|4tt)noaUtot|. 
STRICTURE OF THE LARYNX. 
CLINICAL LECTURE DELIVERED AT THE JEEEERSON MEDICAL COLLEGE. 
BY J. SOLIS-COHEN,' M.D., 
Honorary Professor of Laryngology, Jefferson Medical College, Philadelphia. 
Gentlemen,—As the principal subject-matter for to-day I will 
present to you a case as an object-lesson from which you will be taught 
some very important practical points not detailed in your ordinary 
text-books nor discussed in your didactic lectures. You will notice 
that this boy, a well-nourished lad, thirteen years of age, wears a hand- 
kerchief around his throat, and that he has a whispering voice. You 
will also note that the voice is a laryngeal whisper and not an oral one. 
You should always notice the difference between these two forms of 
whispers. An oral whisper indicates that the vocal bands are not in 
action at all. A laryngeal whisper indicates that there is some ob- 
struction preventing approximation of the vocal bands. 
One of you will be good enough to remove the handkerchief from 
the neck of the lad, and it at once becomes evident that it has been 
worn to hide something. This something is a silver tube which pro- 
jects from within the trachea. You will note also, please, that the 
orifice of the tube is plugged with a cork. Nevertheless, the lad 
breathes freely without any impediment. A tube in the trachea, and 
yet the fact that the patient breathes through his nose despite occlusion 
of the tube, shows that he gets enough air alongside of the tube in the 
trachea, without having to depend upon his breathing through the 
tube at all. Here is an important point to bear in mind,—the size of 
the tracheal tube. It should be as large as is compatible with perfect 
freedom of movement in the trachea. You should never use a tube 
large enough to fill up the entire calibre of the trachea, as you may 
cause ulceration from pressure. You must not use one so loose that 
the lower orifice shall press anywhere on the wall of the trachea. 
Cases are on record of fatal results from ulcerations of the walls of the 
trachea and penetration into blood-vessels. 286 
INTERNATIONAL CLINICS. 
When the patient wearing the tracheal canula desires to use his 
voice, it is usually necessary to occlude the exterior of the canula with 
the finger or with some automatic contrivance, in order to prevent 
escape of the expiratory current of air during phonatiou, and to deflect 
that current upon the vocal apparatus. It sometimes happens, how- 
ever, as I showed in a few instances to my classes in this college years 
ago when I was more actively associated in its teachings, that a 
tracheotomized patient has such a copious volume of air that he can 
speak satisfactorily without occluding the orifice of his canula at all. 
Wheu tubes are used which fill the trachea, it becomes necessary to 
have the upper portion of the canula perforated, in order that the air 
from the lungs shall reach the vocal apparatus, to enable the patient 
to use his voice. When the canula does not occlude the calibre of the 
trachea, a sufficient volume of air will pass by the sides of the canula 
to set the vocal bands into phonal vibration. Nevertheless, it has be- 
come very common for surgical-instrument makers to make an opening 
—a fenestra, as it is technically called—in the tracheotomy canula. 
I pass a number of such fenestrated canulas around : some of silver, 
some of aluminium, some of other metals, some of vulcanized rubber. 
You will notice that the fenestra; are in the horizontal portion of 
the tubes. Now, nine times out of ten these fenestrse are made so far 
forward towards the exterior extremity of the tubes that they will not 
be in the trachea at all when, the tubes are in position, but will be 
located in the track of the wound exterior to the trachea, where their 
presence will produce excessive granulations. When a little farther 
back, excessive granulations are produced at the edges of the tracheal 
incision which straddles them. The granulations may dip down into 
the. lumen of the canula, and not only obstruct the breathing of the 
patient, but seriously interfere with the withdrawal of the canula for 
purposes of cleanliness. 
In order to fix your attention prominently upon this very impor- 
tant and insufficiently appreciated point, I will relate to you an instance 
which occurred in a case of mine which has become historical,—not for 
the intrinsically important features of the case itself, so much as to illus- 
trate the fact that serious injury may be produced by these fenestra. 
