The general principles which we have laid down for the dieting of tuberculosis generally apply to tuberculosis of the larynx. In disease of this organ, which is nearly always co-existent with tuberculosis of the lung, there is the same necessity for maintaining a high level of nutrition. The treatment of patients with laryngeal tuberculosis who have no difficulty in swallowing requires no special notice, but the existence of dysphagia calls for very special treatment. In many cases the dysphagia is of quite slight degree and far from being severe enough to prevent the patient taking an ordinary diet. In general terms it may be said that when a patient can take an ordinary diet without appreciable inconvenience, he should be advised to do so, as the taking of a generous diet is thus rendered much easier and will often bring about rapid improvement in the laryngeal condition with loss of the pain on swallowing. In the case of such patients, however, it is a good plan to inquire whether there is any particular food-stuff which causes pain and if there is to omit the same from the diet. When the dysphagia is severe enough to prevent the patient taking an adequate diet in an ordinary form semi-solids or fluid diets must be relied upon until such time as improvement in the general condition and the condition of the larynx makes it possible to return again to ordinary diet.
When semi-solids and fluid diets are prescribed considerable care must be exercised in the arrangement of the meals to ensure a sufficient amount of nutriment being taken. As a matter of experience, we have found that semi-solid diets are often taken more readily than fluid diets, the latter having more tendency to "go down the wrong way." This tendency can, however, be considerably lessened by the patient taking a fluid diet in the Norris-Wolfenden position. Another advantage of the semisolid diet is that a high nutritive value can be given in this form in a good deal smaller bulk than in a fluid diet. The bulkiness of a fluid diet is very apt to give rise to dyspepsia.
Constant slight variations should be made in the diet whether fluids or semi-fluids are used, as patients soon tire of either of them. In practice, it is usually best to compromise between a semi-solid and a fluid diet or to alternate them. In no form of tubercular disease is there the same necessity for the constant close attention to dietetic detail as exists in these cases of laryngeal tuberculosis, and the secret of success in treating such cases lies in making a close study of every individual case, carefully seeing what solid foods, if any, can be taken, building up the necessary diet round these food-stuffs, allowing the patient at the same time to indicate his own preferences and then varying the diet judiciously day by day. All food-stuffs should be given cold and very often if the fluids are iced they are taken more easily. Anything of an irritating nature, such as pepper and similar condiments, should be omitted.
When the pain in swallowing is very severe it may be necessary to give food in small amounts every four, or three, or even two hours during the day. At all costs the taking of an adequate diet must be secured. There are several measures at our command which are often of the greatest assistance to these patients. The insufflation of the larynx with orthoform or anas-thesin between meals will often allay pain sufficiently to allow of food being taken much more readily. The application, also, of cold to the larynx - preferably by the use of a Leiter's laryngeal coil is often of distinct service in this respect. Again, taking the food when in the Norris-Wolfenden position, i.e. when lying on the side, the food, if liquid, being taken through a tube from a vessel placed slightly below the level of the mouth, or in the Wolfenden position, viz., the patient lying on his chest with the head somewhat dependent and taking the food in the same way, may help considerably.
In the construction of diets for patients with dysphagia many of the concentrated foods which we have described in the article on the treatment of anorexia, etc., will be found very useful. Full use should be made of all the various foods from time to time, so as to get plenty of variety. The following examples of diets which we have used with satisfactory results may perhaps be of value as showing how they should be constructed.
8 a.m......Thin Benger's food, 1 pt.
10 a.m......Egg, 1; milk, 5 oz.
11 a.m......Milk and sanatogen, or soluble casein preparation, 1 pt.
1 p.m......Milk cocoa, 1 pt.
3 p.m. ..... Junket, 1 pt.
5 p.m......Thin Benger's food, 1 pt.
7 p.m......Milk bovril, 1 pt.
9 p.m......Egg, 1; milk, 5 oz.
10 p.m......Thin Benger's food, 1 pt.
During night .... Milk and sanatogen, etc., 1 pt. Total - Benger's food, 3 pts.
Milk and sanatogen, etc., 2 pts. Milk in other forms, 3 1/2 pts. Eggs, 2. Approximate nutritive value : Protein, 180; Fat, 210; Carbo-hydrate, 280; Calorie value, 3,940.
Dysphagia patients constantly fail to take the prescribed diet well at some time every day. As the nutritive value of the above diet is very considerable a certain amount of latitude may be allowed in this respect, and at the same time the patient should be encouraged to persevere with the full diet.
The fluid diet mentioned in discussing the treatment of anorexia, etc., is also frequently suitable.
7 a.m......Egg and milk, 1 pt.
9 a.m......Arrowroot or cornflour milk, or typhoid bread and milk, 1 pt.
11 a.m......Gelatin blancmange or cream (flavoured).
1 p.m......Steamed fillets of fish, or 4 eggs scrambled with 1 oz. butter.
3 p.m......Junket and cream, 1 pt.
5 p.m......Milk and raw meat juice, 1 pt.
7 p.m......Velvet soup, 1 pt. •
During night .... Benger's food or milk, cocoa etc., 1 pt.
Approximate nutritive value: Protein, 164; Fat, 210; Carbohydrate, 220; Cals., 3,013.