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nasal septum proper is made up of the cartilaginous or purely nasal
portion, the vomer, and the perpendicular plate of the ethmoid, any
one of which may be separated from its connections or warped from
its perpendicular plane. Dislocation of the cartilages may also occur
in the young, and, having once taken place, is rarely reduced unless
treatment has been both prompt and scientific.
Angular deviation to an extent which often produces a spur is not
necessarily of serious inconvenience unless it protrude sufficiently
from its proper plane to come in contact with one of the turbinates, in
which case a nearly complete obstruction may result, with symptoms
of constant nasal irritation. Absolute symmetry being rare, and mild
deviations being very common, it is only those which produce either
visible deformity or local irritation which require surgical treatment.
Obviously after injury to these parts attention should be given to
overcome present and prevent further dislocation. This may be
conveniently done by the introduction of small, tubular, nasal splints,
of celluloid or caoutchouc, made for the purpose. In their absence
short pieces of a stout, silk catheter may be used, one inserted on
either side of the septum, and packed around with a light tampon of
antiseptic gauze. All intranasal splints, no matter how made, will
cause considerable local irritation, with tendency to discharge, and
will need to be renewed every day or two.
Deviation having resulted in permanent deformity, no matter how
produced, it can be relieved by operation. Except in the young this
may be performed under local cocaine anesthesia. These measures
fall under two heads—those made for removal of projections, or
spurs, and those directed to straightening of warped or deviated
septa, which do not show much thickening.
For the treatment of projections caustics and the actual cautery
were formerly much in use. They have been now almost abandoned
for the use of instruments, such as a strong knife, a small intranasal
saw, or cutting forceps of various patterns, adapted for use within the
nose. Only these latter means will be mentioned in this place.
Cutting instruments may be actuated by hand or by electric motors.
When the field of operation is small cocaine anesthesia is nearly
always sufficient. Extensive operation involving both nasal cavities
may often be better performed under a general anesthetic. The nasal
cavity should have been previously thoroughly cleansed by the aid of
irrigation with alkaline solutions, and then just previous to operation
with hydrogen peroxide. Instruments should be absolutely clean and
sterile. When local anesthesia is complete it is sufficient to seat the
patient with the head supported, opposite to the operator, to
illuminate the nasal cavity with the head mirror or some substitute
therefor, and to introduce the knife, saw, or forceps in such a way
that the removal may be effected with one movement, while injury to
surrounding tissues is avoided. An intranasal saw should be blunt-
pointed, and should never be pushed so as to touch the posterior
wall of the pharynx. After division of bone the final detachment of the
mucosa should be made with scissors or knife. Bleeding after these
operations is rarely severe, although free at first, and may be
controlled by a tampon made of a narrow, continuous strip of
antiseptic gauze, either packing it into the nostril and occluding it, or
inserting a nasal tube and packing snugly around it. Only in rare
instances is it necessary to tampon the nose from the pharynx by the
use of the Bellocq cannula. (See below.)
Warped and deviated septa, without angular projections, may be
sometimes successfully treated by dividing the septum, either with
knife or scissors, or with cutting forceps whose blades make a
stellate incision, by which the curved surface is so much weakened
that it can be pressed back into normal shape, where it is retained by
tamponing the nostril on the affected side. The pressure required for
this purpose is, however, sometimes irksome or even intolerable. A
method of using a long pin, like a small hat-pin, has been suggested,
it being passed through one nostril into and out of and again into the
septum, in such a way that it serves as a splint, to keep it straight for
a sufficient length of time. Later this pin may be removed without
difficulty, its enlarged head lying meantime concealed within one of
the nostrils.

SUBMUCOUS RESECTION OF THE NASAL SEPTUM.

This was first suggested by Killian as affording a method not
subject to the objections of the older authorities. It may be performed
under cocaine anesthesia, each side of the septum being swabbed
with a 20 per cent. cocaine solution. A semilunar incision made
through the mucous membrane and perichondrium on one side is
the more convenient. Through this opening the coverings are
separated from cartilage by means of a sharp and a plain elevator.
Unless the perichondrium be itself elevated the mucous membrane
will be torn in the pressure of loosening. The cartilage is then cut
through with suitable instruments or burred away with a dental
engine, the instrument being guarded by a finger in the opposite
nostril, which acts as a guide, it not being desirable that the
membrane on that side shall be cut through. In this way any spurs or
ridges may be removed submucously with such instrument as the
operator may select. The separated membranes then fall together
and may be retained by light gauze packing without any suture.