It is my case of epithelioma of the larynx alluded to by Professor von 
Bergmann in his account of the fatal case of the late German Emperor 
Frederick, upon whom he desired to perform the same operation at the 
time the case was taken out of his hands, having successfully per- 
formed it upon another patient three years previously. 
About twenty-four years ago I opened the larynx of a gentleman LARYNGOLOGY : SOLIS-COHEN. 
287 
and removed an epithelioma therefrom in the presence of a dis- 
tinguished galaxy of surgeons, including the two late Professors Gross 
and the elder Pancoast of this college, Professor Jones of Chicago, the 
late Professor R. J. Levis, at one time of this college, the late Pro- 
fessor Elsberg of the University of New York, Professor Agnew of 
the University of Pennsylvania, Professor Brinton of this college, and 
the late eminent surgeon Dr. John L. Atlee of Lancaster, the patient’s 
physician. After I had operated on that patient,—who, let me state, 
is still living, and has visited me at my office only a day or two ago,— 
he continued to wear a tracheotomy-tube which I had placed in his 
trachea a short time before the thyrotomy and the extirpation of the 
neoplasm. I told him that he would have to wear that tube from six 
to eighteen months, in order that any recurrence of morbid growth 
could be readily attacked from above or from below, as might be, with- 
out splitting his larynx open a second time. 
In the mean time we looked after his general health, which had be- 
come somewhat impaired by the severe measures to which he had 
been subjected, and advised him to travel a while in Europe. I gave 
him a list of surgeons in the medical centres of Europe, to whom he 
might apply should he need their services, and to one or other of 
whom he should submit his larynx for inspection at intervals of a 
month or so to determine the presence or absence of recurrent growth 
as might be. But I especially warned him not to let any of them per- 
suade him to have his tube removed, and not to let any of them put 
in a fenestrated tube, as I knew they would be likely to do, for I felt 
certain that if they did so he would have trouble with it. Neverthe- 
less, in Paris he was induced to have his tube taken out and a fenes- 
trated one inserted in its stead. As predicted, exuberant granulations 
grew, and finally projected into his tube. One day, being unable to 
withdraw his canula, the man was nearly suffocated, and sent hurriedly 
for his physician, who had to tear the tube away bodily, cauterize the 
surfaces of proliferation, and replace my tube. The patient was con- 
fined to his hotel for some weeks in great pain, distress, and peril; 
and finally returned to Philadelphia in safety with the same tube that 
had been inserted before he left. After the prescribed period had 
elapsed, I took the tube out, and he has not had occasion for its rein- 
troduction, nor has he had any recurrence of morbid growth. 
I call your attention to this to show you that there is no necessity 
for fenestra in tracheotomy-tubes. Another point: where the patient 
has to wear a tracheotomy-tube for a number of years, as the patient 
before you has had to do, and even after ordinary operations for croup. 288 
INTERNATIONAL CLINICS. 
it is always best to have two tabes. One should always be clean. 
They should be changed on alternate days. One should be a little 
shorter than the other, so as to vary the points of any pressure on the 
trachea or on the track of the wound. In certain classes of indi- 
viduals you will find that the patients not only neglect to change their 
tubes, but that they keep them in a long time without even cleaning 
them; and in this way more or less corrosive destruction of the tubes 
necessarily takes place, exposing the patient to dangers from direct 
injury to the tissues by the jagged edges of the tube, or to its separa- 
tion from its collar and its escape into the trachea as a foreign body. 
The ideal tube should be made out of one solid piece of metal, and 
best of silver. I have sometimes used leaden tubes made in this way, 
such as you see here, for the first few days after an operation; and I 
believe that the presence of the lead acts favorably upon the track of 
the wound. Usually, however, these metallic tubes are made of rolled 
plates, jointed and soldered. Wherever the tubes are soldered there are 
two metals in contact, one in the tube itself, the other in the solder. 
