There are two substances used in medicine and in the arts which

have a proclivity for the tissues of the mouth and jaws. These are

_phosphorus_ and _mercury_, the former usually affecting the bone and

the latter the softer tissues. Before legislation had been enacted

by which the young were prevented from working in match factories

phosphorus necrosis of the lower jaw was not uncommon. Today it is

rarely seen. Again, in the older days when mercury was given in large

amounts, and its effects were not as well guarded against as now,

_mercurial stomatitis proceeding to ulceration_ and even loss of teeth

was not an uncommon event. Now it is seen only in those who have

an idiosyncrasy which makes them peculiarly liable to its effects.

The mechanism of phosphorus necrosis is supposed to be an ossifying

periostitis, with formation of small osteophytes in the alveolar

periosteum, which lower tissue resistance and permit easier invasion of

bacteria from the mouth. (See p. 428.)

The extension of disease from the teeth, especially of the upper jaw,

upward into the _antrum of Highmore_, with its consequent infection, is

elsewhere discussed, and the reader will find the treatment of _empyema

of the antrum_ considered in Chapter XXXVII.

The teeth are also subjects of certain tumor formations which in

general are spoken of as _odontomas_, and have been mentioned in the

chapter on Tumors. (See p. 281.)

Teeth, moreover, show at times excessive development or marked

displacement or defects of development. Thus they erupt in abnormal

positions, or fail completely in eruption, or they project in abnormal

directions or are sometimes amalgamated. The art and science of the

dentist permit of wonderful control of abnormal development of those

teeth which once appear upon the surface. Children whose teeth are

irregularly placed, or which are abnormal in any respect, should be

placed under the care of a competent specialist. The most serious

_tumors of the teeth_ are those connected with _cyst formation_, which

may assume considerable size. A _dentigerous cyst_ is proper material

for the surgeon rather than for the dentist, inasmuch as while the

operation can be usually done through the mouth it may require external

incision and removal of a considerable shell of bone, perhaps with

plastic restoration of tissues.

THE EXTRACTION OF TEETH.

The general practitioner has often to remove diseased teeth as well as

the surgeon. The theory of tooth extraction is simple. Its performance,

especially when the tooth is diseased, may be exceedingly difficult,

for such teeth may be crumbled in consequence of the force needed for

their removal.

_Forceps_ of different shapes are required for the various teeth. At

least half a dozen different patterns are requisite. A form of elevator

is also of use in elevating stumps which may lie beneath the alveolar

border.

The tooth to be removed should be seized along the fang and beyond the

crown. The blades of the forceps should be pressed firmly down and

along the tooth, in order to separate from it the softer tissues of the

gum and the firmer tissue of the alveolar socket. This is thinner upon

its outer aspect than its inner, save in the location of the wisdom

tooth, and it is the outer border which is more easily broken away by

force applied toward the cheek rather than toward the interior of the

mouth. Using first one blade of the forceps and then the other to split

the socket and separate the osteofibrous tissues, the tooth being then

firmly grasped between them, the operator makes a series of rocking

movements, by which it is itself loosened and its further attachments

torn, until by a lifting effort it can be extracted from the socket. In

this minor operation the head must be firmly held with the disengaged

hand, or better between the forearm and the operator’s body, while with

that hand he supports and manipulates the lower jaw, if it be a lower

tooth which is to be removed.

The operation is painful for the moment. With timid patients local

anesthesia may be produced with cocaine or one of its substitutes, the

solutions being sterile, and either locally applied around the socket

or injected into the surrounding tissues with the ordinary hypodermic

syringe needle. Such attempts are not without their own danger, for

I have seen serious infection follow the introduction of unsterile

solutions by dentists not familiar with aseptic technique. Again,

nitrous oxide gas may be administered, it being usually necessary to

employ a mouth-gag. Recovery from anesthesia is prompt and muscle spasm

may not be entirely abolished; therefore, the gag should be inserted

before the gas is administered. It may be sufficient for the purpose to

employ a good-sized piece of cork, to which a cord should be attached

in order that it may not disappear down the patient’s throat during a

violent effort at inspiration. The horizontal position is the safer for

this purpose.

It is especially the removal of fangs or roots which gives the greatest

trouble in these cases. For this purpose special forceps are devised,

but for their use it is necessary to clear away the gum and periosteum

and to cut away a portion of the alveolar process. Such broken

fragments of teeth allowed to remain give rise to curious reflexes,

such as convulsions, neuralgia, etc., all of which makes it apparent

that the extraction of a tooth being undertaken it should be thoroughly

performed. After its removal the patient should rinse his mouth

with water as hot as can be borne, to check hemorrhage. The removal

of the tooth having left an open pathway for infection, antiseptic

mouth-washes should be frequently used and the socket packed with

antiseptic gauze. Except in rare instances granulation tissue fills the

cavity and the process of repair is rapid.

Among the _accidents which may follow extraction of teeth_ are

_hemorrhage_, which may be checked by plugging and the use of

adrenalin. Adjoining teeth are occasionally injured in clumsy

efforts at extraction, while not infrequently a patient who has not

sufficiently described his symptoms has indicated to the dentist the

wrong tooth, whose consequent extraction has, therefore, not relieved

him of his difficulty. Some teeth have such spreading roots as to make

their removal extremely difficult, and even careful operators have

occasionally inflicted fractures, especially of the lower jaw. The

treatment of such an accidental fracture will not be different from

that of fractures otherwise produced. Such an accident as forcing a

tooth upward into the antrum of Highmore should be followed by its

removal, even at the expense of further operation, while excessive

tearing of the alveolar border, or especially of the gum, may be

treated by suitable packing or by suturing. The accident of aspiration

into the larynx of part or all of a tooth just removed has been known

to be followed by suffocation. The operator, therefore, should not

release the tooth from the grasp of the forceps until the latter are

entirely out of the mouth.

By accident or from indifference it may happen that a healthy tooth has

been removed instead of one diseased. Should this happen the tooth may

often be _re-implanted_ after being cleansed, and will usually resume

its previous position and function. So feasible is such re-implantation

of teeth that they have been frequently removed or transplanted from

one mouth to another, for a compensation, a new socket being made for

the reception of the healthy tooth just removed from the mouth of the

individual willing to part with it.

THE JAWS.

While the jaws are not subject to affections peculiar to these parts,

there may be seen in them peculiar expressions of general conditions,

made so by virtue of environment or complexity of tissues. Most of the

acute infections of the jaw bones are propagated from the teeth or the

tooth sockets. There may be _periostitis_ and _osteomyelitis_, and

these may be followed by a sclerosing process or acute suppuration.

The jaws are prone to be thus affected in consequence of the acute

exanthems and the infectious fevers, while the effects of mercury and

phosphorus have been mentioned. The treatment of the inflammatory

affections here is the same as elsewhere, _i. e._, early incision and

complete evacuation of pus, with removal of necrotic bone or other

tissue. Many sequestra may be removed from within the mouth in such a

manner as to avoid disfiguring scars. When external sinuses complicate

the case, incisions through the skin should be made. These may be so

planned as to coincide with the natural wrinkles or folds of the face.

The _temporomaxillary joint_ is a locality of considerable interest.

_Dislocations_ take place here in consequence of blows or of violent

muscular effort, and are easily recognized because of the fixation

and displacement which they produce. Ordinarily they are easy of

replacement. These luxations may be unilateral or bilateral. As

the result of violence the condyle has been driven upward through

the base of the skull, the violence producing such injury usually

being fatal. Aside from these injuries to the grosser structures

the temporomaxillary joint is not infrequently the site of _acute

synovitis_, or more extensive inflammation, usually propagated from

surrounding tissues, but sometimes the result of distant infection.

In phlegmons of this region the structures of the joint rarely escape

a sympathetic participation, while parotid abscess and similar

collections of pus may penetrate the joint and destroy it. Again it

is occasionally the site of a _postgonorrheal arthritis_, or it may

suffer as do other joints after the exanthems and acute fevers. It

also occasionally becomes involved in the disturbances accompanying

irregular eruption of the last molar, _i. e._, the wisdom tooth; in

other words, it may suffer just as may any other joint in the body, and

from similar causes.

_Ankylosis of the temporomaxillary joint_ is an infrequent result of

its involvement in serious disease, or may result from lesions of the

adjoining tissues, as from the cicatricial deformity following noma,

burns, and the like. Thus we may have either a true or a spurious

ankylosis of this joint, in either case the resulting condition being

intractable and exceedingly difficult to manage. When it can be

foreseen as a consequence of extrinsic disease it may be prevented by

the insertion of a mouth-gag, and more or less frequent and forcible

stretching, or by wearing some suitable apparatus between the teeth

which shall keep the jaws apart, and which may be used at night. A

pseudo-ankylosis produced by cicatricial bands, and long neglected,

will become genuine, and require as radical an operation as though it

had been interosseous from the outset.

