EROSIONS AND ULCERS IN THE UPPER RESPIRATORY TRACT 419

diagnosticated without hesitation. The perforation may extend to the mouth, and portions of the hard palate may come away.

TREATMENT.-Syphilitic coryza in children disappears after vigorous antisyphilitic treatment: Calomel (gr. to) twice daily and general hygiene. In adults an inunction cure or injection cure or mixed internal treatment is indicated, in addition to general hygiene and disinfecting nasal sprays. Crusts, granulations, and loose bone must be removed in the usual way.

Syphilis of the Pharynx is usually a secondary manifestation and rarely a primary infection. The mucous patches appear about the time of the skin eruption. When an infiltration or gumma breaks down, we observe deep, craterlike ulceration, surrounded by a reddened zone. In the absence of definite symptoms a therapeutic test will decide the question.

TREATMENT.-Specific local cleanliness by means of the nasopharyngeal toilet is valuable in the management of such conditions. In the second stage mixed treatment is to be adopted, and in the third stage potassium iodide should be given. For local treatment we employ the nasopharyngeal toilet and a chlorate of potassium gargle, also cauterization with a 5 per cent nitrate of silver solution. Adhesions between the soft palate and pharynx must be cut with a rectangular knife and kept open.

Syphilis of the Larynx.-About 3 per cent of syphilitic patients are said. to acquire laryngeal syphilis in the form of erythema, mucous patches, gummata, and ulcers. Syphilitic ulcers have deep red surroundings and spread more rapidly than tuberculous ulcers, and are apt to end in stenosis, owing to widespread destruction of the parts and cicatrization.

The SYMPTOMS are the same as in tuberculous ulceration, but there is much less discomfort and pain.

The DIAGNOSIS is based upon a history of syphilis and evidence of syphilis in other parts and the described local manifestations. Errors of diagnosis are possible. The writer remembers one case, which was pronounced tuberculosis of the larynx because tubercle bacilli were found in the sputum, that cleared up entirely under mixed treatment.

TREATMENT.—Energetic antisyphilitic management, supplemented by mild local measures in the form of oil or alkaline sprays or stimulating inhalations, is indicated. In oedema of the larynx tracheotomy may be necessary.

Tuberculosis of the Nose is seldom primary, but appears as a granulation. tumor or ulcer, most frequently on the cartilaginous septum, which may become perforated. Crusts and epistaxis draw attention to the visible lesion. Pain is seldom complained of.

TREATMENT.-Curettage and cauterization with lactic acid or the galvanocautery or radical removal of the diseased cartilage. Tuberculous ulcers in the nose show very little tendency to heal under any form of treatment.

Tuberculous infiltration and Ulcers of the Pharynx have irregular and undefined boundaries with a tendency to lateral extension.

SYMPTOMS.-Severe pain on swallowing, a tenacious discharge, foul breath, hectic fever, and other evidence of tuberculosis (tubercle bacilli in the sputum).

TREATMENT.-General hygienic treatment. Nasopharyngeal toilet, in

sufflation of iodoform or orthoform, local applications of cocaine, also lactic acid (20 to 30 per cent).

PROGNOSIS.

Few cases are known to be cured. Death may ensue after

six to eight months.

Tuberculous Laryngitis.-About 30 per cent of persons afflicted with pulmonary tuberculosis have laryngeal tuberculosis. The primary involvement of the larynx is rare. Examination shows infiltration and ulceration in localized areas. The ulcers are usually multiple with a tendency to coalesce and not to penetrate deeply. Edema of the larynx is a common complication. Anemia of the larynx and pharynx is usual.

SYMPTOMS.-Hoarseness, aphonia, pain. on swallowing, cough, hæmoptysis.

TREATMENT. In addition to the general hygienic management and rest of the voice, the larynx should be sprayed with an alkaline mixture (Seiler's tablets) or a watery liquid containing menthol, creosote, or cocaine. Insufflations of orthoform and iodoform are to be used. In suitable cases the infiltration may be excised or curetted and the ulcer treated with 25 per cent lactic acid solution applied by means of a cotton carrier. Local treatment, on the whole, is unsatisfactory. Tracheotomy may be nec-essary in cedema with urgent stenosis.

Carcinomatous Ulcers have been observed in all the mucous membranes. In suspected cases the patient should have the benefit of the doubt and undergo an inunction course for syphilis.

NEW GROWTHS, BENIGN AND MALIGNANT, OF THE UPPER
RESPIRATORY TRACT

The Benign Tumors are polyps, papilloma, fibroma, lipoma, chondroma, angeioma, and cysts.

The Malignant Tumors are carcinoma and sarcoma.

New Growths in the Nose

Polyps are soft gelatinous masses, and if located anteriorly they can be seen to move with each breath. Those growing in the posterior nares may be detected by introducing the finger behind and around the soft palate, or they may be engaged in a wire loop introduced through the anterior The symptoms are those of unilateral or bilateral obstruction, with "catarrh." Neoplasms of the pharynx are not frequent. We observe them on the uvula, palate, tonsils, and other parts of the pharynx. Nasopharyngeal polyps and fibromata may arise from the vomer, the choanæ, and the occipital bone.

nares.

TREATMENT.-Polyps are removed by means of a forceps or the wire snare, and if possible under cocaine. The base of the polyp, after removal of

BENIGN AND MALIGNANT GROWTHS

421

the growth, should be cauterized with trichloracetic acid to prevent if possible a return of the trouble, which is very apt to occur. Should bleeding

arise, it may be checked by applying ice cold water or strong alum water. The removal of benign new growths other than polyps may be accomplished by means of the cold or hot snare, electrolysis, or the galvanocautery knife.