Wherever two metals in contact are immersed in a saline solution, 
there an electro-chemical decomposition is set up. Now, the secretions 
which accumulate around the tubes are alkaline, and so at the two 
points where the two metals are joined all the essentials for electro- 
chemical decomposition are present. Hence there is corrosion of the 
tubes from galvanic action. I pass around for your inspection a number 
of tubes thus corroded ; all are in a dangerous condition, some of them 
very precarious. Not only are the rough edges of the metal apt to 
produce ulceration, but after a while the tube may separate from its 
shield and drop down into the trachea. I have had several cases of 
this kind where the tubes got loose and dropped down into the trachea, 
and simply because the patients were too careless to take care of them, 
I have known patients to wear the same tubes seven years or more, 
and never take them out to clean them. Of course there is not so 
much danger to the patient’s life on account of the tube dropping into 
the windpipe as there would be from most other foreign bodies, because 
it is of such a shape that the patient can breathe through it. It can, 
too, usually be easily lifted out by running through it a thick copper 
wire the end of which has been bent into a blunt hook to catch around 
its distal extremity. 
Another point to which I would call attention is the superiority 
of silver, or metallic tubes generally, over hard rubber tubes. The 
reasons why you should use metal and not hard rubber tubes are: 
First, because the hard rubber breaks easily and the tube may escape LARYNGOLOGY : SOLIS-COHEN. 
289 
into the trachea; secondly, because it takes up more room : it is 
thicker, and thus cuts off the patient’s breathing-space to a greater 
extent than a thinner metallic tube. The most important point, how- 
ever, is this: a silver tube becomes tarnished by the secretions. If 
any necrosis of tissues occurs around the tube in the track of the 
wound or in the trachea, as is so frequent after tracheotomy, especially 
in cases of croup or diphtheria, it soils the silver tube and does not 
soil the rubber tube. Hence, when you take out the metal tube and 
see a black or a discolored spot upon it, you are made aware of the 
danger; and you can then relieve the pressure to which it is most 
likely due by putting a compress under the collar or shield of the 
tube, above or below as may be required. 
attention is a very neat way of having 
your tapes attached to the collar of the 
tube with buttons and button-holes, 
instead of having them sewed on. (See 
Fig. 1.) Then, when you want to 
change the tapes, on account of being 
soiled with blood or with other prod- 
ucts, you do not have to pull the tube 
out and leave it out for a time while 
new tapes are being sewed to the collar. 
You just unbutton one side, and replace 
it with a new tape; and then repeat the 
procedure on the other side. Always 
have one tape shorter than the other, 
so that you can fasten the knot on one 
side of the neck, and not be compelled 
to raise the patient’s head to unloosen 
the tube or take it off, as yon have to 
Another point of minor importance to which I desire to call your 
Tracheotomy Tubes for Adult 
(one-half measurement).—1, tube with 
pilot, and tapes secured with buttons 
ready for insertion; 2, perforated pilot; 
3, inner tube; a, section of lumen of 
tracheal extremity of inner tube; cir- 
cular; b, section of lumen of tracheal 
extremity of inner tube: oval. 
do when the tapes are of equal length and are fastened behind. 
You will note, too, that these tubes are provided with a catheter- 
shaped guide to facilitate introduction without stretching the lips of 
the incision. 
There is, in the case of tracheotomized subjects, a point of physio- 
logical interest to which I wish to call your attention. You are aware 
that the air inspired into the lungs receives heat and moisture in its 
passage through the nose. Some physiologists and some laryngologists 
contend that the air thus breathed becomes thoroughly saturated with 
moisture in the nasal passages, and is therefore incapable of receiving 
Yol. 1.—19 290 
INTERNATIONAL CLINICS. 