NEOPLASMS OF THE NASAL CAVITIES.

Of true neoplasms in the nose the most common are those
myxomatous or fibromyxomatous developments from the
Schneiderian membrane, which are called nasal polypi.
Histologically most of these are of myxomatous character. Clinically,
however, they seem to be in large degree products of inflammatory
and irritative conditions. At all events they constitute sessile and later
pendulous outgrowths, occupying different areas or occurring in
clusters, those from the upper part of the nose being covered with
columnar cells, while those of the lower pharynx are covered with flat
epithelium. They are firm or soft, according to the amount of
connective stroma which they contain. They are poorly supplied with
blood and their contained fluid is largely composed of mucin. When
involving a considerable area the condition is referred to as polypoid
degeneration. They are observed at all ages and in both sexes. Their
most common seat is the middle turbinate, toward its posterior
extremity, and they also hang from the septum, but may be found in
any part of the nasal cavity. From it they may spread to fill the
adjoining accessory sinuses, even producing absorption of their
bony walls by pressure. They also produce distortion of the nose,
with such obstruction as to prevent nasal respiration. They may
involve one side or both, and may hang so loosely attached that a
flapping, valve-like sound is heard on respiration.
Symptoms.—They produce nasal obstruction, with irritation; more
or less discharge of watery or acrid mucus, the latter
sometimes leading to excoriation; while by pressure they produce
headache, especially when located high in the nose, or deafness, as
when they press upon the Eustachian outlets, or symptoms of
sinusitis according as they invade one or other of the sinuses. Other
reflex symptoms, such as facial neuralgia, reflex cough, lacrymation,
and conjunctivitis, frequently accompany them, and mouth breathing
and snoring are almost inevitable consequences. The voice
becomes impaired, as does occasionally the sense of taste.
In most cases they are easily revealed by artificial illumination and
exposure with the nasal speculum. In color they are usually pinkish,
and may be seen to move with the respiratory effort. While it is
usually easy to see at least some of them, when present, it is difficult
to detect their exact point of origin. With the rhinoscopic mirror they
may be seen projecting into the nasopharynx. Occasionally one will
be detached by violent effort at sneezing or blowing the nose.

Fig. 479

Jarvis snare.

Aside from the danger of retained secretion, which they may bring
about, and that attending their extension into adjoining cavities, there
is in elderly people at least an actual possible danger of their
undergoing malignant transformation, although this is not common.
There is, however, good reason for their removal, and none for
allowing them to remain, for they are always both irritant and
obstructive.
Treatment.—Almost every other method of treatment has yielded
to that of removal by the Jarvis snare, or its equivalent,
supplemented by the occasional use of forceps. In order, however, to
expose them sufficiently to permit of removal it is often necessary to
cut away a portion of the middle turbinate. In extensive polypoid
disease this would be practically always required, and it should be
done thoroughly, for nasal polypi tend usually to recur unless
radically attacked. Local anesthesia is sufficient for the majority of
cases, but an aggravated instance will call for complete anesthesia
and thorough work, especially if the accessory sinuses have been
infected.
The snare figured in Fig. 479 is a type of instrument which can be
used to great advantage in dealing with these cases. When,
however, it cannot be made effective by being applied around the
actual base of each growth its use should be supplemented by that
of the curette. No actual assurance can ever be given that there will
be no subsequent development of polypi. Nevertheless it does not
follow that new polypoid development is of the actual nature of
recurrence. It may occur independently from the same causes that
produced its first appearance.
It should hardly be necessary to insert here the caution that no
operation of even this degree of simplicity should be effected without
careful cleansing of the nasal cavity.
Of the other tumors that may occur within the nasal cavities none
can be said to frequently occur here, but all varieties may be
encountered. Of the more benign tumors the most common are the
vascular growths and the fibromas, or mixed form of fibromas and
papillomas. Epithelioma and sarcoma occur occasionally.

FIBROMA OF THE NASOPHARYNX.

