Chapter 6 - Diseases of the Nose and Throat
Nasal Catarrh
Acute Laryngitis
Chronic Laryngitis
Laryngitis Sicca
Symptomatic Laryngitis
Tuberculosis of the Larynx
Hare Lip
Elongation of the Uvula
Chronic Inflammation of the Tonsils
A Cold. Influenza
La Grippe
Acute Inflammation of the Epiglottis
Adenoids and Enlarged Tonsils

6.8 Tuberculosis of the Larynx

Tuberculosis of the Larynx.

A POPULAR belief exists among the laity that catarrhal affections of the nose, throat and larynx lead to tuberculosis. It is exceedingly difficult to deny or affirm this assertion by scientific measures.
Certain it is that any part of the respiratory canal may become suitable breeding ground for the tubercles if there is any systemic predisposition to consumption; and this is just as true of the larynx as of the lungs themselves.
It is also true that long standing cases of tuberculosis of the larynx may lead to a general infection from the disease.
But this is not proving, or even implying, that a catarrhal condition, as such and of itself, will eventually, if neglected, bring on tuberculosis.
On the contrary it is rare to find, in any part of the body, tuberculosis following catarrh. To have true consumption the tubercles must be isolated there is no tuberculosis without the germ no matter how closely the condition may resemble this disease or how suspicious the case may be. Catarrhal surfaces are not good soil for the germs of consumption, as a rule.

Symptoms. The signs of a tubercular larynx are plain enough even to the ordinary observer. In addition to the general symptoms of inflammation of the larynx we have a more pronounced huskiness, in some cases amounting to a more or less permanent loss of voice; greater dryness and in the more advanced cases an exudation or throwing off of material which is more putrid than ordinary catarrh, resembling more the contents of an abscess, which in truth it is.
These conditions, together with a noticeable falling off in weight, hectic fever, and a general feeling of malaise should lead at once to a thorough examination at the hands of the best specialist obtainable and his advice rigidly adhered to.

Treatment. The treatment of tuberculosis of the larynx resolves itself into prophylactic, hygienic, climatic, specific, symptomatic, local, surgical and general.

The prophylactic treatment of tuberculosis of the larynx, as in similar trouble elsewhere in the body, involves not only fighting the infection but in combating the large factor of predisposition or heredity. Establi3hed rules as to fresh air, sunlight, forced feeding, and carefully directed exercise apply with double value in prophylaxis. Those who bear the ear marks of a tuberculosis tendency, or who may be exposed to the disease at home or at work should receive timely advice as to occupation, habits of life, diet, and general hygiene. It should be borne in mind in this connection, that the greatest obstacle to be overcome in endeavors along prophylactic lines is the patient himself, who is more likely than not to consider "rules" as irksome. But once the diagnosis is made by a competent physician there must be no let up in painstaking care by the one under exposure.

The hygienic treatment of tuberculosis of the larynx embraces proper clothing, cleanliness, easily digested and nourishing food, outdoor life and properly ventilated or open air sleeping rooms. Air loaded with coal gas or with poisonous organic substances such as is found in cheap theaters and halls, and the more or less immoderate use of tobacco, liquors, ice, etc., is not only irritating but injurious. The use of the voice should be moderated as far as possible; rest plays as important a part in laryngeal tuberculosis as in involvement of the lungs.

The influence of climate is well recognized. In local affections involving general or advanced pulmonary tuberculosis it is far better to remain at home than to seek relief in some indefinite place, especially if financial resources are limited. The inflammatory conditions of the larynx do better in a warm moist climate; but since the lung trouble does better in a high, dry warm climate it is advisable when possible to seek sanatorium treatment in Arizona, New Mexico and the higher parts of Southern California. The treatment of the patient should be at all times in the hands of a competent physician. In the earlier stages of the affection the best results are obtained at an altitude of 6000 feet.
Many cases will improve in a lower altitude, 3000 feet or less, though remarkable cures are reported from Silver City, New Mexico. Here though the altitude is 6000 feet, the nights are cool and the days warm. An ocean trip to the Riviera or Egypt is of great benefit to those who suffer principally from local infection without much lung involvement.
Numerous specifics have been advocated from time to time for the cure of laryngeal tuberculosis, all of which have in part at least some merit. It should be remembered too that failure from their use is due in great measure to the fact that in laryngeal forms in particular there is almost always an attendant pulmonary involvement of more or less importance. Among the specifics may be mentioned tuberculin, antitoxin, serum, vaccines, iodine, chloride of gold and soda, creosote, formalin, nuclein, oil of cloves, the X ray and radium. The most useful of these is tuberculin. If the individual case is intelligently studied and the dose properly regulated, great improvement and even cure may result in a large proportion of cases. This is true in those cases that have gone on to ulceration. When a reaction occurs or the case is complicated with severe anemia valuable aid may be obtained by the use, hyperdermically, of green citrate of iron or sodium arsenate. By this method the stomach and digestive apparatus is spared. The use of phosphorus (gr. 1/100) in a ten minimum capsule of olive oil is of benefit in the more chronic cases. It should be given after meals and quickly discontinued if the stomach shows signs of irritation.
Remedies are also necessary to allay cough, temperature, pain, diarrhea and mental worry. For the first, third and fourth symptoms heroin (gr. l/12) or codeine (gr. 1/8) are efficient but should not be used unless absolutely necessary. The craving for depressing drugs should be denied in cases which offer a hope of cure as the resistance of the patient may be undermined, and digestion and elimination interfered with.

The local treatment consists of inhalations of medicated vapors or powders and the application of drugs to the affected parts. Before this treatment is administered a spray of Dobell's or similar solution is used to remove the secretions from the larynx. Applications of formalin in gradually increasing strength is probably the most efficient of the many drugs used against the tubercles. This is prepared freshly from a 40 per cent solution, using at first a 1 per cent strength, increasing as tolerance is established to 10 per cent, with 2 per cent cocaine if the throat is over sensitive. Applications of lactic acid (20 per cent) are highly recommended by many laryngologists, while insufflations of iodoform are in vogue among the older practitioners. Orthoform and anesthesia are used for the relief of pain. Argyrol (20 per cent) may be used when too much irritation is set up by the formalin. For the relief of pain and cough injections into the tissues of the larynx of guaiacol (2 per cent) menthol and camphor (each gr. ii) in olive oil are recommended. The X ray is attended by dangerous reactions.

Surgical treatment may be necessary when the above measures are insufficient to allay or modify the ravages of the disease, and those lesions affecting the epiglottis removed. Curetting is of value only when the tubercular deposits are of comparatively small area.
When swallowing becomes very painful a spray of 10 per cent cocaine before meals is justifiable or the head may be hung over the edge of the bed and liquid food sucked up through a straw from a glass on the floor, the patient feeding like a horse.
Removal of the larynx, or tracheotomy is hardly ever of value.

Constitutional treatment is of value in the earlier stages of the disease, in the form of cod liver oil, malt, hypophosphites and creosote.
As a last resort, in the advanced ulcerative stages occasional small doses of morphine hypodermically must be administered.

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