For the relief of such conditions various operations have been devised,

in each of which the formation of a false joint is contemplated,

it depending upon the exigencies of the case whether this shall be

produced by the _division of the horizontal ramus in front of the

masseter_, or of the _ascending ramus behind the masseter_, or whether

there shall be actual _resection of the temporomaxillary joint_, with

division of the neck and removal of the condyle. The latter procedure

is the more ideal, at the same time the more difficult, and the more

likely to permit injury to the branches of the facial nerve, with

consequent paralysis of the orbicularis and the facial muscles.

I have elsewhere described a peculiar condition of _relaxation of the

temporomaxillary ligaments_, by which there is a recurring subluxation

of the joint, noticed most often during eating and accompanied by

a snapping sound. This is usually unnoticed by the patient, but is

often observed by others. It is painless, harmless, and not ordinarily

amenable to treatment. (See p. 528.)

_Tumors of the jaws_ proper include mainly _cysts_, which are often

connected with odontomas, _benign tumors_, such as fibroma, chondroma,

and osteoma, most often of mixed type, and the _malignant tumors_, _i.

e._, sarcoma, carcinoma, and endothelioma. Malignant tumors primary

to the bone are usually of sarcomatous type, though these may include

the endotheliomas. Carcinoma and epithelioma do not originate in bone

texture, but may easily spread to and involve it. Thus many cases of

advanced epithelioma of the lip involve the bone as well as the other

neighboring tissues.

_Epulis_ is a somewhat vague term, which has been applied to tumors

which spring from and mainly involve the fibrous texture of the gum

and the periosteum covering the alveolar process. The term itself

simply implies a tumor upon the gum. Microscopically these tumors are

usually of the giant-cell type of fibrosarcoma, and are among its least

malignant varieties. They pursue a slow course, gradually loosening one

tooth after another as they invade the tooth sockets, show very little

tendency to spread rapidly, and are usually sharply circumscribed

growths, tending to ulceration. They seem to be products of irritation.

When removed they rarely recur. The surgeon should excise involved

tissue in order to be on the safe side, sacrificing teeth, gum, and

alveolar process as widely as necessary for the purpose. Formerly

the _epulides_ were made to include different expressions of fibroma

and sarcoma involving the gum, but the name is so vague that it

would be better to speak of each of these cases as its histological

characteristics may indicate.

Benign tumors involving the entire bone may necessitate its removal,

but most of the dentigerous bone cysts may be laid open, their contents

evacuated, their size reduced, and the remaining cavity allowed to fill

with granulation tissue; while malignant tumors call for sacrifice of

every portion of tissue involved, often including the skin, and in the

upper jaw much of the complicated structure of the nasal cavity, or in

the lower jaw the loss of the tongue or a large portion of the floor

of the mouth. A cancer of the lower jaw may be removed, with permanent

good result, but a true cancer of the upper jaw should be seen early

and mercilessly extirpated if the result is to be more than temporary.

OPERATIONS UPON THE JAWS.

Aside from those already mentioned the principal operations upon the

jaws consist of _partial_ or _complete excision_.

_Removal of the upper jaw_ is a rather formidable procedure, frequently

made so by extent of the disease which requires its performance.

The presence of an extensive and ulcerating tumor, by which normal

anatomical outlines are obliterated, will cause mechanical difficulties

as well as unusual liability to hemorrhage. During some portion of its

performance a temporary control of the vessels of the neck may be of

assistance. This can be usually afforded by external digital pressure.

In serious cases a ligation of the external or the common carotid

may be of assistance. If soft, vascular tumors protrude into the

nasopharynx a _preliminary tracheotomy_ should be performed, tamponing

the pharynx in order to prevent escape of blood down the throat. The

position of the patient with the down-hanging head may be also of

assistance in these cases. Of the various incisions employed one should

be selected according to the nature of the case. Most of the operations

include a splitting of the upper lip near the middle, with continuation

of the incision along the margin of the nose, upward toward the

orbit and outward along the orbital border, as originally suggested

by Fergusson. This permits of completely raising the cheek from the

underlying bone in one extensive flap and turning it backward, with

complete exposure of the anterior surface of the superior maxillary.

The operator next proceeds according to the desired extent of removal.

If the roof of the mouth is to be sacrificed the osteoperiosteal and

soft tissues composing the palate should be divided as far from the

middle line as may be permitted, then reflected, and the bone divided

with chisel or with cutting forceps. It may be necessary to remove one

of the incisor teeth to permit the insertion of the chisel for division

of the anterior part of the jaw. Bone forceps or a chain or wire saw

will serve for division of the zygoma and the external or lower wall

of the orbit, while with chisel or forceps the nasomaxillary region

is divided. The loosened bone can now be seized with strong lion-jaw

forceps and wrenched from its attachments, which may then be divided

with scissors or knife as they are encountered (Fig. 474).

[Illustration: FIG. 474

Resection of superior maxilla. (Farabeuf.)]

Hemorrhage will be profuse at this juncture, when the internal

maxillary artery is, with many of its branches, thus torn across or

severed. The surgeon should be ready with tampons and forceps to check

the bleeding and secure the vessels. The complete Fergusson operation

includes removal of the entire upper maxilla, but oftentimes much less

than this will suffice. On the other hand it is necessary sometimes

to go still farther and remove more bone from the orbit or the nasal

cavity, or perhaps to clean out the orbit entirely. A case which

necessitates one of the more formidable operations is too unpromising

to make it often judicious to perform it.

When the tumor involves the overlying skin this should also be

sacrificed, and a plastic operation should be made to cover the defect.

The skin flaps required for this purpose may be taken from the temple,

the forehead, the neck, or adjoining parts of the face.

Bardenheuer has suggested the raising of osteoplastic flaps for removal

of tumors lying within the jaw, and their replacement at the conclusion

of the operation. He has also devised ingenious methods of making

immediate plastic repair which are worthy of study, but which are so

seldom required as to not justify description in this place.

After operation the bleeding should be checked by torsion, by ligation,

by sutures _en masse_, by application of hot water, and by securely

tamponing with antiseptic gauze, by whose pressure oozing is checked

and protection from infection afforded. The patient is allowed to sit

up as early as possible, meanwhile being made to lie upon the affected

side in order to avoid danger of aspiration pneumonia, and using an

antiseptic mouth-wash with relative frequency.

It is sometimes possible to perfect an artificial substitute for

tissues removed, which can be inserted after the operation. The loss of

tissue will cause more or less disfigurement by sinking in of the cheek

and side of the face. After the parts are healed an apparatus made of

gutta-percha or metal, and adapted to each case, by which most of the

lost symmetry may be restored, should be worn, in the same manner as an

artificial denture.

The _lower jaw seldom requires complete removal_. It is rarely

necessary to go so high as the joint or the coronoid process, although

occasionally the condyle must be avulsed and the coronoid either cut

away or its temporal tendon detached. Most of the exsections in this

location are confined to some portion of the horizontal ramus. Except

in rare instances it is not possible to make a complete excision

of the lower jaw through the mouth, and nearly all operations are

practised through external incision, carried along the lower border for

a sufficient length, and extended upward along the posterior border

beyond the angle, if necessary. In most instances the facial vessels

are directly exposed and should be secured before division. Masseteric

attachments are separated and the instruments are kept as near to the

bone as the circumstances of the case will justify. In well-marked

ulcerating cancer, however, the surgeon should go nearly an inch beyond

its apparent border and remove still more if it be visible, taking

everything which seems involved. Here the bone is usually divided with

a chain saw, although stout cutting forceps may suffice. It may be

necessary to remove a tooth in order to clear a place for the action of

the chain saw. Growths involving the skin necessitate not merely linear

incisions, but extensive oval excisions of the overlying tissues.

All the involved structures should be removed in one mass; if it be

necessary to remove the floor of the mouth the divided bone section is

seldom cut away until it can be removed with the rest of the tumor.

The healthy mucous membrane should be preserved and brought together

with catgut sutures at the conclusion of the operation, as the more

carefully the cavity of the mouth can be shut off from the balance of

the wound the more prompt and satisfactory the healing (Fig. 475).

[Illustration: FIG. 475

Resection of inferior maxilla. (Farabeuf.)]

In a few cases it may be possible by the use of stout silver wire, or

some other substitute, inserted between bone ends to keep them apart

and thus nearly preserve the contour of the lower part of the face; but

this can be expected to succeed only when the cavity of the mouth can

be completely closed, so that the wire or other material may be quickly

incorporated in granulation tissue, where it is expected to remain.

When it is necessary to remove the joint end of the bone the operator

should work carefully along the bone toward the joint in such a way

as not to injure the facial nerve, the external maxillary artery, or

Stenson’s duct. With a sharp separator it is possible to thus expose

the joint, and after opening it to avulse the articular surface. In

operating for necrosis the healthy periosteum should be preserved,

while in the removal of cancer it should be sacrificed to the same

extent as the bone itself.

