SUBGLOTTIC LARYNGEAL TUMOR. BY E. FLETCHER INGALS, M.D., OF CHICAGO. FROM THE MEDICAL NEWS, November 3, 188 S. [Reprinted from The MEDICAL News, Novembers, 1888.J SUBGLOTTIC LARYNGEAL TUMOR.1 E. FLETCHER INGALS, M.D., OF CHICAGO. Cartilaginous tumors of the larynx are so rare that I believe the report of a case which, although at present incomplete, seems in a fair way to be cured by endolaryngeal treatment, will be of general interest. At the New York meeting of the American Laryn- gological Association in 1884, Dr. Morris J. Asch2 presented the history of a case of laryngeal ecchon- drosis together with a resume of the literature of the subject. He cites eight cases besides his own, only two of which were accurately diagnosticated and treated during the patient’s lifetime, and only one of these had been treated by endolaryngeal methods. By consulting the library of the Surgeon-General’s Office at Washington I have been unable to find records of any other cases excepting one of immense fibro-enchondroma of the hyoid bone and larynx 1 Read at the American Laryngological Association, in Wash- ington, September, 1888. 2 Trans. Amer. Laryngological Association, 1884,-p. 66. 2 INGALS, which was skilfully removed by Dr. Azzio Caselli1 twenty-four hours before the patient’s death. This, however, should hardly be included with laryngeal growths, although at first it seemed to spring from the outer surface of the thyroid cartilage. Dr. Asch’s case, in which the tumor grew from the upper part of the thyroid cartilage, and Stoerk’s case, in which it occupied a site at the base of the left arytenoid and vocal process, are the only ones that have been successfully treated by endolaryngeal means. Virchow says2 that from the thickness and hardness of these tumors “they cannot be removed per vias naturales. ’ ’ In the case which I have to report the tumor was seated below the glottis, and although a cure has not been effected, four applications, made at intervals of from four to six weeks or more, caused a diminu- tion from its largest dimensions (about the size of a split cherry) to one-tenth of that size, and I feel confident that from two or three more applications it would have been entirely destroyed; therefore I feel justified in recommending a careful trial of the treatment in similar cases. The history is as follows ; Mr. X., aet. twenty-four, commercial traveller, came to me July 24, 1886, complaining of almost constant hoarseness which dated from exposure in a tornado about a year previously. His general health was perfect and there was positive evidence of no spe- cific taint. The vocal cords were slightly congested, 1 Ann. Univ. di. Med. e chir., 1880, ccliii. pp. 504-516. 2 Virchow, Path, des tumeurs, vol. i p. 442. SUBGLOTTIC LARYNGEAL TUMOR, 3 and at about the middle of the left cord there was a small conical outgrowth about three millimetres in diameter. In the subglottic region just below the anterior commissure I found a small, yellowish, somewhat conical tumor, measuring, as nearly as I could estimate, four millimetres in thickness at its highest part and six or seven millimetres across its base. Its surface was smooth but slightly nodular, and its base occupied partly the inner surface of the thyroid cartilage and partly the inner surface of the crico-thyroid membrane. Other portions of the larynx were normal. A solution of sulphate of zinc was applied by spray to the larynx and an astringent spray was ordered for daily use by the patient. This was con- tinued for about four weeks, when I again saw the patient. There had been little or no improvement. At that time, as a forlorn hope, I directed iodide of potassium to be taken in doses of from five to fif- teen grains three times a day. I saw the patient only twice during the next month, and made no further local applications. He continued to take the iodide of potassium in doses ranging from ten to twenty grains t. i. d. for eight months, but during the last six weeks previous to his fifth visit to my office in July 15, 1887, he had taken no medicine and had not used the spray. The cartilaginous tumor had increased in size so that, as near as I could estimate, it was six milli- metres in thickness and fully a centimetre in diameter at its base. The outgrowth had disappeared from the vocal cords and the congestion had subsided. At this visit, now fourteen months ago, I decided to suspend all other treatment and try the effects of cauterization with chromic acid. I anaesthetized the larynx with a ten per cent, spray of cocaine and then applied the caustic accurately to the whole sur- 4 INGALS, face of the tumor until it appeared of a uniform brownish-yellow color. This I succeeded in doing, without touching surrounding parts, though shortly afterward I found that the diffusion of the acid had tinged the anterior half of the vocal cords of a yellowish color. Six days later I found the larynx highly congested and I then applied a spray of a thirty-grain solution of sulphate of zinc. I did not see the patient again until the end of a month, when I found the tumor materially reduced in size. I again applied the caustic in the same manner. He returned again at the end of two months, when I find from my notes that his voice was perfect and as a result of two applications of chromic acid the growth had diminished to two-fifths of its former size. Owing to the patient’s business engagements the tumor was not cauterized at this time, but two months later, December 22, 1887, I cauterized it again, and again two months later I repeated the treatment. One month later, March 15, 1888, I found the tumor diminished to about one-tenth of its former size. On this date I made the sixth cauterization. I did not see the patient again until the 7th of August, about five months, when the tumor appeared to me somewhat larger than at the last treatment, or about one-fifth of its largest size. I again cauterized it with chromic acid. I saw the patient once more at the end of a month and found that the growth had been reduced about one-half by the last applica- tion. He was usually hoarse for three or four days after each treatment, therefore, because of his business engagements, further treatment was postponed until the end of September. SUBGLOTTIC LARYNGEAL TUMOR. 5 Dr. J. E. Rhodes, who has seen this case with me two or three times, concurs in my belief that the treatment would speedily eradicate the growth if two or three applications could be made at intervals of three or four weeks. I expect to follow this course the present fall and hope to be able to report a perfect cure. In making the applications of chromic acid I used an aluminium wire on the end of which a small amount of the acid was fused. Over this wire I slipped a section of small rubber tubing which had been cut away at its lower end to expose the acid in front. The section of tubing was made secure by tying it with a silk thread, which was extended along the wire to the handle so that there could be no possible chance of its dropping off. This I have found the simplest and most convenient instrument for applying caustics to the larynx. The rubber tubing protects the surrounding parts better than any other device I have seen. 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