient secretion ammonium chloride is indicated. In cases associated with impaired digestion, with excess of acidity, the prolonged use of alkaline mineral waters is advisable; preferably, if convenient, at their sources. In cases associated with chronic diarrhoea the mineral acids are indicated. Cod-liver oil, hydrated chloride of calcium, and preparations of iodine and of arsenic are useful in patients of the scrofulous diathesis. Iodoform, one grain for the adult, rubbed up with glucose or some other excipient, in pill or capsule, three times a day, is often useful in patients with the tuberculous diathesis. Specific remedies are required for syphilis. In like manner, any constitutional abnormality is to be systematically attacked.
The functions of skin, kidneys, and intestine are to be maintained as nearly normal as may be, or even a little in excessive action from time to time for derivative purposes. Abstinence is to be enjoined from all exposures or indulgences deleterious to the parts diseased; with as sparing a use of the voice as is compatible with ordinary domestic or social demands, and absolute rest for prolonged periods of days at a time whenever unusual demands have resulted in exacerbating the malady. Under such treatment many cases of simple catarrhal or glandular chronic laryngitis may get well, as has been intimated, without any special local measures.
Topical Treatment.—The difficulty of impressing patients with the necessity of submitting to these hygienic measures and to dietetic restrictions, and for avoidance of occupations or habits which favor or maintain the condition of chronic inflammation, renders topical treatment necessary in many instances. Direct instrumental medication requires the personal attention of the medical attendant. Medication by inhalation or insufflation may be entrusted to the patient or the nurse in most instances. In instituting a course of topical treatment several things must be taken into consideration, such as the condition of hyperæsthesia, hypersecretion, insufficient secretion, congestion, hemorrhagic infiltration, hemorrhage, hypertrophy of tissue or tissue-elements, erosion, fissure, ulceration, and excessive granulation. The first three of these furnish the clue to the nature of the home-treatment, the remainder to that required at the hands of the physician. The home-treatment is to be directed to keeping the parts clean and comfortable; the manipulation of the physician is to be directed toward overcoming special pathological conditions.
Should secretion be defective, alkaline sprays inhaled at regular intervals, for a few minutes at a time, tend to augment secretion and to facilitate the detachment of adherent mucus. For the purpose choice may be made of the following drugs in the proportion of about five grains to the ounce for the adult, dissolved in distilled water or tar-water, with the addition of a sedative when the parts are hyperæsthetic, or an opiate when they are painful: ammonium chloride, sodium borate, sodium bicarbonate, sodium chloride, sodium chlorate, sodium iodide, potassium iodide, potassium chloride. The spray should be propelled by means of compressed air, with what is known as the hand-ball atomizer, in preference to steam, the effect of which is too relaxing in most instances. A few drops of some aromatic or balsamic product will render the spray more agreeable in many instances. Should these agents fail, pyrethrum or jaborandi may be found more serviceable, in the proportion of from one to five minims of the fluid extract to the ounce of water.
Should secretion be excessive, astringents are indicated; and choice may be made from alum, five grains to the ounce of rose-water; tannic acid, two or three grains; zinc sulphate or zinc sulphocarbolate, two grains; lead acetate, two grains; ferric chloride, one grain; and silver nitrate, half a grain to the ounce. Personal supervision of the initial inhalations is requisite to ensure proper use of the spray. Whether the medicament is to be propelled directly into the larynx by means of a tube with a vertical tip to be passed beyond the tongue, or to be inhaled by efforts of inspiration from spray projected horizontally, will depend upon the skill of the individual using it. Hard-rubber spray-producers are furnished with series of tips, so that either method may be employed. When the horizontal tip is used, the instrument should be held some distance from the mouth, so that the spray may be deflected into the larynx by the act of inspiration. When the tube is placed within the mouth most of the spray becomes condensed upon the pharynx, and very little can be drawn down into the larynx. As metallic tubes are liable to become reduced by certain remedies—ammonium chloride, for instance—tubes of glass or of hard rubber are to be preferred.
Should a steam apparatus be employed, the patient should remain housed for half an hour after inhalation, except in very warm weather. In cases of hyperæsthetic mucous membrane the home inhalation of volatile remedies daily is often useful. Compound tincture of benzoin, camphorated tincture of opium, oil of pine, oil of turpentine, terebene, eucalyptol, creasote, carbolic acid, may be inhaled from a bottle containing hot water or from a special inhaler, a few drops of chloroform being advantageously added when there is a good deal of irritative cough. A few drops of the more pungent volatile substances, such as terebene, eucalyptol, and creasote, may be dropped on the sponge supplied with the perforated zinc respirator of Yeo of London, and the apparatus be worn for an hour or longer continuously. In cases with excessive secretion and in syphilis, ethyl iodide is indicated as a remedy appropriately administered by this method. When the parts are very irritable, a respirator of this kind or some similar contrivance, or a fold or two of woollen or silk gauze worn in front of the mouth and nose while in the open air, will often protect the tissues from too cool an atmosphere, and enable the patient to bear exposure with comfort.