The same rules apply here as above with reference to the closure of the

wound and the construction of flaps; an extensive plastic operation

being sometimes necessitated, as when a large portion of the lower

lip, the chin and the bone are removed for extensive epithelioma. Dead

spaces should be avoided, any cavity should be packed sufficiently,

opportunity for drainage afforded, and the mouth cavity closed.

Mouth-washes should be frequently used.

These cases should be prepared for operation by a careful cleansing

of the mouth and the local use of antiseptics. During any of these

operations, diseased teeth which may require it should be removed,

whether they occupy the site of the operation or some other portion of

the jaws. The cleaner the mouth the more prompt will be the healing

process.

CHAPTER XLI.

THE RESPIRATORY PASSAGES PROPER.

MALFORMATIONS OF THE RESPIRATORY PASSAGES.

The _congenital malformations_ of the upper respiratory passages

pertain mainly to the nasal septum and the interior of the complicated

nasal cavities, which are rarely symmetrically arranged, and which

often differ considerably. The _nasal septum_ is frequently deviated

or warped to one side, often to an extent making one nostril too

restricted for easy breathing purposes. The _nostrils_ are occasionally

seen to be abnormally retracted. Malformations of the _pharynx_ are of

rare occurrence. The _soft palate_ is occasionally found to be more of

a diaphragm than is natural, and _imperforation_ is sometimes seen.

_Pharyngeal fistulas_ have been mentioned in connection with incomplete

closure of branchial clefts. They occur more commonly on the right than

on the left side, and are usually incomplete. A _fistula_ placed in the

middle line and opening into the larynx or trachea is also occasionally

seen, its inner opening being generally found on the side of the

pharynx and just below the tonsil. This is not necessarily a persistent

remains of the thyroglossal duct, but may have a different origin.

_Cystic distentions_ not infrequently occur along these fistulous

tracts. Malformations of the _larynx_ are rare and consist mainly of

narrowings or stricture formations.

_Acquired malformations_ of the respiratory passages are common and

are the result usually of previous disease or injury. They may assume

the _obstructive type_, as when the tonsils or the other adenoid or

lymphoid tissues of the nasopharynx become hypertrophied, or they

may assume the _constrictive type_, as when strictures result from

ulceration, produced either by disease or by caustics. Such diseases

as diphtheria cause not only paralyses, through the nervous system,

but cicatricial deformity in consequence of ulceration. The latter is

also true of burns, while fractures may permanently displace parts,

this being particularly true of the nose, but holding good also for the

hyoid, and even for the larynx. Nearly all these malformations permit

of more or less surgical improvement by operations, some of which are

simple and easy of performance, while some will need the highest degree

of trained skill.

=Ozena.=--Ozena is a general term applied to ulcerative lesions,

especially involving the Schneiderian membrane in the nose, and

causing more or less discharge of mucus, pus, and crusts, nearly

always offensive, and accompanied by evidences of deeper ulceration,

involving the fragile nasal bones or the nasal septum, and constituting

expressions of caries or necrosis in this region. Ozena may be the

consequence of a milder catarrhal inflammation, occurring in patients

of vitiated constitution and bad habits of life, with insufficient

attention or no care whatever. Another type of ozena is from the

beginning of _syphilitic_ origin, and it is especially the syphilitic

cases which present the most offensive types of lesions, yet which are

the most satisfactory to treat, because of the relative certainty with

which they yield to properly directed treatment. Any case characterized

by profuse and offensive nasal discharge, in which by suitable

illumination and examination ulcerations can be detected, should be

considered ozena.

=Treatment.=--The treatment for all these cases should consist of

local cleanliness, alkaline solutions in spray or by irrigation

being especially indicated because of their cleansing properties.

Warm sterilized salt solution may also be used for the same purpose.

All visible ulcerations should be treated by local applications of

mild silver nitrate solutions, or some other combined antiseptic and

stimulant; or these may be alternated with local applications of an

ointment of the yellow oxide of mercury in strength of 0.5 to 1 per

cent. Local treatment, however, is but a part of that which should

be instituted. In every case where the syphilitic element can be

recognized, or where there is good reason for even suspecting it,

vigorous antisyphilitic treatment should be begun and prosecuted.

While these cases nearly always need one of the iodides, administered

internally, there is no way of so quickly bringing them under the

desired influence as by inunction with the ordinary mercurial

ointment. Both measures should be carried along simultaneously until

the combination proves to be too active, when the inunction may be

discontinued.

In addition to these measures such cases need improvement of

elimination and of nutrition, and the best restorative tonics may be

combined to advantage with any other special medication which may seem

to be indicated.

FOREIGN BODIES IN THE RESPIRATORY PASSAGES.

Nowhere, except perhaps in the ear, are foreign bodies more likely to

find entrance, and become impacted, than in the respiratory passages.

They are introduced either through the nose or the mouth. They consist

of almost all imaginable substances, introduced either by accident or

design, and belonging to all three kingdoms--animal, vegetable, and

mineral. According to their nature, size, and lodging place, symptoms

of more or less severity will ensue. Migratory bodies, especially small

insects and parasites, may escape from the nasal cavity into one of

the accessory sinuses, where they will give rise to great irritation,

and necessitate perhaps serious measures for relief. The presence of

a foreign body is not always promptly recognized. In some instances

it is discovered only by accident, as when, having been present for

some time, it has produced irritation, with or without ulceration and

offensive discharge. Thus a shoe-button may have been pushed up the

nose of a little child, and remain there undetected for some time,

perhaps to be spontaneously extruded in the act of blowing the nose.

The presence of a foreign body in the nasal passages, then, will be

manifested by symptoms of obstructed nasal respiration and by other

evidences of local irritation, with pain, tenderness, swelling, and

discharge.

An object easily seen is ordinarily easily removed, unless it has some

peculiar shape which impedes its easy withdrawal. Local cleanliness is

the first prerequisite, and then in most instances local anesthesia,

which may be produced with cocaine or one of its substitutes. After

this a probe, bent into the shape of a blunt hook, or forceps of

various patterns and shapes may be required, and will usually suffice

for all ordinary cases which can be detected by inspection through the

nostrils or with the rhinoscope. In more difficult and unusual cases

the fluoroscope or the skiagram may be made to render great service.

Should some larger object be found, particularly in the antrum, deeply

within the cranium, then a more formal operation will be demanded,

whose details should be made to suit the needs of each individual case.

When a mass of inspissated secretion or of granulation tissue more or

less conceals the outline of the foreign body, everything should be

cleaned away with irrigating spray, or with cotton wrapped around a

probe or held within the forceps.

=Calculi.=--A rare condition of _calculus formation_ is occasionally

met with in the nose, the concretions being formed by precipitation

of the mineral elements from the nasal mucus, and constituting the

ordinary _rhinoliths_. These become, in effect, foreign bodies, and

are to be recognized and treated as such. After syphilitic ulceration

portions of bone may be loosened spontaneously, and dropped into

locations where they are caught instead of being spontaneously expelled.

It is known, also, that, especially in tropical climates, there are

several species of _insects_ which enter the nostrils and there deposit

their _eggs_, which later are hatched into the resulting _larvæ_, the

latter sometimes being expelled, or perhaps developing and burying

themselves further within the nasal recesses. Any living organism may

be killed by administration of chloroform or ether, and then expelled

as an ordinary foreign body; or, in most cases, such larvæ or eggs can

be washed away with an irrigating stream to which a little extract of

tobacco should be added. Thus maggots have been found buried within

the nasal mucosa, and requiring extraction by means of forceps. When

larvæ have invaded the sinuses the case becomes more serious, for it

will require free exposure by perhaps a somewhat formidable operation

on the interior of the sinus, which should then be carefully cleansed

and suitably drained. Living organisms within the nasal cavity or the

sinuses will cause headache, lacrymation, sneezing, nasal discharge,

perhaps with epistaxis, and almost every possible expression of local

discomfort.

=Foreign Bodies in the Pharynx.=--Foreign bodies in the pharynx are

usually, when small, lodged in the neighborhood of the tonsil, or

caught in the lymphoid tissue of the tonsillar ring. According to their

size they may become impacted at almost any point, and may even cause

suffocation. They may be detected sometimes by the finger alone, or,

at other times, only with good illumination and local anesthesia. The

irritation which they produce leads to frequent acts of swallowing, the

latter always exaggerating the former. Such objects as small fish-bones

and the like, which may cause irritation, may easily escape or defy

detection; moreover, such objects may be multiple.

For the sake of comfort pellets of ice may be frequently swallowed and

cocaine may be used locally. Their _extraction_ should be promptly

practised. In rare instances emergency may call for prompt tracheotomy,

but this is rarely the case unless the object be impacted below the

epiglottis. Curious instances of impaction in the nasopharynx, of

strange foreign bodies, have required the administration of anesthetics

and even serious cutting operations for their removal, by combined

manipulation through the nostril and the oropharynx. Such bodies,

however, can be in some way always removed.