any more moisture from the lungs. They infer from this that our 
notions are wrong that any of the halitus of the expired breath, which 
we know will condense upon a polished surface, is due to saturation of 
the air from the lungs. While experiments with glass tubes upon the 
normal subject may confirm this inference, clinical observation on the 
tracheotomized patient does not support the opinion. The air expired 
from the cauula of a tracheotomized subject with complete occlusion 
above the artificial orifice will sully a polished surface and condense in 
the atmosphere on a cold day, just as will the breath from the nostrils 
of the normal subject. A tracheotomized patient of mine, with prac- 
tical occlusion of the glottis, who could not bear his canula to be 
stopped up even for a minute, was very much annoyed in winter-time 
by having people come up to him and tell him that his collar or neck- 
cloth was on fire. He wore a cloth over his canula, and the expira- 
tory current of air escaped above it. The stream of condensed 
moisture issuing from his neck behind his collar looked like smoke, 
and led some of the passers-by to imagine that a spark from a cigar 
had fallen on his neck-gear and had set it on fire. While the air 
breathed through a tracheal cauula becomes heated by the warmth of 
the garment the patient may wear over his tube, its moisture in cases 
of complete occlusion must certainly be derived entirely from the 
tracheo-bronchial tract and the pulmonary spaces. 
And now, as to the history of the case before you. Eight years 
ago this boy had croup or diphtheria in Denver, Colorado, followed by 
multiple papillomata in the larynx, for which Professor Davis, in the 
college there, performed tracheotomy when the lad was almost in the 
agonies of death. In consequence of inflammatory action, papillomata 
developed here in the larynx, as they often do after measles, croup, 
and diphtheria, and sometimes after whooping-cough. I know of no 
more frequent cause of papilloma in the child than the inflammation 
in the larynx accompanying measles. The physicians were unable to 
remove the papillomata through the mouth, on account of the youth 
of the patient, and Dr. Davis then split the larynx and removed the 
growth. Recurrence ensued, and two years later Dr. Davis kindly 
sent the patient to me. I sent him to the German Hospital for opera- 
tion. Recognizing my inability to remove the morbid growths through 
the mouth, I split the larynx open a second time and removed the 
growths thoroughly by direct access. Although we did not practise 
antisepsis then as now, the reaction was so slight that the next day, 
when I had just repeated a similar operation on an adult, this child was 
found standing by in his night-dress to see what the doctor had done LARYNGOLOGY : SOLIS-COHEN. 
291 
to him the day before. He got perfectly well. A few weeks after- 
wards, on account of a recurrence of these growths, I split open the 
larynx a third time. A few months afterwards I was compelled to 
open the trachea below the tube and remove some growths there. I 
think I performed the last of these operations some six years ago. 
Since then there has been no occasion for a major operation; but there 
has been a great disposition to repullulations in the parts originally 
implicated, and I have taken out several masses through the mouth 
upon various occasions and at varying intervals. The result of these 
repeated proliferations of tissue and removal by evulsion and by elec- 
tric cauterization has been to produce an irregular stricture of the 
larynx at the glottis, so that the lad has been compelled to wear his 
tracheotomy-tube as a permanent fixture. I made repeated attempts 
at dilating this stricture as opportunities presented in the very irregular 
intervals of the patient’s attendance, but without much progress. The 
methods pursued will be described to you a little later, in connection 
with some general observations on the treatment of stricture of the 
larynx. 
Some two years ago I thought I would attempt to relieve the boy 
of his tube, and sent him to the Children’s Hospital and put in an 
intubation-tube, which he wore for several weeks. I did not see that 
it did any good. After removing the tube I thought the parts were 
more constricted and the passage for air smaller, and I replaced the 
tracheotomy-tube. Shortly afterwards I removed the tracheotomy-tube 
and had the child carefully watched, thinking perhaps he might be able 
to do without it; but a few days later he was brought to my office in 
the arms of a nurse, black in the face and unconscious,—in fact, 
almost asphyxiated. I seized an ordinary trocar and canula that was 
lying on my table and plunged it into the trachea at the seat of the 
original orifice, withdrew the trocar and left in the canula; and a few 
minutes later, after respiration had become re-established, I enlarged 
the wound and put in a tracheotomy-tube. He has worn a trache- 
otomy-tube ever since, though not the same tube all the time. I 
determined to defer further efforts at relief until the period of puberty 
should be reached, and which is now approaching. 