Fibroma of the nasopharynx is much more common than in the
nasal cavity proper. Here it assumes its usual characteristics as a
more or less firm and dense tumor, growing slowly, sometimes from
a large base and again in pedunculated form. A form occasionally
met with springs from the periosteum of the base of the skull and
slowly extends into the nasopharynx, causing in time a complete
obstruction, with disappearance of the surrounding structure by its
pressure effects. Some of these growths are of a considerable
degree of vascularity. When arising from the base of the skull they
become almost inoperable after obtaining considerable size. I have
seen death upon the operating table, in one of the foreign clinics,
from uncontrollable hemorrhage occurring during the removal of one
of these growths. A growth thus situated should be attacked with
extreme caution, and preferably after easier access has been made
to it by division of the soft palate, and removal of a portion of the
hard, or perhaps by a temporary or permanent resection of the upper
jaw; the route being left in each case to the decision of the operator.
Provisional ligation of the carotids may be also made.
The same is true of the other tumors of the nose and
nasopharynx. The less malignant they are the more they justify
radical attack. By the time a sarcoma or adenocarcinoma of deep
origin has declared itself it is usually too late to justify its removal.

ADENOIDS OF THE PHARYNX.

A new-growth of different form, occurring in the vault or around the
outlines of the pharynx, is frequently seen in the shape of great
hypertrophy or overgrowth of the lymphoid tissue, already and
elsewhere alluded to as composing a part of the original lymphoid
ring which marks the site of the embryonic nasopharyngeal canal.
This lymphoid hypertrophy, whose commencing expressions are
seen in the tonsil, is referred to as adenoid growth. Associated with it
occurs more or less hypertrophy of the other tissues, fibrous, etc.,
according to whose proportion the growths will be soft and spongy or
more dense and resistant. The so-called adenoids occupy more or
less of the nasopharynx proper, reducing its dimensions,
encroaching upon the vault of the pharynx, materially reducing the
breathing space, thus leading to the establishment of the mouth-
breathing habit, as well as to alteration of voice and the
accompanying disagreeable features of increased secretion of the
parts. It leads to characteristic appearances which may be
recognized at a distance, consisting of a mouth habitually open, with
more or less projecting teeth, pinched nostrils, Gothic roof of mouth,
stooped shoulders, deformed thorax, loss of hearing, irritative cough,
and possibly remote reflex effects, such as laryngeal spasm, general
neuroses, chorea, and epilepsy. The effect of these changes is to
give not merely an appearance of stupidity, but actually to interfere
with mental development. Save in exceptional instances, a child with
the mouth-breathing habit, and with that peculiarity of voice which
indicates nasal obstruction, will nearly always be found to be
defective in cerebral activity, if not actually stupid. The longer the
condition is allowed to persist the greater the permanent alterations
and damage permitted.
Pronounced degrees of the condition may be easily recognized by
the habitually open mouth and the character of voice. A moment’s
inspection will usually reveal the character and the degree of
involvement. When adenoids in the nasopharynx attain a size
sufficient to produce these results the tonsils are also usually
involved, and the clinical picture is thereby made more pronounced.
The rhinoscopic mirror, if it can be used, will give a picture of the
condition, while the finger-tip passed upward behind the soft palate
will give an idea as to the extent to which the cavity is filled.
By virtue of the interference with the vital function of respiration
thus produced, and because of the retention of secretion and the
greater exposure to irritation through the constantly open mouth,
individuals with this condition are usually anemic, while many of
them give evidence of the status lymphaticus, to which attention has
been called in the preceding pages. To such an extent is this true
that the administration of an anesthetic is frequently attended by
extra danger, and the operator should give the necessary relief only
after careful preparation. This should consist not only of general
measures, by which the condition of the patient may be improved,
but by local cleansing of parts; and finally, as a preparation for the
anesthetic, of the local use of a weak cocaine solution, by which
reflex excitability may be controlled. Just before administering the
anesthetic in these cases it is well to spray into the nostrils and
pharynx a weak cocaine solution, after which the anesthetic may be
administered. In most instances it would be better to use ethyl
chloride or ether than chloroform, not because the latter is
necessarily more dangerous, but because one is placed less upon
the defensive in case of accident, owing to the belief that it is not so
safe as some other anesthetics. (See p. 164.)
Operation.
—Local applications being of small avail in producing either
condensation or resorption, the treatment of this condition is
essentially surgical. With children an anesthetic is always necessary.
With adults cocaine may be sufficient. The best position for the
patient is that with the down-hanging head (Rose’s), as blood is not
swallowed nor passed into the lungs, but may be removed as fast as
it collects. The hemorrhage in these operations is generally profuse
but of short duration.
Adenoids are removed either with a snare, the curette, or by
special instruments constructed on the type of a tonsillotome, and
having a concealed blade. The curette is also used as forceps. Two
or three curettes and forceps are sufficient for nearly all purposes. In
operating the instruments are guided entirely by the sense of touch
and the operator’s knowledge of anatomy, for he relies upon his
finger-tip for information as to whether the tissue has been
completely removed or needs further attention. These instruments
are used until the entire vault of the pharynx and its openings into
the nasal cavities (choanæ) are freed from all hypertrophied tissue or
excrescence. The posterior wall of the pharynx should be scraped
until it is smooth. In addition the tonsils should be removed if it be
necessary, while the lingual tonsil may be also removed with curette
or forceps if it be involved. For a few moments there will be a free
flow of blood through both nose and mouth. In some instances there
will be indications for cutting away hypertrophied turbinates and
removing nasal polypi. Hemorrhage, at first profuse, quickly
subsides. A mixture of 1 per cent. cocaine solution with a little
adrenalin is the best hemostatic for local use. The nostrils may be
packed if the turbinate has been cut away, or the entire passage-way
may be left open for the purpose of permitting the later use of an
irrigating stream, by which blood clot may be washed away and
antiseptics applied. While using and relying upon instruments for the
greater part of this work there is no better curette for concluding the
work than the finger-nail of the index finger. The finger being
introduced recognizes the degree of relief afforded, and the finger-
nail may be used to scrape away any remaining projecting tissue.
Various operators have devised formidable operations, varying
from the temporary resection of one upper jaw to Cheever’s
ingenious method of dividing and separating both upper jaws in one
piece from the cranium, and thus exposing the nasopharynx from in
front and above. Such operations are rarely performed.
Other neoplasms in this region are cysts and dermoids of
congenital origin—those involving the original craniopharyngeal
canal, and those produced from pharyngeal diverticula. These
produce only the ordinary manifestations of tumor and are of
pathological rather than surgical interest.