Liquids may be aspirated through the nose, and cause strangling attacks

of coughing. They are then more easily drawn into the larynx or

trachea, where they will cause reflex phenomena and actual obstruction,

according to their nature. Again by free inhalation of steam, natural

or superheated, burns and scalds of the respiratory passages may

be produced, which will be followed by edema of the glottis or by

pneumonia. The inhalation of extremely strong vapors, like that of

ammonia, may cause spasm of the glottis. The entrance of blood, as

from rupture of an aneurysm, or of pus, as from a bursting abscess, or

the escape of pus from one side of the chest into the other lung by

way of the trachea, may cause serious symptoms or may produce actual

suffocation. In operations for pyopneumothorax, for instance, with one

side of the chest well filled with pus, one should be careful to avoid

turning the patient in such a way that pus may run over into the other

lung and thus suffocate him. I have seen death occur on the operating

table from this cause, in spite of every precaution, when the accident

itself had been anticipated.

Solid objects may be of all shapes, sizes, and materials; living

insects are occasionally aspirated and may not be at once killed, the

local irritation caused by their presence producing intense spasm of

the glottis. I have personally known of two cases of suffocation in

restaurants, where men eating hastily died as the result of impaction

of pieces of meat within the rima glottidis. Again, bodies may pass

beyond the glottis proper and enter the trachea, or even one of the

great bronchi; shoe-buttons, for instance; and in one case in my

knowledge a small hat-pin passed down and was only removed after a

low tracheotomy and careful search, aided by a skiagram. Owing to the

anatomical arrangement the right bronchus is more frequently entered

than the left. Immediate danger of suffocation, of obstruction, or

spasm having passed, there is still serious menace from _pneumonia_,

with or without abscess or gangrene of the lung. Such condition

occurring in a young child, in the absence of the history of passage of

a foreign body, may cause some difficulty in diagnosis. The greatest

help would be afforded by the use of the Röntgen rays, although the

laryngoscope alone will sometimes be sufficient. To use the latter to

advantage it will probably be necessary to allay local irritation with

the cocaine spray. (See Figs. 476 and 477.)

=Treatment.=--Treatment should be operative, although in some cases

it is sufficient to invert the patient and slap him on the back. With

an object impacted in the glottis relief may be afforded with the

finger, but this may be exceedingly difficult, for in the later stages

of suffocation the jaw may be convulsively shut and it will be almost

impossible to effect entrance. In such case the jaw should be hastily

pried open and the index finger carried down behind the base of the

tongue, lifting the epiglottis and dislodging the object. If this fail

and respiration have ceased, attempt should be made to hastily open the

trachea, even with the blade of a penknife, and to follow this with

artificial respiration. Under these circumstances the vessels of the

neck will be engorged with venous blood, which will escape freely; this

may, however, be disregarded, the primary indication being to get into

the trachea, which may be held open by turning the knife-blade at right

angles, while artificial respiration is practised, and until a couple

of hair-pins, for instance, can be secured, bent into shape of blunt

hooks and made to act as temporary retractors. This is an illustration

of what may be done in emergencies.

[Illustration: FIG. 476

Toy-pin (actual size) removed by external pharyngotomy from pharynx and

esophagus of a two-year-old child. Recovery. Skiagram by Dr. Plummer.

(Buffalo Clinic.)]

[Illustration: FIG. 477

Skiagram of Fig. 476.]

On the other hand these operations should, when possible, be done

deliberately and with local anesthesia. Foreign bodies should be

located with the laryngoscope, after which they may be removed with the

aid of the illumination thus afforded, or by mere sense of touch. _An

object impacted in the larynx proper_ may be extracted by _thyrotomy_,

whereas when it has passed below the larynx it will be necessary to

open the trachea, perhaps even low down, making more than an ordinary

opening for purposes of manipulation. Numerous forceps have been

devised for these purposes. Roaldes reports having removed a piece

of impacted iron from the bifurcation of the trachea, by means of a

powerful _electromagnet_.

In the ensuing chapter there will be mentioned a method of exposing

both the trachea and the esophagus by posterior incision or resection

of the thoracic wall.

[Illustration: FIG. 478

Tack in bronchus of young child, removed after a low tracheotomy. Case

of Dr. Parmenter’s. Skiagram by Dr. Plummer. (Buffalo Clinic.)]

INJURIES TO THE RESPIRATORY PASSAGES.

Besides those inflicted by _foreign bodies_ injuries may be produced

here from external conditions, _gunshot wounds_, _fractures_, and a

variety of causes which need not be specified. The inhalation or the

entrance of violent _caustics_, either fluid or volatile, may produce

edema at least, or actual destruction of tissue. The glottis, being the

narrowest portion of the respiratory tract, offers the greatest danger

under conditions of obstruction, and fatal dyspnea may ensue. Thus, for

instance, _burns_ caused by inhaling _steam_, or hot vapors or _flame_,

will be followed by most intense reaction, often extending beyond the

trachea and to the air cells. Edema will be prompt, while pain, shock,

dyspnea, and loss of voice will be instantly produced. If the patient

survive the early complications he may succumb to pneumonia or other

disastrous sequels in the lungs.

=Wounds of the Larynx.=--Wounds are nearly always complicated by other

injuries of the neck or face, which may involve vessel or nerve trunks

of primary importance. Moreover, such wounds are mostly infected and

lead to extension of phlegmonous involvement, which may later cause

mediastinal or deep cervical abscesses, and all sorts of septic and

pyemic complications. Even when recovery ensues cicatricial contraction

may produce laryngeal or tracheal stenosis, with defective voice, or

sometimes _fistulas_, connecting usually with the trachea.

=Treatment.=--In the treatment of such wounds provision should be

made for drainage, and it is seldom advisable to make too accurate a

closure lest its very intent be thereby defeated. Unless the patient

be suffocating the first indication is to check hemorrhage, then to

cleanse the wound, and later to make such approximation of its surfaces

as the case may permit. Occasionally in order to obtain a good result

in the upper part of the respiratory tract it would be good practice

to make a tracheotomy below. At other times an O’Dwyer tube may be

inserted.

The occurrence of edema may be prevented, or at least its severity in

a measure controlled, by the use of adrenalin solution, 1 to 10,000,

while the local use of mild cocaine solutions will be frequently

indicated, in order to check irritability and the reflex phenomena to

which it will lead. Local symptoms may also be combated by inhalation

of vapor, with soothing solutions, such as weak preparations of

cocaine or of one of the opiates, followed by mild astringents and

antiseptics--tincture of benzoin or oil of eucalyptus, or some of their

equivalents, being nebulized and used in a spray. Opiates internally

should be prescribed; while with delirious, drunken, or maniacal

patients every effort should be made to secure physiological rest and

to subdue restlessness or frenzy.

=Fracture of the Larynx.=--Fracture of the larynx is a somewhat

uncommon accident, due to direct violence, which may instantly

precipitate symptoms of the greatest severity. It may be simple or

compound, the thyroid being obviously most often involved and the

cricoid next. These injuries will occur more frequently in the aged,

in whom the external cartilages of the larynx are prone to calcify and

thus become more brittle. A fracture of the larynx precipitates extreme

danger of suffocation, either from displacement or edema, and will

usually require a prompt tracheotomy, which may be performed with a

penknife in the absence of any better instrument. It may be indicated

also by expectoration of bloody mucus, with froth, with stridulous

respiration, dyspnea, pain--which is increased by pressure or motion,

as in swallowing--and the local indications of injury. Thus death has

occurred upon the field during a game of baseball, from a direct blow

of the ball upon the larynx, no one who knew sufficient to perform it

reaching the patient in time to do an emergency tracheotomy as above.

Edematous laryngitis, which is not sufficiently serious to call for

operation, is characterized by dyspnea, aphonia, dysphagia, cough,

laryngeal irritability, and by more or less chemosis and congestion of

the mucosa. The specialists treat certain of the milder forms of this

condition by local scarification (_i. e._, with a knife made for the

purpose), in order that by considerable local hemorrhage the vascular

engorgement may be relieved.

NASAL DEFORMITIES.

These consist in large measure of deviations of the nasal septum,

with or without turbinate hypertrophy, due to previous disease of

the Schneiderian membrane, and followed by thickening and structural

change. Nasal deviations are either of _congenital_ or _acquired

origin_. An absolutely symmetrically arranged and divided nasal cavity

is a rarity. Thus, though one side is rarely a replica of the other,

deviations which are sufficiently marked to cause nasal obstruction

are commonly the result of rapid or slow disease. They will be seen in

connection with other body deformities by which the head is habitually

held in an abnormal position, so that growth in one direction is

thereby favored. Such conditions may be caused either by irregularities

of vision, by enlarged tonsils, or by spinal deformities.

The _acquired deviations_ are frequently the result of injuries, not

necessarily of those sufficiently severe to produce fractures. The

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.

[Illustration: 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.