For the last few months the boy has been able to breathe with the 
orifice of the tube closed with a cork. And now I propose to have 
him stay in this hospital a while where he can be watched, while we 
make another attempt to see whether he can do without the tube. 
You know that after puberty the larynx in the male grows very 
rapidly. Before that period the larynx of the male and that of the 292 
INTERNATIONAL, CLINICS. 
female are much the same, and the voices are very much the same; 
but as the boy grows to manhood his voice gets deeper and more sono- 
rous, and he accordingly becomes able to take in a larger volume of 
air. 
This case, then, is one of stricture of the larynx, the result of re- 
peated operations for the removal of multiple growths near the glottis; a 
stricture which has long restricted the breathing-capacity of the patient. 
But now, as you see, the patient breathes with the tube occluded by a 
stopper, and I think that he may be able to breathe without it. Ido 
not intend to withdraw the tube and then close the exterior orifice at 
once. That would not be prudent. I have provided here a plug to 
place in the track of the wound, so that it will not close up after I 
have removed the tracheotomy-tube. It is cylindrical as far as it goes 
into the track of the wound. Beyond that point it is merely a thick 
wire with a bulbous extremity to facilitate its introduction. There is 
rarely any occasion to freshen the edges of a tracheal fistula of this 
kind to make it close. Closure is often complete after a few hours; 
almost invariably after a few days. Sometimes the outer opening will 
close almost immediately after removing the tube. In the very case 
which I detailed to you in exemplification of the uselessness and 
danger of a fenestrated tube, the orifice closed so tightly within ten 
minutes on one occasion that I was compelled to administer chloroform 
and enlarge it by incision so as to reintroduce the tube. It was this 
occurrence that taught me always to have a clean tube ready to replace 
the one withdrawn. The plug prevents this constriction of the orifice 
Pig. 2. 
by filling up the track of the tracheotomy-wouud 
just as the tracheotomy-tube does, and the slender 
wire in the trachea itself does not interfere with the 
breathing. Two tapes are tied to it, as to the plate 
of the tracheotomy-tube, so as to secure it around 
the neck. Thus protected, the fistula remains patent, 
and the resident physician can put in a tracheotomy- 
tube if necessary, in case the boy cannot breathe with- 
out it. 
Apparently cured 
stricture of larynx; 
extreme inspiration. 
(After protracted 
treatment by dilata- 
tion.) 
This boy has a deformed glottis (Fig. 2), and the 
vocal band on the left side is adherent to the ventricu- 
lar band above it, and does not move in phonation, but 
remains in the middle line. That is why the boy has this peculiar voice. 
The constriction prevents the vocal bands from coming together, and 
there is no truly vocal sound. Besides this, the larynx is a very 
small one. Under ordinary circumstances I would not trust it, for, LARYNGOLOGY : SOLIS-COHEN. 
293 
when a larynx is constricted by chronic disease, it takes but little 
acute inflammation to close it entirely. But, as the lad has become 
accustomed to his constricted glottis, he may probably be able to con- 
tinue to breathe through it. It may even become dilated under the 
influence of the compressing and somewhat forcible inspiratory current 
of respiration. We find, too, in chronic disease, that the larynx 
gradually becomes accustomed to gradually increasing stenosis, so that 
the patient can live comfortably with a breathing-passage so small 
that it would be certain to produce suffocation were the occlusion to 
occur suddenly as the result of accident or of acute disease. In chronic 
diseases, therefore, we do not run the risk in trusting to a constricted 
orifice that we would run in acute disease. 
