noxious vapors or impure air; or it may spread to the larynx from the pharynx; or occur in the course of other diseases as the eruptive fevers. Symptoms.-Soreness of the throat, hoarseness or even aphonia, laryngeal cough, and tenderness on pressure over the thyroid cartilage, accompanied by febrile symptoms. On laryngoscopic examination the parts are seen red and swollen, and the cords do not come together properly. The treatment consists in rendering the atmosphere moist by the steam kettle, in inhaling soothing vapors, and abstaining from using the voice; while if the attack is very acute, leeches, or cold in the earlier stages, may be applied over the thyroid cartilage. Should the inflammation assume the cedematous form scarification or tracheotomy may become necessary (see Edematous Laryngitis).

Chronic laryngitis may be due to exposure to wet and cold, over-exertion of the voice, excessive smoking, inhalations of dust and vapors, syphilis, tubercle, and malignant disease. The mucous membrane appears thickened and indurated and covered with a muco-purulent discharge, while the glottis is narrowed in consequence of the thickening of the mucous membrane. The symptoms are cough, hoarseness, laryngeal voice, dryness and irritation in the throat, and dyspnoea, varying with the amount of narrowing of the glottis. A variety of chronic laryngitis, in which the mucous follicles are chiefly affected, is known as follicular or granular laryngitis, or clergyman's sore throat, and is frequently associated with a similar condition of the pharynx. Treatment. -The application with the brush of a strong solution of nitrate of silver, half a drachm to the ounce, or even stronger, absolute rest of the voice, residence at a suitable spa, avoidance of all sources of irritation, and appropriate remedies, if there is any specific disease.

Edematous Laryngitis or Edema of the Glottis. In this form there is an effusion of serous fluid into the submucous tissue of the larynx, especially that about the aryteno-epiglottidean folds (Fig. 165). But the cedema does not extend below the vocal cords, as the mucous membrane is tightly attached to them without the intervention of any submucous tissue. Cause.-It generally comes on suddenly, and often supervenes upon some previous inflammatory condition of the larynx or neighboring parts. It is of common occurrence after scalds or burns of the throat, stings of insects, or the impaction in the larynx of a foreign body; or it may occur in the course of such diseases as erysipelas, fevers, and small-pox; or be engrafted on tubercular or syphilitic ulceration of the larynx, perichondritis, or necrosis of the cartilage. Edema of the larynx of a passive character is also a frequent termination of Bright's disease. The symptoms

are most urgent, dyspnoea is excessive, and if not relieved rapidly ends in spasm and death. When less severe the voice is affected, inspiration is often stridulous and labored, and swallowing is painful and difficult-symptoms which may be followed by cyanosis, coma, and death. The treatment must be energetic; an emetic should be given at the onset, and leeches, ice, or, if preferred, hot sponges, applied over the thyroid cartilage. These means failing, the oedematous part must be scarified by the laryngeal lancet, or a Schroetter's tube, if at hand, passed through the glottis, and retained there until the oedema subsides; otherwise laryngotomy or tracheotomy must be performed.

Membranous laryngitis, laryngeal croup, or laryngeal diphtheria, is a disease of childhood, and may either begin in the larynx, or spread to it from the fauces and pharynx. It is characterized by the formation of a false membrane, which may extend into the trachea and bronchi (Fig. 166). The membrane, which may be hard and tough, or soft and crumbling, and of a yellowish or grayish-white color, is produced by the coagulation of fibrinous material exuded on the surface of the mucous membrane. It consists of a delicate network of fibres enclosing leucocytes, cast-off epithelium, and granular débris in its meshes. On its separation the mucous membrane beneath is generally, though

not invariably, found to be denuded of epithelium, congested and inflamed; but the mucosa is not usually involved, as is the case in diphtheritic inflammation of the fauces and pharynx. This difference would appear to depend on the site of the inflammation and the intensity of the process, though some consider it a point in favor of the non-identity of croup and diphtheria, a question, however, which cannot here be discussed. The symptoms, when the disease begins in the larynx, generally come on very gradually; and at first cannot be distinguished from an ordinary catarrh. Soon, however, and often first during the night, the cough acquires a ringing or brassy character, and soon afterward, if not simultaneously, the inspiration becomes stridulous, and later the voice "hoarse, cracked, and whispering, or in young children totally suppressed." Dyspnoea is now marked; the soft parts of the chest walls recede during inspiration; the inspiration is heaving; expiration as well as inspiration may also become impeded, and the child, if not relieved, rapidly becomes cyanosed and dies. When the disease spreads from the pharynx, the laryngeal signs may at first be masked; but later, they are similar to those given above. Treatment.Internally quinine and perchloride of iron may be given, while locally when any membrane is visible on the fauces and pharynx it should be removed, and prevented, if possible, from reforming by swabbing out the throat at frequent intervals with boro-glyceride, carbolic acid, or other disinfectant. The child may be placed under chloroform, if necessary, to ensure the thorough removal of the membrane. Should the larynx become obstructed, tracheotomy must be performed. The chief indications for this operation are retrocession of the soft parts of the chest walls, suppression of the voice, and especially impeded expiration. Before introducing the tracheotomy tube the membrane should be thoroughly removed both from the trachea and larynx by a feather or by the suction-tube apparatus, and their reformation, if possible, prevented by constant spraying of the part through the tube with an alkaline lotion. The patient's bed should be surrounded with curtains, and the atmosphere kept moist by steam to which an antiseptic is added. He should be