[Illustration: 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 treated as are

those of tuberculosis, by soothing sprays and the local application of

anesthetics, astringents, and the like.

INTRALARYNGEAL AND INTRATRACHEAL TUMORS.

Within the larynx tumors may occupy the space beneath the glottis,

where they are referred to as _subglottic_; they may grow from the

structure of the vocal cords and become _intraglottic_, or they may

spring from above the glottis and from the aryteno-epiglottic fold.

Certain forms of benign tumor are relatively common in this location,

while others are almost unknown. The former include cysts, papillomas,

fibromas, angiomas, and adenomas, as well as the ordinary granulomas.

A nodular lesion seen upon the vocal cords, especially in singers,

which is hyperplastic in character, irritative in origin, and often

called “_singer’s node_,” is frequently found upon the edges of the

cords, either as a single or bilateral lesion. The adjoining structures

are usually quite vascular. These lesions occur in those who abuse

their voices, as, for instance, in amateur singers and newsboys. The

nodules themselves vary in size from that of a pin’s head to that

of a split pea. The condition produces hoarseness and impairment of

the voice, is recognized with the laryngoscope, and is amenable to

treatment, which should consist in absolute rest from vocal effort and

gentle astringent and stimulating applications. If the node project

very far it may be removed by the intralaryngeal guillotine.

_Laryngeal polypi_ include the forms of benign tumor above mentioned,

most of which assume in time a polypoid form, and cause impairment of

function according to their location.

[Illustration: FIG. 481

Multiple papilloma of larynx. (Bergmann.)]

_Papilloma_ is by all means the most common of these growths, and may

present either the vascular type, bleeding easily and growing rapidly,

or the firmer and denser type from admixture with fibromatous tissue.

It occurs frequently in the young, and may even be present in the

newborn. Here it can scarcely be detected with the laryngoscope, but

may be felt with the finger. _Cysts_ take their origin from the mucosa,

save those which, possibly of embryonic character, protrude into or

encroach upon the larynx from without (Fig. 481).

=Symptoms.=--The symptoms of benign intralaryngeal growths are largely

irritative, including cough, with hoarseness and change of voice, and

going on to production of dyspnea in proportion to the size which they

attain. Later complete aphonia, with spasm of the glottis, may be

the result of their presence, while pedunculated growths, or polypi

with long pedicles, may cause aggravated symptoms by circumstances

of position, the patient being much of the time relatively free.

Hoarseness, dyspnea, and cough, without other evidences of inflammation

or epidemic disease, should always lead to careful inspection with

the laryngoscope, and this will reveal the size and situation of

the growth. These examinations can be made with cocaine and give

satisfactory information. Only in young children are they difficult, or

sometimes impossible. Even in an infant with a hoarse cry and spasmodic

or suffocative attacks the condition may be suspected.

=Prognosis.=--The prognosis will depend upon the character of the

tumor and the local conditions--_i. e._, size, fixation, location,

etc. In the young it is serious because of the danger attending its

removal. Rational adults can be usually put in excellent condition for

endolaryngeal operation by the aid of local anesthesia, and expert

specialists become dexterous in their manipulation of the specially

shaped forceps, curettes, and the like which are required for removal

of these growths. As elsewhere a truly innocent tumor in this location

does not recur after complete extirpation.

MALIGNANT TUMORS OF THE LARYNX AND TRACHEA.

Of these tumors the most common is _epithelioma within the larynx_.

_Sarcoma_ occasionally originates from the vocal bands, true or false,

and will usually form a nodular tumor, of rugose surface, until it

begins to ulcerate. Once it begins to break down it is difficult to

distinguish from the other varieties without the aid of the microscope;

but epithelioma may be met with in any part of the larynx, generally

arising from the ventricular bands. Here, as ordinarily upon mucous

surfaces, it begins as a small nodule with a definite zone of

infiltration about it; if seen early it may be mistaken for innocent

papilloma. As infiltration progresses the hoarseness resulting from its

presence will change to loss of voice, because of the fixation of the

tissues whose mobility is essential to voice production. Pain may be an

early feature, depending upon ulceration and exposure of sensory nerve

endings. Later when the ulcerated surface has become deep, irregularly

covered with fetid discharge, and more or less concealed by edematous

surroundings, the picture is more complete in one respect, although

the details may be obscure. From the mucous and softer tissues the

disease will spread and invade the cartilages themselves, as well as

the tissues outside, and so with the progress of the cancer the entire

larynx becomes fixed in a bed of infiltrated tissue extending in all

directions, involving the upper part of the trachea, the epiglottis,

and the base of the tongue. Meantime the loss of voice, the distressing

cough, and the other evidences of local invasion will have kept pace

with the progress of the disease, and dyspnea will come on sooner or

later as the passage-way becomes blocked, while from sudden, violent

efforts at coughing acute attacks of edema, which may result fatally,

are liable to occur.

_Tumors of the trachea_ proper are far less common. They may be benign

or malignant. In either event they will prove to be of about the same

type as those already discussed above as occurring within the larynx.

They cause less interference with speech, but as much or even more

difficulty in respiration.

When tracheotomy was a frequent resort in croup and diphtheria a

peculiar form of new formation in the trachea was occasionally

encountered, resulting from the irritation of the trachea tube, whose

presence sometimes provokes excessive formation of granulation tissue,

whose subsequent contraction brings about not only the formation of

a dense granuloma, but cicatricial contraction. Hence in the older

literature references to _granulation stenosis_ were common. Now

that intubation has almost completely replaced tracheotomy for these

purposes the latter is rarely performed, and tubes are seldom left more

than a day or two _in situ_, so that this kind of local provocation,

with its consequences, is rarely encountered.

It may be possible by expert use of the laryngoscope to see a tumor

located within the trachea. If the patient cannot tolerate its use the

parts may be made tolerant by the use of a weak cocaine spray. Such a

growth, if accessible from above, may be removed through the glottis

by forceps. Most operators, however, prefer to make an opening through

the trachea and thus profit by the larger surgical opportunities thus

afforded. Such an operation should be made with the patient’s head low

in order that blood may gravitate to the pharynx rather than to the

lungs.

OPERATIONS UPON THE LARYNX.

Cancer of the larynx was regarded, until the last quarter of the

previous century, as an absolutely hopeless condition for which

nothing could be done until it became necessary to do a tracheotomy,

this simply affording relief from some of the distressing features,

but aiding nowise to check the progress of the growth. The first

demonstration of the possibility of successful removal of the larynx

was made by Czerny, in 1870, upon dogs. Watson, of Edinburgh, had

removed a syphilitic larynx _in toto_ in 1866, but this summary

operation only became known to the world through a publication of

Foulis in 1881. Meantime, Czerny’s experiments were so successful

that Billroth was induced to attempt the removal of the entire larynx

in a case of cancer, with results which astonished the profession

of that day. Thus introduced, nevertheless, the mortality rate was

great, the principal cause of death being inspiration pneumonia--that

is, rapid infection of the lung through the widely opened trachea and

the entrance of saliva and fluids from the mouth. Hahn, of Berlin,

undertook the improvement of the technique and was able to reduce the

mortality from this cause. Meantime another radical method--namely,

_thyrotomy_, _i. e._, opening the laryngeal box--had not fared much

better than the measure just mentioned. Thus until about twenty-five

years ago the radical treatment of laryngeal cancer stood in an

unpleasant light, partly because diagnostic methods were unsatisfactory

and our general knowledge of the disease incomplete, partly because

operation was always delayed until late, and because operative measures

had yet to be much improved. Tremendous impetus was given to the

whole subject by the celebrated case of the Emperor Frederick, and

the acrimonious criticisms concerning its conduct were not without

benefit, since they led to a careful re-study of the whole situation,

with its numerous subsidiary questions, among which was the possibility

of transformation of a benign into a malignant tumor. At present,

largely through the labors of Hahn and Billroth, in Germany, and Semon,

in London, the question of operative procedures is fairly settled,

everyone now believing that the disease should be radically attacked at

the earliest possible moment, opinions differing only in regard to the

route which the surgeon should adopt, _i. e._, whether he should make

an intralaryngeal operation, as is now favored in Germany; a thyrotomy,

as preferred in Great Britain, or a laryngectomy, as some of the

general surgeons in all parts of the world prefer.

The different methods of attack upon the larynx for cancer may then

be summarized as including _intralaryngeal extirpation_ through the

natural passages, _thyrotomy_, and partial or complete _laryngectomy_.

The _intralaryngeal method_, seen from the general surgeon’s

view-point, can only be suitably applied to a limited class of cases

which are recognized early, and may be best performed by an expert

laryngologist, _i. e._, one accustomed to instrumentation within the

pharynx and larynx. It includes the use of various instruments for the

excision of small areas, for the application of the galvanocautery,

etc. The writer agrees with Semon in regarding it as irreconcilable

with the principles which should guide us in dealing with malignant

growths, the fundamental one being the removal not only of the growth

itself but of an area of surrounding tissue. This intralaryngeal method

may then be satisfactory in the removal of benign growths, but will

seldom appeal to the operating surgeon when he deals with cancer.

