CHAPTER IV.

TREATMENT OF ACUTE, AND LARYNGEAL PHTHISIS.

THE preceding observations upon the treatment of phthisis are applicable to every chronic case, whether it assume the florid or the languid type; but very different measures are required in the acute form of the disease.

Acute Phthisis.-The question of depletion in this disease is a very delicate one, and open to much variety of opinion. When active pneumonia or bronchitis constitutes the chief feature in its early symptoms, and when, at the same time, the patient's strength is considerable, moderate abstraction of blood, either by cupping or leeches, may be desirable. But whenever it is manifest that the inflammatory complication is more of a secondary character; or, when the physical powers are but small, the slightest loss of blood is evidently contraindicated. In the majority of these cases, there is more to be apprehended from early exhaustion of the system, than from excessive action. As the acuteness of the first symptoms passes away, blisters, or a milder form of counter-irritation, are

likely to prove useful. When the attack sets in with great severity, antimony, in small and repeated doses, may be useful; but mercury should never, in my opinion, be resorted to:-in the few cases, indeed, which have fallen under my own observation, neither of these remedies was indicated, and their use would certainly have been rather prejudicial than otherwise. Generally speaking, perhaps, but little can be done by any medicinal agents, beyond relieving the urgency of the cough and feverish disturbance by simple expectorants and salines, and keeping up the strength by ammonia or other diffusible stimulants. The diet should not be much reduced, but carefully adapted to the particular requirements of the patient; wine or brandy being freely given so soon as there is the slightest appearance of exhaustion.

But it would be impossible to lay down any precise rule for the treatment of acute consumption, since it must be entirely governed by the peculiarities of each case. To subdue inflammatory action without inducing physical exhaustion, in persons who can seldom endure even the least active treatment, is the general principle upon which it must be based, and at once exhibits the difficulty which has to be encountered.

Laryngeal phthisis being nothing more than a complication of the ordinary form of chronic consumption, requires precisely the same treatment as the latter disease, with the employment of some few additional remedies devoted to the larynx.

When the voice becomes hoarse, or when from other symptoms there is reason to suspect that the laryngeal mucous membrane is implicated, local applications to the upper part of the respiratory passages should immediately be tried, since, at this early period, there is, at least, some hope of checking this most distressing complication. Such applications may be made externally or internally. Externally, a strong tincture of iodine, or the compound iodine ointment, or the croton oil liniment, or small and frequently repeated blisters, or, indeed, any form of counter-irritation, may be usefully employed, and may sometimes check the local symptoms in a most decided manner. The use of applications internally, involves a practice upon which there is much difference of opinion, both as regards its practicability and success,-I allude, of course, to what has been called topical medication of the upper part of the respiratory passages.

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In the former edition of this work I spoke, in favourable terms, of the local use of the nitrate of silver by means of a piece of sponge introduced into the laryngeal opening. More recent and increased experience, however, has induced me somewhat to modify such an opinion. Of the possibility of introducing the sponge-not perhaps to the distance which some of its advocates maintain, but certainly to an extent sufficient to ensure the free application of the solution to the interior of the

larynx, I do not entertain the slightest doubt; although I am equally convinced that the operation is neither so certainly nor so constantly successful as is generally imagined, the opening into the larynx being, in many persons, far too sensitive to admit of its performance.

For some time past I have preferred freely brushing the pharynx and neighbouring parts with a solution of the crystals of nitrate of silver, in the proportion of twenty or thirty grains to an ounce of distilled water. By this means-owing possibly to continuity of mucous membrane, but possibly also to some of the solution, after a few applications and under the diminished sensibility of the glottis, finding its way into the diseased larynx-considerable benefit is sometimes effected, without producing the distress and alarm which frequently attend the introduction of the probang.

As a general rule, in cases at all advanced, as well as in others where there is much general or local sensibility, the brush is by far the best instrument; it is also preferable where there is a tendency to hæmoptysis, the cough and spasm which frequently attend the passage of the probang having more than once appeared to me to produce this symptom. Indeed, I believe the probang to be inapplicable, both when there is reason to think that the laryngeal structures are extensively ulcerated, and when the general symptoms of the patient are indicative of advanced phthisis. The early stage of the laryn

geal disease, and when the lungs are not much affected, nor the strength much reduced, present the only opportunities for its employment; and it may fairly be questioned, whether the brush might not, in nearly every case, become its substitute.

When the pharynx has been relaxed, I have applied a solution of tannic acid in glycerine, in the proportion of five grains to the drachm; and I have also used the iodide of iron in a similar manner. Where, however, local applications are beneficial, the nitrate of silver generally answers the best.

Although such applications are sometimes useful in at least relieving the local symptoms, and checking the progress of the laryngeal disease, it must nevertheless be admitted, that, far too frequently, they are unsuccessful, and only disappoint both the physician and the patient.

Inhalations seem to have very little influence upon the laryngeal affection. I have tried them in various forms, both with a curative and palliative view, but hitherto with but trifling success. The vapour of hot water sometimes soothes the irritable cough, and the addition of conium, hyoscyamus, hops, or hydrocyanic acid, occasionally affords still further relief; but I have generally found, after a short time, a decided unwillingness on the part of patients to persevere with their employment,-a very conclusive testimony of their trifling utility. In two or three instances, however, I have found the inhalation of the fumes of iodine serviceable; and, in early cases, perhaps, it is worth a trial.