There is no symptom that calls for special treatment in the earlier stages of laryngeal tuberculosis; it suffices to say that the same high standard of nutrition must be adopted as is necessary for tuberculosis generally. Even if slight pain on swallowing is complained of, the patient should be urged to try and take the full standard diet, as in this way his chances of recovery are greater. If any special articles of food are observed to cause more pain or discomfort than others, they should be discontinued and others substituted.

If, however, dysphagia is complained of to such an extent that the standard diet cannot be adopted, a diet composed of semi-solids and fluids must be used until such improvement has taken place that the patient can return to an ordinary diet.

These laryngeal cases, complicated by dysphagia, require ingenuity and care in order to get in sufficient nourishment with the least suffering to the patient.

All foodstuffs should be given cold, and very often if the fluids are iced they are taken more easily.

All condiments such as pepper and mustard are irritating, and must be omitted.

Careful notice should be taken to see if any solid foods can be taken, and the diet should be carefully built up round these.

Semi-solid diets are often taken more readily than fluid diets, and these can be given in smaller bulk than a fluid diet, and therefore are less liable to cause dyspepsia.

When the pain on swallowing is very severe, the following plans may be tried to alleviate the pain of taking food :-(a) Insufflation of the larynx with various anaesthetic powders, orthoform or ansesthesin; or the larynx may be painted or sprayed by a 10 or 20 per cent, cocaine solution, or with eucaine, menthol, and parolene a 20 or 30 per cent, may be employed for spraying with-will often allay pain sufficiently to allow of food being taken more readily.

The application of cold to the larynx by Leiter's laryngeal cell is often of distinct use - or a cold compress with ice may be applied. When there is difficulty in swallowing fluid, the Norris Wolfenden position may be assumed, i.e., the patient lying on the side, and liquid food taken through a tube from a cup placed slightly below the level of the mouth; or Wol-fenden's position can be tried, viz., the patient lying on the face with the head over the couch, and sucking up food in the same way.

The food should be concentrated, and given at fairly frequent intervals, and in small quantity. The following diet and recipes will be found helpful: -

I. A Fluid Diet For Dysphagia

8 A.M. - Thin gruel, made with milk and cream ; or Invalid food, made with milk and cream 1 pint.

10 a.m. - Egg beaten up in milk, 1/4 pint.

11 a.m. - Milk with Plasmon or Sanatogen, flavoured with cocoa, 1 pint.

I P.M. - Velvet soup, 1/2 pint (p. 439), with egg. 3 P.M. - Junket, I pint, with cream.

5 P.M. - Thin invalid food, 1 pint.

7 P.M. - Milk bovril.

9 P.M. - Egg and milk, 1/4 pint.

10 p.m. - Beef-tea, with 2 ounces raw meat, 1/2 pint.

During night

Milk and Sanatogen, 1 pint.

The fluid dietary for Anorexia of tuberculosis would also be found suitable (p. 430).

2. Semi-Solid Diet For Dysphagia

7 A.M. - Milk, 1/2 pint, with egg. 9 A.M. - Arrowroot or cornflour milk, 1 pint, with cream.

Breadcrumbs and milk, 1 pint, with cream.

11 A.M. - Milk blancmange (p. 439).

Vanilla cream.

Iced vegetable cream.

I P.M. - Fish or chicken cream.

Fish or chicken souffle.

Beef quenelles.

Eggs, scrambled, with butter (four eggs).

3 P.M. - Curds with cream, and iced cream or jelly. 5 P.M. - Bovril custard. 7 P.M. - Velvet soup, 1 pint; or Soup with raw-meat juice, I pint. During night - Benger's food, 1 pint; or Cocoa and milk, 1 pint.

The following preparations are specially useful in dysphagia: -

Custards

The custard is made with milk and eggs, as described. The milk used can be fortified with Plas-mon, or casein, from 3j to 3iv to the pint. The flavouring can be varied - a sweet custard flavoured with vanilla or lemon, or nutmeg or grated chocolate, or sherry; or a savoury custard, made with the addition of Bovril or Bovinine, or a strong chicken essence, to the milk and eggs.

Cheese can also be added to the milk and eggs. Two ounces of grated American cheese, a pinch of bicarbonate of soda mixed with the milk and eggs, and either boiled or baked.

Creams and blancmanges are much better taken by dysphagic patients when made with gelatine than with cornflour or arrowroot.

Jellies, either in the form of a sweet or savoury jelly, are well taken. Gelatine, 1/3 ounce added to 1 pint milk, will thicken it sufficiently to enable a patient to take it without pain when the plain milk causes much pain.

Curds and cream, freshly prepared, is sometimes more easily taken than milk.

Velvet Soup

A clear soup very blandly flavoured, fortified with 1 tablespoonful of Casumen to the pint, may have one or two eggs stirred in when very hot immediately before serving.

Fish souffle, or cream and chicken treated in the same method, can be taken.

Breadcrumbs and milk, strained, can be often taken. Boil half a round of bread crumbled down in 1/2 pint of milk, strain through fine muslin, and serve.