Epithelioma may commence at the accessible tip of the epiglottis, but

intrinsic cancer of the larynx should be dealt with in a more radical

manner. Thyrotomy is the operation of choice, especially among the

British laryngologists. It seems rational to believe that in cases

where diagnosis is made early a thyrotomy, with removal of the growth

and a wide area of surrounding tissue, including portions of cartilage,

if necessary, may prove the ideal operation, while vocal results are

better than after extirpation. It is necessary, however, that diagnosis

should be made early and that operation be made thoroughly; while if,

after opening the thyroid, it should appear that complete extirpation

of the growth is otherwise impossible, then the operator should make a

complete laryngectomy.

All of these operations are best preceded by use of a cocaine spray, by

which extreme irritability of the interior of the larynx is allayed,

and the reflex lowering of blood pressure prevented. (See p. 178.)

_Thyrotomy is performed as follows_: The patient is preferably in

the position with down-hanging head. An incision in the median line,

about three inches in length, is made from the upper border of the

thyroid cartilage down to a point below the cricoid. With but slight

separation of the tissues it is made to extend directly down upon the

abrupt ridge-like anterior border of the thyroid cartilage, below

which will be exposed the cricothyroid membrane. Into this the knife

may be inserted and made, with cutting edge up, to split the halves

of the larynx exactly in the middle line, the blade passing between

the vocal cords, unless they have been much distorted by the growth.

In that case the dissection may be made more deliberately. The larynx

being thus split, the cricoid should be divided, after which, with

suitable retractors, the interior is exposed to such an extent as to

permit both inspection and palpation. Through the opening thus afforded

all suspicious tissue should be removed, from one side or both, the

primary question being not what will be the resultant effect upon the

voice, but how best to completely eradicate the cancerous tissue. With

the patient’s head hanging downward there is less likelihood of the

entrance of blood into the trachea. Nevertheless the _tampon cannula_

should always be accessible so that it may be inserted should it be

required. The tampon cannula is a trachea tube around which there is a

small rubber bag, with a tube through which it may be inflated, so that

after the cannula is introduced into the trachea it may be tamponed by

air pressure in such a manner as to permit no passage of blood.

In the absence of one of these specially designed tubes an effective

substitute may be made by the ordinary trachea tube wrapped with a

covering of antiseptic gauze, the latter held in place by a few turns

of fine silk or catgut.

The thyrohyoid membrane bears the superior laryngeal vessels and

nerves, and it should be entered through the middle line in order

not to disturb these. Whatever operation may be required upon the

tissues within the laryngeal box may be conducted with knife,

scissors, curette, and the fine point of the actual cautery. The

interior of the larynx should be cleaned, leaving it simply as a part

of the respiratory tube, without reference to what may become of the

structures within it devoted to voice production. The cartilaginous

shell, with or without a part of its previous contents, having been rid

of the suspicious tissue within, it may be held together by one or two

sutures of silver wire or by superficial sutures of chromic gut, while

the trachea tube which may have been used may be left for a day or two,

or removed at the time. Ordinarily the latter course will prove the

better.

_Laryngectomy, or total extirpation of the larynx_, is the most

severe procedure of all, but will be requisite when there is evidence

of escape of malignant growth from within the true confines of the

laryngeal box. Not only the larynx but more or less of the surrounding

tissue may be removed, with infected neighboring lymphatics, the upper

portion of the trachea, and the base of the tongue.

The operation may be preceded by a low tracheotomy or otherwise. If

necessary this should be done several days in advance, in order that

the patient may have become tolerant of the tube and of the new method

of breathing. If requisite the ordinary trachea tube may be substituted

for the tampon tube above described, in which case it will not be

necessary to lower the patient’s head. Otherwise the operation is

perhaps best performed with the head and neck in the Rose position.

The incision is a long median division of tissues from above the hyoid

to an inch or more below the cricoid cartilage. Through it the anterior

border of the thyroid should be easily exposed. It is then necessary

to separate on either side the sternohyoid and sternothyroid muscles,

the lateral mass of the thyroid body being drawn to either side along

with the musculature, the isthmus having been previously doubly ligated

and divided for this purpose. Now as rapidly as may be the larynx is

completely isolated from all the structures around it, the dissection

being bluntly made. After freeing it on both sides it is drawn forward,

first to one side, then to the other, so that on either side the

superior laryngeal artery may be exposed and secured, the superior

laryngeal nerve being necessarily divided. The cricothyroid branches

need also to be secured, as well as any other vessels which may spurt

blood. Circumferential isolation of the larynx is now completed by

dividing the inferior constrictor of the pharynx and separating it

from the side of the thyroid, keeping close to the cartilage. After

this isolation is completed the surgeon has the choice of first

dividing the respiratory tube either above or below the larynx. This

will depend largely upon his own choice, but usually the procedure is

easier when the first division is made either through the cricothyroid

membrane or between the cricoid and the upper ring of the trachea or

even below this point, if necessary. With a low division first the

patient will immediately begin to breathe through the opening thus

made unless a previous tracheotomy has been done. Ample time will be

afforded for the introduction of a trachea tube and protection around

it to prevent entrance of blood, when the larynx may be lifted and

separated with knife or scissors from the tissues remaining attached.

The esophagus begins at the level of the cricoid cartilage, and if

the cricoid is to be removed the esophagus should be separated from

it; otherwise it is not disturbed. Last of all, in this order, the

thyrohyoid membrane will require division, and then the extirpation is

completed.

The wound is large, the communication with the oropharynx is

unobstructed, and there will be constant escape into the newly formed

cavity of secretions from the nose and mouth. At first the patient

will be unable to swallow, although there may be constant desire to

reflex attempts in this direction. The questions to be decided are the

management of the wound in gross and the suitable treatment of the

upper end of the trachea, as well as of the esophagus, if this has been

touched. The greatest danger is that of inspiration pneumonia. Other

consideration should be secondary to that of prevention of the escape

of fluids down the trachea and the consequent production of pneumonia.

General experience is rather to the effect that the best results are

obtained with a minimum of sutures, the large cavity being lightly

packed with absorbent material, while the upper end of the trachea

should be sewed to the skin as high as possible on either side, the

esophagus being allowed to take care of itself. The patient should

wear a trachea tube for several days after the operation. Through the

exposed upper end of the esophagus a tube may be passed three or four

times a day, and sufficient nourishment be thus introduced into the

stomach. The patient may be kept lying upon the side for the greater

part of the time, so that saliva may escape from the mouth.

The question comes up later as to what substitute, if any, may be

afforded for the lost larynx. Gussenbauer devised an improvement on

what was called the “artificial larynx,” devised originally by Foulis

and then modified by Hahn, which afforded an ingenious mechanical

substitute for the larynx, permitting the production of voice by

vibration of a metallic reed, such tone as it produced being, like that

produced by the vocal cords, modified by the vocal organs above into

perfectly intelligible speech, but always in a monotone. It consisted

of a tracheal tube through whose external opening another tube could

be passed upward to a point where it lay beneath the epiglottis, if

this were left _in situ_, or behind the base of the tongue, if the

epiglottis had been removed. Through this the patient could breathe

under ordinary circumstances. By a little device at the external

opening the touch of the finger upon a spring would throw into the air

current a thin, metallic reed, by whose vibrations tone was produced,

to be modified as mentioned above. This was the principle of the

_artificial larynx_ which was worn by many patients and which in many

gave good results. One patient of my own wore one for seven years,

although he discontinued using the reed because the peculiarity of

the tone attracted more attention than did the loud “stage whisper”

which he had cultivated. Around the instrument there is always more or

less moisture or discharge, and there are many disagreeable features

attending its use, even though it permit the act of swallowing without

any difficulty.

Solis Cohen introduced a method of treating these cases by fastening

the trachea to the external wound and permitting the cavity above to

close as rapidly as possible. In this way the trachea is permanently

terminated in the middle of the neck and patients breathe through

this opening. It has been found that with practice they can retain

sufficient air in the mouth and pharyngeal cavity to permit them to

whisper several words at a time. This simplifies the procedure, and is

now usually adopted after extirpation of the larynx.

_Partial laryngectomies_ have been practised through external openings,

one lateral half or more of the larynx being removed. These operations

have been few in number and often unsatisfactory. They should be

reserved for cases with favorable indications. When required they are

performed on the same principles as those already outlined, only the

extirpation is incomplete. Certain modifications have been proposed

by individuals, as, for instance, the suggestion made by Gluck, to

suture the opening in the trachea to a buttonhole opening made in

the overlying skin, by which means he thought to prevent inspiration

pneumonia.

OPERATIONS UPON THE TRACHEA.