EPISTAXIS (NOSE-BLEED).
The escape of a small amount of blood from the nose, especially
in childhood, is a common occurrence, and may occur in
consequence of slight traumatisms or even spontaneously. The so-
called nose-bleeding of children, then, is scarcely of sufficient
importance to justify consideration here, nor would it were it not for
the fact that it may become severe and even dangerous. Children in
whom it frequently recurs will lose sufficient blood to become
anemic, while the effect of its frequent occurrence may bespeak a
depraved condition of the blood as well as of the tissues which
permit of its escape. A history of repeated nose-bleed should prompt
an investigation into the general condition of the patient as well as a
local examination of the nasal passages, where some explanation
may be afforded. For instance, a polypus may be found whose
removal will then be indicated, or an exceedingly spongy and
vascular area may be revealed, which will call for a touch of the
actual cautery or the use of the curette.
Besides the frequent expressions of this kind in childhood, some
of which may occur during sleep, there are other forms of nasal
hemorrhage. A vicarious menstruation is known to assume this type,
individuals thus losing blood every month. This is a rare but well-
known phenomenon. A plethoric individual may suffer serious
epistaxis at any time, and this may be beneficial unless it be too
extensive. Nasal hemorrhages may occur with certain fevers.
Individuals with a hemorrhagic diathesis are peculiarly liable to it,
and it is seen in connection with purpura hæmorrhagica. When this
occurs in the debilitated or dissipated it may be fatal. Thus epistaxis
may terminate fatally in spite of all that can be done. This statement
requires some explanation. The nasal cavity may be tightly plugged,
but such plugging cannot be made permanent because of
decomposition of products thus retained and their absorption, with
consequent septic infection. Nasal tampons should be removed
every day or two, for the purpose of cleanliness, although their
removal is contra-indicated when the necessity for physiological rest
of the part is realized. The treatment, then, of epistaxis may be
trying, at least, and in rare cases will prove absolutely disappointing
and ineffectual. I have even been compelled to tie the common
carotid to save life.
Treatment.—The ordinary nose-bleed of a young child will usually
subside with the application of cold to the nose,
elevation of the arms, or firm pressure upon the upper lip just below
the nasal septum. It may be also checked by an irrigating stream of
cold water, or by a spray of cocaine or weak adrenalin solution. A 5
per cent. antipyrine solution also makes an excellent styptic for the
purpose. Within a day or two after a serious hemorrhage, after the
remaining clots have been cleaned away, a thorough inspection of
the nasal cavity should be made in order to reveal the source of the
hemorrhage and permit local treatment.
Nasal hemorrhage may be subdued by plugging the anterior nares
with strips of gauze, or, better still, after the introduction of a tube
through which air may pass freely, and around which packing may
be firmly inserted. The ordinary dry styptics should not be used, for
they may produce such a crusting of tampons as to make it difficult
to remove them. More efficient materials can be used in solution. No
tampon should be introduced into the nostrils which is not tied with a
ligature of silk in such a way that it may be by it more easily
withdrawn, and, at the same time, prevented from going too far. If the
source of the bleeding be in the anterior part of the nasal cavity
anterior packing may be sufficient. The surgeon should not, however,
be deceived by the apparent cessation of bleeding, which cannot
escape through the nostrils under these circumstances, but may
continue into the nasopharynx, the patient swallowing the blood as it
trickles down. Inspection of the pharynx should be made after the
use of tampons. A much greater degree of safety is afforded by
posterior tamponing of each side of the nasal cavity, which is most
easily effected by means of the little instrument known as Bellocq’s
cannula, whose use is illustrated in Fig. 480.