And now, gentlemen, a few remarks upon the general treatment of 
stricture of the larynx, which is essentially the same, as far as the 
mechanical features are concerned, no matter what the cause of the 
stricture. It is caused by inflammation and infiltration of the tissues 
and the concentric cicatrization of breaches of continuity. It may be 
due, as in the case before you, to recurrent morbid growths and the 
operative procedures for their eradication. It may be due to syphilis, 
to tuberculosis, to lupus, and other diseases, or to surgical or other 
Injury. The treatment is by dilalation, like that of stricture in any 
other passage,—the urethra and oesophagus, for example; only it is 
considerably more difficult, on account of involving the narrow portion 
of the respiratory tract, the patency of which must be preserved at all 
hazards. Graduated dilators of various kinds, so bent as to be readily 
introduced through the mouth, have been devised. When they are to 
remain in the passages more than a very few seconds at a time, they 
should be perforated so as to permit the passage of the respiratory 
currents of air. Especially is this necessary when the patient is not 
wearing a tracheotomy-tube. When the patient wears a tracheotomy- 
tube, solid dilators are sometimes used. They may be retained for hours 
at a time with impunity to the breathing, as they are inserted above the 
orifice of the fistula in the trachea. As the treatment progresses, larger 
and larger dilators are used, until the normal calibre of the narrowest 
portion of the laryngeal cavity has been attained, or until it becomes 
evident that no further dilatation is practicable. If the calibre of. the 
constriction becomes sufficient for respiratory purposes, the trache- 
otomy-tube is withdrawn under precautions somewhat like those that 
have just been shown you. Treatment by gradual dilatation is a very 
protracted procedure. If you ever attempt it, be frank enough to 
your patient to state that it will take a period varying from six to 294 
INTERNATIONAL CLINICS. 
eighteen months to accomplish any permanently satisfactory result. 
Your experience will then be like mine. You will lose a number of 
patients who will waste time in attendance upon practitioners who 
give them more encouragement; but you will have the satisfaction of 
curing most of the few who do remain under your care, while your per- 
centages of successful results will be better. I have succeeded in 
permanently curing several desperate cases of stricture of the larynx. 
And now let me give you one important piece of advice in com- 
mencing this treatment. Remember that you have a concentric con- 
striction, more or less irregular of course in the majority of cases, but 
practically concentric and retractile. You can stretch it with suitable 
contrivances, but when you relax the stretching force the constriction 
will recur, and may even become greater than when you began, as it 
did in this boy, who wore an intubation-tube with perfect safety for 
several weeks. I should, therefore, recommend you to nick the stric- 
Fig. 3. 
Mackenzie’s Dilatob (two-fifths measurement).—A (closed).—h, ring-handle; d, dial-plate 
s, dilating screw. B, open. 
ture with an exposed or guarded knife, as may be, at one or more of 
the most constricted portions, before you leave any dilator in the stric- 
ture for therapeutic purposes. In this way you enlarge the stricture 
before you dilate. Then with some special dilating contrivance you 
may stretch the stricture, and will be able to insert a much larger LARYNGOLOGY : SOLIS-COHEN. 
295 
dilator than otherwise. When the fresh wounds cicatrize around this 
dilator, you will probably have gained a little, after a while a little 
more in the same manner, and so on. The permanent pressure of the 
dilator, too, promotes absorption of resorbable elfused products in the 
constricting tissues, and thus tends to enlarge the constricted portion of 
the passage permanently. 
I show you a number of instruments, machines we might call them, 
devised to dilate a stricture of the larynx. They may be used to tear 
a stricture apart at some points by divulsion, but this use I do not 
recommend. One of the most ingenious is this device of Sir Morell 
Mackenzie (Fig. 3). It consists, as you see, of a three-bladed instru- 
ment with the laryngeal curve, the terminal or intralaryngeal portions 
of which are separable by turning a screw at the proximal extremity. 