fed with soft, solid nourishment, and, if necessary, by a flexible silk tube passed through the nose. Stimulants are generally required.

TUBERCLE OF THE LARYNX, also called laryngeal phthisis, may sometimes occur as a primary affection, though it is generally secondary to tubercle of the lung. It is characterized by the formation of miliary tubercles under the mucous membrane, which subsequently break down, leading to ulceration.

The

symptoms are those of ordinary chronic laryngitis, but in addition to these, the patient often presents signs of pulmonary phthisis. On examination the mucous membrane looks pale, and the aryteno-epiglottidean folds swollen and often of a pyriform shape; later, ulceration will be discovered, and may be followed by caries and necrosis of laryngeal cartilages, dysphagia, and oedema of the glottis. Treatment-The usual constitutional treatment for tubercular diseases must be employed. When ulceration has occurred, painting the part with cocaine, or insufflation of morphia, may be tried to relieve the cough and difficulty and pain in swallowing. Should swallowing become impossible, the patient must be fed with the oesophageal tube and tracheotomy performed when suffocation threatens.

SYPHILIS OF THE LARYNX.-In the secondary stages of syphilis, catarrhal inflammation, superficial ulceration, and mucous patches may occur; while in the tertiary stages characteristic ulcers due to the breaking down of gummata are not very uncommon. Tertiary ulceration may extend to the perichondrium, or a gumma may begin beneath that membrane, and in either case lead to necrosis or caries of the cartilages. On the healing of the ulcers, contractions and adhesions producing stenosis of the larynx may ensue. General syphilitic treatment, appropriate to the stage, should be employed. Scarification or tracheotomy are called for in tertiary affections should oedema of the glottis supervene. In stenosis an attempt may be made to dilate the contracted glottis by means of Schroetter's tubes, or the stricture may be divided with a guarded knife, or with the galvanocautery.

TUMORS both innocent and malignant occur in the larynx. Of the former the papillomata and fibromata are the most common, of the latter the epitheliomata. The papillomata occur as warty or pedunculated excrescences, or as soft, flocculent, villouslike bodies, and generally grow from the vocal cords and front of the larynx (Fig. 167). They may be single or multiple. The fibromata are less common than the former, and occur as small, smooth, solitary, spherical, pedunculated or sessile growths, springing from the vocal cords. The epitheliomata usually grow from the mucous membrane covering the arytenoid cartilages, or from the ventricular bands or cords. A sarcomatous tumor is shown in the accompanying illustration (Fig. 168).

The chief symptoms of a growth in the larynx are hoarseness or aphonia and dyspnoea. When the growth is pedunculated the symptoms are often paroxysmal and intermittent in character, in consequence of the growth being moved by the current of air

in respiration. The laryngoscope is essential for the diagnosis. In the early stages it may be difficult to distinguish an innocent from a malignant tumor, but if a small piece can be removed, a microscopical examination will clear up the point. Later, the rapid growth of the tumor, its tendency to ulcerate, its induration, its involvement of surrounding parts, the enlargement of lymphatic glands, and the accompanying pain and cachexia will indicate malignancy. At times the lymphatic glands may not be involved, and there may be no cachexia.

Treatment.-Innocent growths should be removed, if possible, by the intra-laryngeal method. This may be done by evulsion with the laryngeal forceps, or by excision with the cutting-for

ceps, or with the cold wire or galvano-cautery snare, local anæsthesia being induced by cocaine. When of very large size, or broad-based, or situated below the cords, or in other parts where they cannot be removed by this method, laryngo-tracheotomy or thyrotomy may have to be performed. When a malignant growth is confined entirely to the larynx, and the glands of the neck are not involved, the whole or part of the larynx should be extirpated. Otherwise palliative treatment only can be employed, or tracheotomy performed if suffocation threatens.

OPERATIONS ON THE AIR PASSAGES.

Under this head are included tracheotomy, laryngotomy, laryngotracheotomy, thyrotomy, subhyoid pharyngotomy, and extirpation