Fig. 480

Plugging the nares with Bellocq’s cannula. (Fergusson.)

It is, however, by no means necessary to have this special

instrument in order to accomplish the purpose. A soft catheter may
be passed backward through the nostril until its end appears in the
nasopharynx, where it is caught with forceps and drawn into the
mouth. Here, by means of a needle or knot, a piece of silk is
fastened to this end. When the catheter is drawn out from the nose it
pulls up after it and out through the nostril this bit of silk, to whose
middle is tied a tampon, made of a sufficient amount of gauze or
similar material, folded or rolled into the desired shape. By combined
manipulation, as the silk thread is drawn upward and outward
through the nostril, it pulls up the tampon into the nasopharynx,
where it should be guided into its place by the tip of the index finger
of the disengaged hand. If necessary this procedure is then repeated
upon the other side, and thus a complete double tamponing can be
effected. If the procedure be made difficult by the extreme
sensitiveness of the part this can be overcome by local anesthesia.
The tampon may be saturated with a weak adrenalin solution if
desired. Ordinarily such a tampon can be easily disengaged and
removed by again passing the finger up behind the soft palate and
dislodging and withdrawing it, using curved forceps for the purpose
of securing it. A tampon inserted for the control of hemorrhage
should be left in situ for at least forty-eight hours, possibly longer.
The case should be watched for a while after its removal, lest it
might require re-introduction. This maneuver is made easier by
fastening the tampon in the middle of a long piece of silk as
described; one end being brought out through the nostril is tied to the
other portion, which is allowed to come out of the mouth. The latter
will provoke some discomfort, and patients should be cautioned not
to disturb it, its purpose being explained to them.
Mulford, of Buffalo, has suggested a method of dealing with cases
of epistaxis by injecting two or three drops of reduced adrenalin
solution into the tissues at the base of the upper lip, in close
proximity to the course of the arteries which pass upward on either
side and supply the septum. The injection should be made in the fold
of the mucous membrane just beneath the septum of the nose.

RETROPHARYNGEAL ABSCESS.
This has already been referred to as the product of tuberculous
disease in the upper cervical vertebræ, or in the neighboring lymph
nodes, or as the possible sequel of more acute infections occurring
in the upper portions of the neck, proceeding usually from infected
tooth sockets or other lesions within the nose and mouth. Collections
of pus in this location may be circumscribed or may be extensive and
rapidly assume serious phases. A chronic abscess is essentially a
tuberculous expression. Acute abscesses, either in the tissue behind
the pharynx or to either side of it, may be seen in cachectic children
and assume serious phases.
The first evidences in these cases are those of pharyngitis, but
swelling and edema occur rapidly, septic indications become
unmistakable, and, finally, almost complete nasopharyngeal
obstruction may occur. The discovery by the palpating finger of a
fluctuating swelling will make the presence of pus practically positive.
If the operator be still in doubt he may use the exploring needle. The
experienced practitioner will at once plunge the point of a knife into
such a swelling, and, at the same time, plan his opening in such a
way as to afford the best possible drainage.[48] For the purpose it
may be necessary to have the patient in the position of down-
hanging head, or, in extreme cases, the patient may be almost
inverted in order that pus as it gushes forth may escape through the
mouth rather than into the larynx or down the esophagus. The
operation should be done without an anesthetic. The mouth may be
opened with the O’Dwyer mouth-gag, or it may be forced and held
open with the ordinary tongue depressor. When pus has travelled to
such an extent as to give the case the importance and aspect of a
deep cervical phlegmon, such as described in the chapter on the
Neck, then anesthesia is necessary in order that by external,
combined with internal, incision, escape of pus and provision for
drainage may be permitted.
[48] Nevertheless in one instance an eminent American practitioner thus
hastily incised a fluctuating intrapharyngeal swelling and found, to his
dismay, that he had opened a carotid aneurysm, the patient dying within five
minutes.

