More radical surgical procedures are, however, clearly indicated when the ulcerating process fails to respond to rest of the larynx, soothing and antiseptic applications and intratracheal injections employed every 24 to 48 hours.
The laryngeal surface having been brushed with a solution of cocaine 15 per cent. applied on cotton-wool firmly fixed upon a suitable holder, the ulcerated spot should be curetted carefully and thoroughly and the raw surface rubbed with a Go to 75 per cent. Lactic Acid.
Many surgeons, however, content themselves with a thorough applica tion of the pure acid without previous curetting, since this substance has marked penetrative power and effects the destruction of all diseased cells without injury to the healthy elements in the mucosa. Formalin is employed in a similar manner (5 to so per cent.), and strong Carbolic Acid is sometimes used.
Barwell's caustic pigment consists of so per cent. Lactic Acid, 7 per cent. Formalin and lo per cent. Carbolic Acid,and he insists upon the importance of its being well rubbed in. Protargol and other silver salts are also employed.
Various types of cutting or punch forceps are used for excision of the ulcerated spot instead of curetting. Many laryngologists prefer the galvano-cautery. This may be employed for the removal of ulcerating tissue or it may be used for the destruction of tissue before abrasion has occurred, in which case the method of procedure is to make one or two deep punctures into the indurated spot.
When the disease is limited to the upper part of the epiglottis the best procedure is to excise it by means of the punch forceps. Barwell removes the entire organ in one piece by large cutting forceps, having previously been in the habit of employing the galvano-cautery.
The operation of thyrotomy is practically never justified, and tracheo tomy or laryngotomy is reserved for those cases where urgent dyspncea immediately threatens to cut short the life of the patient.
Perichondrial abscess will require prompt incision from without, and though excision of the larynx is seldom if ever permissible, it may be found necessary to remove a portion of the diseased cartilage.
Syphilitic treatment should consist of constitutional remedies suitable to the stage in which the syphilitic affection is existing at the time. in the later part of the secondary stage of syphilis rapid mercurialisatiun should be carried out by inunction of Mercurial Ointment and Salvarsan should be administered. Laryngeal mischief occurring
during the tertiary stage of the disease is best met by vocal rest, perfect hygiene. nutritious food and heroic doses of Iodide of Potassium-3o grs. three times a day after meals. When the case does not respond to the iodide, and the symptoms increase in gravity, a course of mercurial inunction may be cautiously tried. The local symptoms can be best met by the various anodyne and astringent sprays and inhalations previously mentioned. A weak solution of Corrosive Sublimate ( gr. to s oz.) is the best spray to use in such cases.
Orthoform, iodol, Iodoform and the newer iudoform substitutes may be employed by insufflation, and are of the greatest use in many cases where Touch ulceration exists. In the late stages of the disease Menthol or Cocaine may enable the starving patient to swallow with comfort.
Nitrate of Silver (i dr. to s oz.) or the solid stick or Argyrol may be freely applied to ulcerations, or a solution of Corrosive Sublimate (5 grs. to I Oz.) may he used, with the aid of the laryngeal mirror. Sulphate of Copper (15 to 2o grs. to s us.) is a local remedy of much value.
(Edema or gum matous infiltration with sprouting vegetations may at any time demand tracheotomy, and some laryngulogists resort to this in order to secure absolute rest to the larynx in intractable cases. Before, however, deciding to open the trachea or larynx it will be well to attempt curetting or excision and the application of Perchloride of Mercury solution. The cautery must be used with caution, as the danger of a permanent stenosis of the larynx must be always kept in mind.
The treatment of chronic laryngeal stenosis consists in the daily intro duction of a Schroetter's dilator passed into the cocainised larynx through the vocal cords after incision of any webs of cicatricial tissue. The dilating tube will soon be tolerated in the stricture for half an hour at a time. O'Dwyer's tubes may be advantageously employed and worn for a month. When these measures fail tracheotomy should be performed, and the stenosis dilated from the inside or by means of instruments introduced through the tracheotomy wound.
LEAD POISONING—see Colic, Plumbism, and Poisoning.