Tracheotomy is the general term made to cover any opening into the

lower air passages between the larynx proper and the upper end of the

sternum. Laryngotomy, cricotracheotomy, tracheotomy, etc., may be

described as implying by these names the exact location of the opening.

The principle is, however, the same, and the details of the operation

vary but little.

[Illustration: FIG. 482

Position of patient for tracheotomy. (Wharton.)]

Tracheotomy as a deliberate operation is different from tracheotomy

as it was formerly practised for diphtheria, and as it is yet done in

emergencies, some cases being so serious that suffocation will occur if

the opening be not promptly afforded. In the former case preparations

can be made; in the latter, operation may have to be done with the

blade of a penknife. It makes considerable difference also whether an

anesthetic can be used. To administer chloroform to a child with a

heart already weakened by the toxins of diphtheria is almost to invite

disaster, and yet to do the operation without an anesthetic is perhaps

impossible.

The _middle line is the line of safety_ in all of these operations.

The danger of heart failure from the anesthetic, or of suffocation

from tardiness of relief, being passed, the other principal danger is

that of hemorrhage. The isthmus of the thyroid may be divided, but

always with preliminary ligatures, or it should be caught between

the blades of pressure forceps on either side before dividing it. A

patient with a short, fat neck, whose cervical veins are dilated and

engorged with venous blood owing to partial asphyxia, makes a difficult

and undesirable subject. The trachea lies nearer the surface at its

laryngeal end than in its lower portion--_i. e._, if the operation be

low in the neck deep search will have to be made for the tube. The

first incision should be made sufficiently long, never less than two

inches, and should be so planned as to bring the operator down upon the

tracheal rings. By this time sufficient engorged veins may have been

divided to cause a serious oozing of dark, venous blood, by which the

field of vision is much obscured. Except in emergencies the surgeon

may wait for this engorgement to be relieved. The trachea, being

recognized by the finger-tip, is seized with a tenaculum, by which

it may be held forward, and then at least two of its rings divided

with the knife-blade. The instant the opening is made, if the patient

be still breathing, bloody foam and frothy blood will be ejected,

and for a moment or two the bleeding may be uncontrollable. Under

these circumstances the normal blood color soon returns. Artificial

respiration should be practised at the same time. Supposing this to

be an emergency case, with little or almost nothing at hand, sutures

should be passed through the tracheal opening and through the skin

margin on either side. If no other retractor be at hand the suture

materials may be left long and tied behind the back of the neck,

sufficient tension being made to prevent the wound edges from coming

together. Formerly when the surgeon was called to do this operation

with little or no help the writer has extemporized a couple of

retractors out of hair-pins, bent for the purpose, hooked into the

tracheal wound, then tied with tapes, which were united behind the

neck, while the wires were kept from being pulled out of place by a

skin suture on each side. There is now less occasion for these crude

methods since the introduction of O’Dwyer’s intubation.

With _tracheotomy done deliberately_, and at the point of election,

usually above the thyroid isthmus, with or without division of the

cricoid, the vessels may be secured as they are exposed or bleed, and

the trachea should not be opened until all oozing from its exterior has

been checked. For this purpose the patient is placed upon the back, the

shoulders raised, the head thrown backward, and the neck exposed, a

pillow being placed beneath. (See Fig. 482.) The operation may be done

under cocaine local anesthesia or with a general anesthetic. Incision

in the middle line, below the lower border of the thyroid cartilage,

is made two inches or so downward, the fascia beneath being divided in

the same line and the tissues retracted to either side from this median

exposure. Thus one makes access to the cricothyroid membrane, the

cricoid, the upper tracheal rings, and the thyroidal isthmus. According

to the size and location of the latter (it usually lies in front of

the second tracheal ring) it may be retracted or doubly ligated and

divided in the middle. The difficulty now afforded is from the upward

and downward play of the larynx, which may occur during forced efforts

at respiration. To steady it a tenaculum should be introduced just

above the cricoid, a little to one side of the middle line, firmly

fastening it. With this held in the left hand, thus steadying the

parts, a sharp-pointed knife is so employed as to divide the cricoid

and one or two upper rings of the trachea, being cautious not to wound

the posterior wall. The opening thus made should be about one-half inch

in length. Through it a second hook is now passed into the other side

of the cricoid and the incision held open by their agency while the

trachea tube is introduced.

This procedure may be modified in accordance with any local

indications, and may be made according to the needs of the case. When

the opening is made into the trachea below the isthmus it is called a

low tracheotomy. Here the anterior part of the trachea lies free from

the skin, but may be covered with a plexus of veins connecting with

the inferior thyroid. Farther down the _arteria thyroidea ima_ may be

encountered. There is always reason for operating as high as the case

will permit. The trachea may itself be displaced by the growth which

compresses it and necessitates the operation. Thus it may be crowded

to one side, other anatomical relations being disturbed, or it may be

compressed into scabbard shape, and thus be difficult to find or to

open.

The moment the trachea is open more or less marked expulsive efforts

will drive blood and foam in all directions, and may for a moment

obscure the field of vision. Every precaution should be taken to

prevent the entrance of blood into the trachea. Pressure of the

tracheal walls against the tube to be inserted may check hemorrhage

from its margins. The operator should be ready to suspend all other

procedures and make artificial respiration, and he should also be

prepared to open the trachea suddenly, should impending suffocation

require it.

In a general way, then, the _indications for tracheotomy_ are symptoms

of rapidly or slowly threatening obstruction to respiration from causes

either within the larynx--_e. g._, diphtheria, foreign bodies, tumors,

and the like--or causes external to it, such as tumors, phlegmons,

cicatrices, etc. Any cause which interferes with the free play of air

through the respiratory tube, which can be either relieved or atoned

for by the operation, will always justify it.

_Tracheotomy tubes_ are mechanical devices for not only keeping the

tracheal wound open but permitting the unobstructed passage of air.

They are made of various materials, of which silver is the most

satisfactory, as aluminum is too easily acted upon by the fluids of

the body, and rubber occupies too much space. The tracheotomy tube

is a double tube, the inner one slipping easily into and out of the

outer, and being necessitated by the ease and abundance with which

secretions may collect and dry, and thus obstruct. Were it necessary to

remove the entire tube for each cleansing, difficulty might be met in

re-introducing it, whereas the inner tube is easily removed, quickly

cleansed, and restored to place within the outer without disturbance or

pain to the patient.

Aside from the tracheal tubes ordinarily used there are others made

exceptionally _long_, and with flexible lower ends, which may be used

in case of tumor low in the neck or high in the mediastinum--for

instance, in cases of enlarged thymus, where it is necessary to go

beyond an obstruction.

In the _after-care_ of these cases it should be remembered that air

passes directly into the lung without being warmed, or moistened, by

passage over the mucous membrane of the upper respiratory tract. The

patient, therefore, should be kept in a warm room, and the air should

be kept moist by the use of a croup kettle or a spray machine. The

inner tube should be kept unobstructed, the length of time during

which it should remain depending on the nature of the case. So soon

as its usefulness is passed it should be removed. A tracheotomy wound

kept open but for a day or two will quickly close, but one which has

remained open for weeks may close with difficulty, and then there may

be trouble from granulation stenosis or cicatricial contraction. (See

above under Stricture.) In instances where a permanent opening is to be

maintained it is desirable to remove the tube as early as circumstances

may permit.

INTUBATION.

The perfection by Joseph O’Dwyer of a method, at which others

had worked, of substituting intubation of the larynx for the old

tracheotomy, not only shed the greatest luster upon his own name, but

has afforded a speedy and bloodless method of accomplishing much more

than had been previously possible by the older procedure. The method

comprises the emplacement of a suitably sized and shaped tube within

the larynx, by a manipulation guided almost entirely by the sense of

touch, for the relief of suffocative symptoms due to disease at this

level, and leaving the tube _in situ_ for a sufficient time to permit

morbid activity to subside and justify its removal.

It is advisable to have a half-dozen tubes, varying in size from 1¹⁄₂

inches to 2¹⁄₂ inches in length, and of corresponding increase in

other dimensions, each of which affords a passage-way for respiratory

purposes, and is also provided at its upper end with a flange, which

shall rest upon the false vocal cords and prevent the descent of

the tube into the trachea below. The complete set of instruments as

now furnished by all the manufacturers provides an assortment of

these tubes, with a scale indicating which one to use upon a patient

of a given age, and includes a mouth-gag, which may be used for

many purposes, and two handled instruments--one intended for the

introduction, the other for the extraction of the metal tubes.

[Illustration: FIG. 483

O’Dwyer’s laryngeal tube and introducer.]

[Illustration: FIG. 484

Mouth-gag.]

[Illustration: FIG. 485

Extractor.]

[Illustration: FIG. 486

Intubation of the larynx.]

[Illustration: FIG. 487

The tube in the pharynx.]