Two dangers attend inexcusable delay in such acute cases—one

is of suffocation from pressure or from sudden spontaneous rupture
of abscess; the other is of invasion of large blood trunks in the
vicinity and possibility of hemorrhage after erosion, either into the
abscess cavity or directly into the outer world.
 THE UVULA AND SOFT PALATE.

ELONGATION OF THE UVULA.

As the result of constant irritation by coughing, or other reflex
motions of the pharyngeal muscles produced by local irritation, the
uvula frequently becomes elongated to a point which permits it to
rest upon the base of the tongue and there to produce still more
irritation and reflex phenomena. Patients suffering in this way will be
noticed to make frequent attempts at swallowing and coughing,
which may be depressing, and may lead to disturbed sleep and even
an asthmatic form of breathing. The uvula is a useless organ when it
has attained such dimensions, and its amputation, or at least its
shortening, are indicated in all such cases as those above described.
Local anesthesia is sufficient. Its tip is caught with a pair of forceps
and it is clipped off, not too near its base, by long-handled and sharp
scissors. This is a much neater and more expeditious method than to
include it within the grasp of a wire snare and somewhat slowly
crush it off.
Upon the uvula, as upon the soft palate, papular lesions of syphilis
are frequently seen, rarely the primary chancre, but very often
mucous patches or the deeper ulcers, which characterize the
secondary and tertiary lesions. Gummas also may form within the
thickness of the palatal tissues, which will in time break down and
form ragged ulcers, while the destruction may extend to the bony
portions, either of the nose or roof of the mouth, and then necrosis
will be added to the evidences of ordinary ulceration. The rapidity
with which these specific lesions will disappear under prompt and
vigorous constitutional treatment, along with that local cleanliness
which should include removal of necrotic tissue, is surprising and
gratifying.

THE EPIGLOTTIS.
The epiglottis is composed of yellow elastic cartilage and it does
not tend to calcify during the later years of life, as does the white or
fibrocartilage of the balance of the larynx. Thus its elasticity and
flexibility are fortunately maintained throughout life. It may be
sometimes injured by the incised wounds elsewhere described under
the term “cut-throat,” and is at least often thus exposed when not
actually injured.
The epiglottis seems to be exempt from most of the primary
diseases, but is occasionally involved in lesions of surrounding
tissues, in which it may then participate. Thus it may be deformed by
cicatricial tissue and unduly bound down, or it may succumb to
advancing ulceration of syphilis, tuberculosis, or cancer. Injuries
which break the laryngeal box rarely affect the epiglottis because of
its elasticity.
While an extremely useful portion of the body, the epiglottis is not
an absolute necessity, for even after its removal individuals can
swallow, although the act requires some extra care. Should the
epiglottis become involved in cancerous disease it should be
removed with the rest of the diseased tissue, while syphilitic and
tuberculous lesions will usually prove amenable to a combination of
local and general treatment. New-growths in this region are
extremely uncommon, but will prove relatively easy of removal when
present.

THE LARYNX.
The laryngeal cartilages, save the epiglottis, are composed of
white fibrocartilage which manifests a tendency in the later years of
life to undergo calcification. This makes the organ less elastic,
changes the tonal qualities of the voice, and makes it more brittle
and subject to possible fracture by external violence. Fractures of the
organ, as of the adjoining hyoid bone, have been elsewhere
discussed, with the indications which may make an emergency
tracheotomy necessary because of hemorrhage or edema of the
narrow laryngeal passage.
Of the inflammatory affections of the cartilages chondritis and
perichondritis are most common. These are usually seen in
connection with other expressions of tuberculous, syphilitic, and
malignant disease. Nevertheless they are known to occur as sequels
of the exanthems and ordinary infectious fevers. They may be
followed by destructive ulceration, which will lead to a necrosis of the
cartilage corresponding closely to death of bone under similar
circumstances. In due time there may form a cartilaginous
sequestrum, and this will require removal as though it were bone.
Dangers attend these lesions in two peculiar directions. The very
condition which produces the destructive inflammation may also
produce either hemorrhage or edema, with suffocation which can
usually be prevented by an emergency tracheotomy. On the other
hand, when repair follows spontaneous recovery or successful
treatment, it may be accompanied by such cicatricial contraction as
shall materially change the shape and impair or possibly destroy the
function of the larynx itself. In this case either thyrotomy,
tracheotomy, or laryngotomy may be called for, the opening thus
made being expected to permanently remain.