Attached to this screw is a dial-plate so graduated as to indicate the 
calibre reached by the blades at the other end. Several other instru- 
ments of this kind have been devised by other practitioners. Mac- 
kenzie’s is the best, because the blades separate in such a way as to 
represent the normal shape of the distended glottis. But they all have 
Cohen’s Dilator.—2, blades open; 3, anterior; 4, posterior surface of open blades. 
the objection that the pressure is made only at certain points. It is 
not always the case that dilating force at these points will rupture a 
stricture or even dilate one that has been previously nicked. I far 
prefer an instrument devised by myself some sixteen or eighteen years 
ago, and then used for the first time upon a gentleman from Zaceteeas, 
Mexico, sent me for the purpose by an old friend, Dr. Prevost, of that 
city. It is composed, as you see (Fig. 4), of two flat rectangular blades 
which by scissors-movement at the handle are made to move upon a 
hinge anteriorly, so that when opened they represent precisely the tri- 
angular shape of the distended glottis, while they press upon the entire 
surface of the two sides of the triangle; the same sides pressed upon by 
one point only in Mackenzie’s instrument and other instruments of 
that class. In this instrument the pressure is uniform, dilatation is 
more systematic, regular, and effective, and is less injurious upon the 296 
INTERNATIONAL, CLINICS. 
parts pressed upon. I have seen no instrument devised since which 
appears to me equal to it. 
The stricture having been nicked and dilated, the procedure may be 
repeated at intervals to prevent reconstriction. The instrument I have 
just shown you was used daily, or almost daily, by the patient himself 
for a prolonged period. A better method, however, is to follow each 
nicking and stretching by the introduction of catheter-like perforated 
dilators of the configuration of the glottis, such as I show you here, 
and which are the device of Professor von Schrotter, of Vienna (Fig. 
5). It was by the use of these dilators that we have been able to 
overcome the stricture in the case before you. Here are a series of 
such tubes made of hard or vulcanized rubber, and graduated from 
the smallest to the largest size; and in connection with them here 
are a series of solid pewter plugs, externally of the configuration of 
the glottis, which are intended to replace the tubes for hours or days 
Schrotter’s Perforated Dilator.—a, extension tube to direct products of cough downward. 
B, external extremity of dilator; C, body of dilator; I), catheter-like inner extremity. 
at a time in cases of stricture in which a tracheotomy-tube is in use. 
The method of treatment is essentially as follows : As large a dilator 
as practicable is introduced and allowed to remain, according to the 
patient’s tolerance, from five minutes to half an hour or longer. It 
is then removed, and a dilator of the next larger size is immediately 
introduced and withdrawn a few seconds or a few minutes later. If 
the patient is wearing a tracheotomy-tube, the corresponding size of 
solid plug is introduced into the larynx and allowed to remain a 
number of hours or a day or longer as may be. These plugs, as you 
see, are three-cornered cylindroids with rods running through them. 
The upper portion of the rod is perforated so as to carry a string by 
means of which the plug can be withdrawn. The lower portion of the 
rod is knobbed so as to be seized in the grasp of a pair of forceps, 
which is introduced into the tracheal cannla through a large fenestrum 
in which the lower end of the plug penetrates a short distance. Lat- 
terly Schrotter has abandoned the knob, and has simply obliquely LARYNGOLOGY : SOLIS-COHEN. 
297 
perforated the tower extremity of the plug itself, which he fastens in 
position with a bolt which takes the place of the ordinary inner canula 
and is constructed practically in the same form. When the ping is to 
be removed, the bolt is drawn out, and a pull is made on the string 
which projects from the mouth. Introduction of the plug requires the 
use of a specially contrived conductor which clasps the upper end of 
the rod in the plug, and from which it is withdrawn by a tug when 
the ping has been placed in position. 
Introduction of the plugs requires the services of the physician ; 
but treatment by dilatation with the tubes only is sometimes confided 
to the patient, who often learns to introduce them much more deftly 
than the physician can. 
The frequency of these manipulations will, of course, depend upon 
conditions which vary in individual instances and concerning which 
you must depend upon your individual judgment. 
The patient should be taught to introduce the tubes himself, and 
should be instructed to repeat the process at intervals after withdraw- 
ing from professional care, on the same principles with which you give 
analogous instructions to a patient who has been under your care for 
stricture of the urethra. 
[The patient—seven weeks later—is still breathing comfortably 
without his canula, and is attending school.]