Topical treatment of a more decided character being required, the physician usually chooses between powder and solution. Powders are usually propelled by a puff of air through a properly curved tube, whether from a rubber ball, a reservoir of compressed air, or the mouth. The mouth allows the most delicate and accurate application, but the mouthpiece should be protected by a valve from receiving a return current when the patient coughs. Solutions may be applied by means of pipette, syringe, brush, cotton wad, or sponge, according to indications. A fragment of sponge securely fastened to a properly-bent rod or pair of forceps is the safest and most effectual material for positive contact against a limited surface, and a brush the best for painting larger surfaces. The use of the cotton wad involves a slight risk of leaving a detached shred of fibre in the larynx, but renders the manipulation less unpleasant to the patient than the use of the sponge, and is less irritating to the mucous membrane. Spasm of the larynx is usually excited the first time that a medicinal application is made within it, and even death by suffocation has followed the incautious use of powerful agents. Hence strong solutions should not be used until the tolerance of the parts has been sufficiently tested by weak or innocuous ones. The remedies which have been employed topically for intra-laryngeal medication seem to include every available medicinal agent that could be mentioned, from rose-water to the incandescent cautery. The list of really useful ones is not very long. Those upon which the most reliance is placed by the writer comprise tannic acid (a saturated glycerite), zinc sulphate (thirty grains to the ounce of rose-water), and silver nitrate (forty to sixty grains to the ounce) in obstinate and protracted cases of simple chronic laryngitis; iodine and carbolic acid, singly or in combination (one grain or more to the ounce of glycerin), and chinoline tartrate or salicylate (five or more grains to the ounce), in cases attended with infiltration; iodoform (finely pulverized or in recent saturation in sulphuric ether) in ulcerative or proliferative tuberculosis; and iodoform and acid solution of mercuric nitrate (one part to ten or twelve of water) in progressive ulcerative syphilis resisting appropriate constitutional treatment. Other astringents in the simple varieties; resorcin in the glandular, hypertrophic, polypoid, and tuberculous varieties; chromic acid and incandescent metal in the circumscribed hypertrophic and in the polypoid varieties; and zinc chloride and copper sulphate in the syphilitic varieties,—proffer additional resources. These applications are to be made at intervals of one day or more, according to results. Hyperæsthesia and pain, whether of the larynx or of parts adjacent, can usually be subdued by the local anæsthetic effect of solutions of erythroxyline hydrochloride (2 per cent. or stronger) applied at intervals of a few hours, or even by the fluid extract or a strong aqueous infusion of the erythroxylon-leaves. Before the anæsthetic effect of this drug was known, morphine powder (one-eighth to one-fourth of a grain, alone or associated with tannin or with iodoform) or aqueous solutions of morphine salts and of aconite were employed to relieve pain and obtund sensitiveness. The oleate of morphine (2 to 4 per cent. solution) and the oleate of aconitine (2 per cent. solution) are similarly useful. Morphine, by its constitutional influence, is preferable to erythroxyline in some instances, though less prompt in its effects. Where ulcerative processes at the top of the larynx or thereabouts entail odynphagia, these preparations should be used before administering nourishment. The use of erythroxylon products may be entrusted to the nurse or to the patient with comparative safety. Morphine and aconite should be applied only by a medical attendant or an exceptionally skilled nurse. Before any medicinal curative or reparative agent is applied the parts should be thoroughly cleansed of suppurative and secretory products. This may be done with sprays of alkaline solutions—five or more grains of sodium borate or bicarbonate, for example—dissolved in pure water, in tar-water, or in an emulsion of coal tar. An excellent agent, especially in the presence of pus, is hydrogen dioxide, usually furnished in a 10-volume solution which should be diluted with two or more parts of distilled water. It is likewise disinfectant and gently stimulant to mucous membrane. The manipulations by the physician preparatory and medicatory should be performed laryngoscopically, otherwise the entire procedure must be haphazard.
Neoplasmata and fungous growths may require removal should they interfere with respiration. In the presence of stricture, surgical interference by tracheotomy may become requisite. Elsberg, according to the testimony of his assistant, Schweig, seems to have been particularly favorable to the performance of this operation in obstinate cases of ulcerative laryngitis of whatever character, and even in protracted non-ulcerative cases, for the purpose of securing physiological rest to the parts, although the procedure might not be indicated to relieve any embarrassment in respiration. The writer's experience in tracheotomy as a factor in producing rest has not been favorable, such a result being usually defeated by the cough so frequently following a tracheotomy, no matter how well-adjusted a tube may have been inserted. His recommendation, therefore, is limited to cases of embarrassment to respiration due to stricture or constriction unamenable to intra-laryngeal interference.
Morbid Growths of the Larynx.