STRICTURES OF THE LARYNX.

Various forms of stricture of the larynx may be similarly produced.
Such strictures, then, are due to previous disease or to injuries, and
here as elsewhere stricture is a consequence rather than itself a
disease. It occurs in consequence of syphilis and of the destruction
following laryngeal diphtheria.
What is, in this respect, true of the larynx is also true, though less
often, of the trachea, where constrictions may occur at various
points, with reduction of caliber or such distortion of shape as to
produce partial or even finally complete obstruction. The peculiar
scabbard-shape which the trachea may be made to assume by
compression between the lobes of a growing goitre has been
elsewhere described. While the trachea itself is in this case free from
disease the obstruction is none the less pronounced. Similar effects
are produced by pressure, as from aneurysms or tumors, even at a
distance. Loss of voice, shown to be due to paralysis of one or both
vocal cords, should always prompt an examination of the chest, in
order that the presence of an aneurysm or other tumor making
pressure upon the recurrent laryngeal may not be overlooked.
 Symptoms.—Symptoms of laryngeal and tracheal stricture
comprise (1) those of the primary and active disease
which produces them; (2) those of obstruction; (3) those of
suffocation in emergency cases. The earlier symptoms are those of
increasing dyspnea, which may vary in rapidity and extend over
weeks and months, or which may become most pronounced within a
few hours. There is also a change in the character and sometimes
complete loss of voice, hoarseness of the speaking voice changing
into a whisper. The condition is frequently complicated by attacks of
serious dyspnea, often at night, which are due to an added
spasmodic feature, and in which death may suddenly occur. Usually,
however, with asphyxia comes muscular relaxation, and individuals
may pass through a large number of these attacks, which are
accompanied with extreme mental and physical suffering, in which
death is only avoided by final relaxation. Again the heart may
suddenly give out, and then the case becomes practically hopeless.
In recognition of causes and location of such troubles it may be held
that when hoarseness precedes dyspnea the lesion is in the larynx;
when the reverse, it is in the trachea. Careful auscultation of the
chest and thorough laryngoscopic examination will usually enable
the lesion to be recognized. The lower the location of the stenosis
the worse the prognosis, because of its inaccessibility. So long as
the trachea below the stricture can be opened life may be prolonged
indefinitely; but when due to a mediastinal tumor or an enlarged
thymus, the case assumes desperate aspects and may baffle the
best-directed efforts.
Treatment.—Strictures in the larynx proper may be treated by
dilatation, as by the introduction of intubation tubes of
increasing size, a method which ordinarily gives satisfactory results.
Nevertheless such laryngeal strictures manifest an almost
permanent tendency to recontract, and whatever measures are
addressed to them have to be frequently and thoroughly practised
and over a long period. Fortunately, however, these patients are able
to wear an O’Dwyer tube nearly all the time. When these internal
operative methods fail there remains only an external opening, which
may be made through the larynx proper (thyrotomy), or a low
tracheotomy, which may require the insertion of short or long tubes,
according to circumstances. Long trachea tubes are made, their
lower portion being composed of rings fastened together in such a
way as to cause them to be called lobster-tailed, and such a long
tube may be passed through a low tracheotomy opening and made
to extend beyond the point of pressure produced by an extrathoracic
or an intrathoracic tumor. By the use of such an expedient life may
be prolonged, although the exciting cause may prove fatal.

TUBERCULOSIS OF THE LARYNX.