Benign Tumors of the Larynx and Trachea

The most frequent benign tumor of the larynx is the papilloma, which is found in children and adults. It is often multiple and may be located on

the vocal cords or in the subglottic region. The principal symptoms are hoarseness, aphonia, and attacks of dyspnoea. The diagnosis is established by the laryngoscope. The endolaryngeal treatment of papillomata in children is not advisable according to the experience of the writer. Even after splitting the larynx and removing all growths, recurrence is frequent. All other tumors and cysts require surgical or endolaryngeal treatment.

Malignant Growths

Those of the tonsils and soft palate are slow of growth, with involvement of the lymph nodes. Malignant growths in the larynx, sarcoma and carcinoma, give the same symptoms as benign growths in the beginning, but with every malignant ulcerative process we have in

early diagnosis radical means may be employed in good time (partial or total extirpation of the larynx) and life may be prolonged for two or three

years. The knife alone does not cure cancer, and the near future may give us a better insight into its pathology and better methods of cure.

In sarcoma, injections of Coley's erysipelas toxines may be tried. Loeffler has recently suggested the antagonism of malaria and malignant new growths. The x rays and radium are also being employed in the treatment of "inoperable" malignant new growths. In doubtful cases antisyphilitic treatment should be tried before operating or before giving an unfavorable prognosis.

FOREIGN BODIES IN THE UPPER RESPIRATORY TRACT

Foreign Bodies in the Nose.-In addition to rhinoliths (calculi in the nose), all kinds of foreign bodies have been found in the noses of children and demented persons. One sided suppuration of long duration is sugges

tive of a foreign body, which may remain impacted for years. The discharge in such cases is foetid and headache is a prominent symptom.

TREATMENT. After cleansing the nose, a strong light may be thrown into the nostril, and a careful search is then made by means of a probe. The removal of a foreign body is accomplished by insufflation on the sound side with a Politzer air bag, or by means of a sharp curette or forceps, if necessary under narcosis.

Foreign Bodies in the Pharynx.Fishbones and needles may be seen in a good light, but are usually detected by a careful digital examination and removed by means of a suitable forceps. Eating dry bread and swallowing a raw egg helps to dislodge a fishbone. Sometimes the foreign body has been expelled without the patient's knowledge, but no relief is felt, on account of the wound in the mucous membrane.

Foreign Bodies in the Larynx.-The entrance of a foreign body into the larynx is attended with coughing and attacks of suffocation, and unless it is expelled inflammation and ulceration may supervene.

TREATMENT.-When a foreign body is impacted above the vocal cords, it may be extracted with forceps. If it is below the vocal cords, the patient should be inverted, in which position gravity and a coughing spell may force out the foreign body. In case of a foreign body in the trachea, place the patient on a lounge in the abdominal posture, head downward, arms on the floor, and instruct him to take a slow, deep inspiration and follow it with a forcible cough. If this is unsuccessful, tracheotomy should be done, when the foreign body may possibly be reached with forceps. Foreign bodies have been located by means of the bronchoscope.

HÆMORRHAGE AND NASAL DEFORMITIES

423

HÆMORRHAGE FROM THE UPPER RESPIRATORY TRACT (EPISTAXIS) Hæmorrhage from the nose may be due to traumatism, nasal disease, local erosions from picking with the fingers, racemose veins, or circulatory disturbances (hear disease). Persons with acquired or hereditary hæmophilia or other constitutional diseases (scurvy) are apt to bleed from the nose. The bleeding may be of a vicarious nature, as in young girls at the time of menstruation. Syphilitic or tuberculous ulcerations and granulations are prone to bleed. In most instances the bleeding point is found at the anterior cartilaginous part of the septum.

TREATMENT.—The nose should be cleansed and the bleeding point cauterized with the galvanocautery or lunar caustic or some other caustic. Antipyrine in 10 per cent solution, suprarenal solution, or strong alum water is also efficacious. Should the bleeding interfere with the investigation, it is proper to plug the nostril and make a further search later. Anterior tamponade and postnasal tamponade are readily accomplished by means of punk, gauze, or absorbent cotton saturated with strong alum water or tannin and glycerine. The tampons should be removed on the second or third day and the tamponade renewed if necessary. The postnasal tamponade is accomplished by means of Bellocq's cannula or a flexible catheter.

Laryngeal Hæmorrhage.-A traumatic submucous hæmatoma may embarrass respiration to such an extent as to require tracheotomy. Bleeding from the free mucous surface may occur in healthy persons or in persons suffering from a circulatory or constitutional disease. A careful examination is necessary in order to ascertain the source of the hæmorrhage, which usually subsides after the use of ice and suprarenal capsule internally and rest of the voice. Hæmorrhage from the trachea may be due to severe constitutional disease, to erosions and ulcers of tuberculous or syphilitic origin, or to cancer. The treatment must be in harmony with the ætiological factors.

DEFORMITIES

Saddle Back Nose.-Deviations of the septum and spurs and enlargement of the turbinated bodies are frequent causes of nasal obstruction. They may be bony, cartilaginous, or membranous, presenting symptoms almost identical with those of hypertrophic rhinitis.

TREATMENT. The treatment in such cases is strictly surgical, usually under cocaine (suprarenal) anesthesia. Soft tissues may be removed by means of the knife or a cutting forceps (punch). Bony tissue may be reduced by means of the hand saw or the electric drill. After septum operations splints are introduced to keep the septum straight until it is healed. Hæmorrhage may be controlled after the operation by introducing a firm pledget of cotton soaked in alum water or suprarenal decoction.

After some operations on the septum we observe a permanent perforation, which, however, is of no special importance.

Saddle back nose, from whatever cause, such as syphilis, traumatism, tuberculosis, infectious abscesses, or lupus, may be corrected by the use of paraffin subcutaneously injected, and by other surgical means. Other deformities require surgical correction.