A suitable tube having been selected, a strong thread is passed through

a small opening near its head, thus affording means for withdrawing

it should there be need before it is finally left in its resting

place. The particular obturator meant for the tube to be used is then

firmly fastened upon the handle and over it the tube is slipped. The

instrument should then be tested to make sure that disengagement of the

tube will easily take place. Everything being ready, the patient is

then held in the arms and on the lap of an assistant, in the position

indicated in Fig. 486. The individual holding the patient should be

perfectly reliable in the matter of presence of mind and self-control,

for a great deal depends upon having a child firmly and properly held

during the moment of intubation. The arms and hands of the patient

should be well wrapped with a towel and firmly held by the side of the

chest, for the temptation is inevitable to put the hand to the mouth

and interfere with the operator. A second assistant should stand above

and behind, holding the mouth-gag in position, as represented, and

steadying it as well as the head. It is necessary that the mouth-gag be

held firmly in place, for if it should become disengaged the child may

bite the operator’s finger.

[Illustration: FIG. 488

The tube penetrates the larynx. (Lejars.)]

[Illustration: FIG. 489

The stem is withdrawn while the finger fixes the tube. (Lejars.)]

Standing in front of the patient the operator identifies the tip of

the epiglottis with the forefinger of the left hand in the pharynx,

this finger being used at the same time to raise and fix the epiglottis

and also to serve as a guide to the tip of the tube, which is passed

downward alongside it, by a maneuver similar to that by which the

laryngoscopic mirror is used in the pharynx (Fig. 487). When the tip

of the tube reaches the location behind the epiglottis the finger may

be passed a little farther downward, plugging the entrance to the

esophagus, while at the same time the handle of the instrument is so

manipulated as to bring the tube forward. With gentle movement in

the right direction it passes into the larynx (Fig. 488). It is then

pressed downward until the flanged upper end has passed the epiglottis,

after which the tube is disengaged, the handle and the obturator

withdrawn, and the upper end of the tube pressed gently into place by

the finger which still rests in the pharynx (Figs. 488, 489 and 490).

During the manipulation there is almost complete obstruction of the

glottis for two or three seconds. The effort, therefore, should be

to shorten the procedure, and at no time should it occupy more than

two or three seconds. If the landmarks are not easily recognized,

and the tube is not placed at the expiration of three seconds, the

operator should discontinue for a few more seconds in order that a few

inspirations may be taken, after which he should try again.

[Illustration: FIG. 490

The finger pushes the tube into place. (Lejars.)]

[Illustration: FIG. 491

Withdrawal of the thread. (Lejars.)]

When the tube is in place there will come ease of respiration, at the

same time violent coughing efforts, because of the irritation thus

suddenly produced. So soon as it is apparent, both to the finger in

the pharynx and from the relief of obstructive symptoms, that the tube

is in its proper place, the finger may be once more passed into the

pharynx, the tube pressed down, while the silk thread is withdrawn,

since it is not intended to leave it for more than the time necessary

to be assured that the tube will not have at once to come out again

(Fig. 491). Before removing the thread the gag should be removed for a

few moments, so that the effect of the excitement may pass, after which

it may be re-introduced for the purpose of withdrawing the thread.

The procedure is by no means a simple nor necessarily easy one, and

it should be practised with the instruments upon the cadaver before

resorting to it on the living child.

The tube being placed it will remain to be decided by the subsequent

course of events how long it should be allowed to remain--in some

cases a few hours, in others a few days. With young children it should

remain for at least a week. The time having arrived for its _removal_,

the procedure is similar to that required for its introduction. The

assistants hold the child in the same position as before, while the

operator substitutes the extractor, guiding its tip again by the sense

of touch along the left index finger, which, passed down into the

pharynx, is made to discover and identify the upper end of the metallic

tube. So soon as the point of the extractor is engaged within the tube

the blades are separated and it is then drawn out, while the finger

is withdrawn along with it in order to make its removal easier and to

prevent its loss should it slip off the instrument. Unless the patient

struggles violently the whole procedure should be conducted so as to

scarcely cause the slightest staining of the expectoration with blood.

_Various causes may require abrupt removal of the tube._ Thus it

is possible for its caliber to be become occluded with tenacious

secretion. This may produce a violent fit of coughing, during which

there may occur spontaneous expulsion of the tube. At any time, when it

is seen that asphyxia is increasing, or when violence of respiratory

effort would indicate obstruction within the tube, it should be

removed, cleaned, and re-introduced. After its introduction and removal

the operator should remain within easy reach for a short time, to be

sure that no unpleasant effects result and that no re-introduction

may be suddenly required. Should obstructive efforts occur the child

should be held head downward and be slapped vigorously upon the chest.

This may loosen membrane or it may permit dislodgement of the tube and

its spontaneous expulsion. The latter may also occur during the act of

vomiting.

The above description is meant especially to apply to intubation

as performed upon young children for the relief of the laryngeal

obstruction consequent upon diphtheria. It has given better results

than tracheotomy, which was the only resort previous to O’Dwyer’s

device. It is usually performed easily, and is devoid of the horrors

frequently attendant upon an emergency tracheotomy. But intubation is

not necessarily limited to children nor to cases of diphtheria. The

emplacement of such a tube may be called for at any time in cases of

threatening or actual _edema of the glottis_, as, for instance, from

inhalation of steam or flame. It may be advisable in other forms of

intralaryngeal disease, both acute and chronic, while individuals

suffering from laryngeal stricture or stenosis find that they can wear

an O’Dwyer tube almost constantly, not only with relief, but that they

are thereby saved from the more serious measure of opening the trachea

or removing the larynx.

Impending suffocation having been relieved by intubation, the question

of feeding arises. The principal disadvantage attendant upon the use

of the tube is partial or complete inability to swallow, for the

epiglottis does not always easily close over the tube and prevent

entrance of fluid into the larynx. It is necessary to feed patients,

especially the young, with extreme care. For this purpose there is no

food better than ice-cream, while little children should be placed upon

their backs, with the head lower than the body, and made to swallow

in this position, at least until they have been accustomed to the

presence of the tube and instinctively learn how to avoid irritation by

involuntary regulation of the act of swallowing.

CHAPTER XLII.

THE NECK.

CONGENITAL ANOMALIES OF THE NECK.

These consist largely of defects due to arrest of development along

the lines of the branchial clefts. Necessarily of embryonic origin,

they do not reveal this until varying periods after birth, sometimes

not until old age. They consist of fistulas, opening either externally

or internally, or more commonly of cystic dilatations of the interior

portions of the original fissures. External openings are usually seen

along the sternomastoid, either in front or back of it, or between

the larynx and the clavicle. Vestiges are also present in the shape

of little tags of skin containing portions of cartilage or bone. They

frequently occur together, the tag indicating the location of the

fistula, whose opening may be found obstructed with crusts. Internally

the openings are usually found in the pharynx, perhaps in the larynx or

trachea, generally near the tonsil and base of the tongue. An external

fistula may be tested for its completeness by injecting a colored fluid

and inspecting the pharynx. The fistulous portion is usually marked

by a cord-like mass which extends inward, usually toward the hyoid

bone. Internal blind fistulas may gradually expand and constitute one

variety of the so-called pulsion diverticula of the pharynx and upper

esophagus, their dilatation being due to accumulation of food, and

gradual stretching in this way.

All of these embryonic relics are of interest because from their small

beginnings large growths may take place, constituting even serious

surgical problems. These growths may present in almost any region of

the neck and frequently extend into the mouth, where they give rise to

certain forms of _ranula_. Almost every cystic tumor beneath the tongue

or jaw is open to the suspicion of having an embryonic origin. Most of

these vestiges are amenable to surgical treatment should they give rise

to discomfort or trouble. The operations required are sometimes quite

extensive, as any tumors of branchiogenic origin are especially liable

to adhesions to the large vessels; moreover, they are nearly always

firm and the dissection thus made difficult. A dermoid cyst may be

evacuated and its wall or sac destroyed or dissected out. It may then

be made to heal by packing.

=Treatment.=--In the treatment of fistulas of the neck, König has

advised that a curved probe be passed through the tract to a point

close to the tonsil, at which point on the inside of the mouth or

pharynx the mucous membrane is incised, a silk thread is fastened to

the end of the probe, pulled out with it, then made to pass to the

external end of the fistulous tube, which is then invaginated and

pulled back into the mouth, where it is reduced to a short stump which

is fastened to the margins of the opening of the mucous membrane. The

external wound is then made to heal as usual. This treatment suffices

for blind internal fistulas of the cervical region.

It is a matter of great surgical importance and interest that certain

branchiogenic remnants persist in a perfectly harmless manner until

advanced life is reached, after which there take place therein

cancerous changes which convert them into the so-called _cancers of

branchiogenic origin_. These are too often of hopeless character by the

time they are seen by the surgeon.

Other congenital defects consist of atrophies, such, for instance,

atrophy of the sternomastoid muscle, or of certain hypertrophies which

may be unilateral or symmetrical.

WOUNDS AND INJURIES OF THE NECK.