Tuberculosis of the larynx may appear in a generally disseminated
form, involving nearly all the structures, or in circumscribed localized
form, as a tuberculous ulcer, which may produce symptoms
depending upon its exact location. Laryngeal tuberculosis may,
moreover, be but a local expression of the disease, apparently
primary, or as often happens, it may be an accompaniment of
pulmonary tuberculosis, the laryngeal trouble appearing as a local
infection, taking place by the constant passage over the surface of
tuberculous sputum which the patient is expectorating at frequent
intervals. Thus, clinically, we may have a miliary, an ulcerative, or a
gummatous form of the disease.
The condition is frequently referred to as laryngeal phthisis, and is
mainly to be distinguished from syphilitic laryngitis, or occasionally
from commencing malignant disease. Local symptoms include those
of chronic laryngeal catarrh, with hoarseness, impairment of voice,
sensation of dryness within the larynx, and frequent short, hacking,
unsatisfying cough. To these features are later added more or less
pain, especially in deglutition, while aphonia will finally succeed
dysphonia. When the epiglottis and the structures near it are
involved there are more irritation and pain. Dyspnea is a measure of
the encroachment upon the breathing space left by the progress of
the disease. Infiltration of all the parts within and later of those
around the larynx finally takes place, and with further implication
nervous reflex symptoms are added to those above mentioned.
Cough is usually a distressing feature; the sputum varies in amount;
saliva is increased in flow, and the expectoration is frequently
streaked with blood. In advanced disease the sufferings of the
patient become excessive, while constitutional symptoms keep pace
with those of the local disease. Thus anemia, emaciation, debility,
insomnia, and general malaise cause the patient great discomfort,
and, coupled with his terminal local symptoms, make death an
absolute relief.
With the laryngoscope varying pictures may be seen, either of
ulceration or of general involvement of the entire interior of the
larynx, which will be tumefied, irregularly swollen, ulcerating here
and there, while the vocal bands show thickening and roughenings
as well as ulcerations. Gummatous outgrowths may be seen at
almost any point and in various stages of ulceration. A more
distinctly lupoid form of tuberculosis is also occasionally seen in the
larynx, where it assumes more of the nodular appearance
characteristic of lupus, the nodules coalescing or disappearing by
ulceration, which may leave a dense, cicatricial tissue after healing.
Primary lupus of the larynx is rare.
Tuberculous lesions of the larynx are mainly to be recognized with
the laryngoscope, but they, like all other local diseases in this
location, produce alteration and final loss of voice, with difficulty of
breathing, reflex cough, and are accompanied by general
constitutional symptoms, according as the disease is purely local or
an expression of a general affection.
Treatment.—Treatment should be both local and general. The
latter may be summarized by stating that all measures,
including proper climatic environment, which are found to be of
advantage in ordinary tuberculous disease, will prove of equal
advantage here. There should be avoidance of exposure to all
irritation—coal gas, tobacco smoke, vitiated air, etc.—while absolute
rest of the vocal organs should be prescribed and all attempts at
singing or unnecessary speaking be prohibited. All measures
regarded as of value in general tuberculosis will find an equally wide
field for their activities.
Local treatment is directed toward amelioration of discomfort and
improvement of local lesions. The former may be afforded by steam
inhalations with some soothing, volatile antiseptic added to the
spray, such as methol, oil of eucalyptus, some gentle opiate, or
anything that may give local anodyne effect. Cough may also be
treated by the milder anodynes, of which cocaine or heroine will
serve for most instances. Sleep is to be secured by some of the
ordinary hypnotics. Local applications may be made by an applicator
guided by the laryngoscopic mirror, by the medical attendant, or
through watery or oleaginous solutions in a spray. For absolute local
relief a mild cocaine solution, followed by the use of a very weak
solution of silver nitrate, lactic acid (C. P.), or even the more
thorough treatment of local ulceration by means of the laryngeal
curette or touching with the point of the galvanocaustic loop, may
give relief. The treatment of laryngeal tuberculosis rarely comes
within the domain of surgery proper, until the disease has reached a
degree necessitating some radical measure, such as thyrotomy, with
erasion of the affected tissue, or possibly a laryngectomy, with
complete removal of an organ which is too thoroughly diseased to
warrant hope of repair.

SYPHILIS OF THE LARYNX.

Syphilis of the larynx is more common than tuberculosis, the
lesions usually belonging to the later stages of the diseases,
including especially mucous patches, and the ulcerative expressions,
with or without the formation of small gummatous tumors. The loss of
voice is rarely as pronounced, and the entire course of the disease is
accompanied by less irritative and offensive features than is
tuberculosis. Diagnosis will be materially assisted by the discovery of
suggestive expressions of syphilis, either in adjoining or distant
parts. Thus if mucous patches appear within the larynx they will also
be seen within the mouth. Ulcers which are produced by syphilis
have well-defined edges, and are rarely multiple; while those
produced by tuberculosis are more often multiple, are seated upon
an anemic base, produce more distortion of laryngeal structures, and
more residue of cicatricial tissue at points where healing has
occurred.
Treatment.—The treatment of laryngeal syphilis is essentially
constitutional, for nearly every local expression will
clear up under the influence of properly directed remedies. However,
when local symptoms are uncomfortable or depressing they may be