DISEASES OF THE THROAT. REPORT OF DISEASES OF THE THROAT. 
F. I. Knight, M.D. Harv. 
trary, the polyp is situated 
high (at the tip of the epiglottis, for in- 
stance) to permit it to be seen directly, or 
when, with the laryngoscope, it is disco- 
vered in the cavity of the larynx, if its 
volume occasions slight dyspnoea, if it is 
implanted in such a manner that its dis- 
placement cannot lead to an unforeseen ac- 
cess of asphyxia ; if, in a word, it is possi- 
ble to prepare the patient, the operation 
will be performed per vias naturales 
Laryngotomy for the Removal of Neo- 
plasms (Krishaber, Planchon, Guyon, Cut- 
ter, Schwebel, Luschka).—A distinguished 
German laryngoscopist who has had much 
experience in the removal of neoplasms 
from the larynx, recently remarked that he 
had never performed laryngotomy for this 
purpose, because he had never had a case 
in which it was necessary in order to re- 
move the growTth. Still, there are cases in 
which it undoubtedly may be necessary on 
account of the situation of the growth (e.g., 
in the ventricle of Morgagni), the age of 
the patient, or some other peculiarity of 
the case. His remark, however, shows the' 
great improvements which have been made 
in the methods of operating per vias natu- 
rales. 
Per vias Aetificiales. 
“ Laryngotomy in cases of polyp of the 
larynx has hitherto been made very rarely. 
The proceedings employed are thus classi- 
fied : 
We wish, however, in the present article, 
to lay before our readers some account of 
the improved methods of laryngotomy, when 
this operation is necessary. Until the ap- 
pearance of Krishaber’s article (Diction- 
naire Encyclopedique des Sciences Medi- 
cates, 1868), no general laws in regard to 
the limitation of the operation had been laid 
down for the guidance of the surgeon. In 
this excellent article, M. Krishaber says : 
a. Section of all the parts of the larynx 
(cricoid, thyroid, the membrane which 
unites them and the thyro-hyoid mem- 
brane), plus some rings of the tra- 
chea. (Ehrmann, Gordon Buck, Gibb, 
Boeckel). 
b. Same operation without section of the 
cricoid (Debron). 
c. Section of the thyroid alone (Brauers, 
of Louvain). 
d. Section of the thyroid and of the thyro- 
hyoid membrane (Busch, Koeberle). 
e. Section of the cricoid and trachea 
(Gilewsky). 
f. Section of the thyro-hyoid membrane 
alone (Pratt, Follin).;? 
“ We have just seen, in considering the 
two dominant symptoms, that the polyp 
of the larynx being diagnosticated, the sur- 
geon, according to the nature of the symp- 
toms which it establishes, should make, 
sometimes, direct laryngotomy, sometimes 
this operation preceded by tracheotomy ; 
and ought sometimes, on the contrary, to 
operate per vias naturales.” “ When the 
polyp is voluminous and, situated in the 
cavity of the larynx, is liable to cause 
asphyxia, it is necessary to perform tra- 
cheotomy. If the polyp is multiple, if its 
extraction per vias naturales encounters dif- 
ficulties pertaining to the age or particular 
condition of the patient, if the nature, even, 
of the polyp causes a fear that a partial re- 
moval may cause a rapid multiplication, in 
all these cases the polyp should be extract- 
ed per vias artifidales. When, on the con- 
From a consideration of the cases referred 
to above, M. Krishaber draws the follow- 
ing inferences, which, on account of the 
limited number of cases, diversity of the 
operations and multiple conditions, he does 
not claim to be conclusive. 
“ 1. There are cases where destruction 
at their seat and removal of polyps of the 
larynx are impossible per vias naturales, 
perhaps on account of their volume, per- 
haps for very many other reasons which we 
have developed at length. 
2. In these cases, two operative proceed- 
ings may be employed : 2 
a. Sub-thyroid laryngotomy, that is to 
say the section of the thyro-hyoid mem- 
brane, in case of multiple vegetation, 
as these have a tendency to recur (pa- 
pillomata) and as their seat docs not 
extend below the vocal cords. 
b. Sub-cricoid laryngotomy, that is to 
say the section of the tracheo-cricoid 
membrane, plus the section of some of 
the rings of the trachea, when the 
polyp is inserted below the vocal cords. 
d. Section of the thyroid cartilage and 
of the thyro-hyoid and crico-thyroid 
membranes. 
e. Section of the thyroid cartilage, of the 
thyro-hyoid, crico-thyroid membranes, 
and of the cricoid cartilage. 
f. Section of the thyroid cartilage, of the 
crico-thyroid, tracheo-cricoid mem- 
branes, of the cricoid, and of the first 
rings of the trachea. 
g. Section of the thyroid cartilage, of the 
thyro-hyoid, crico-thyroid membranes, 
of the cricoid, and of the first rings of 
the trachea. 
2. Laryngotomy indirect, comprising:— 
a. Horizontal section of the thyro-hyoid 
membrane. 
b. Horizontal section of the crico-thyroid 
membrane. 
c. Horizontal section of the tracheo-cri- 
coid membrane. 
d. Section of the cricoid and of the first 
rings of the trachea.” 
3. The section of the cricoid ought never 
to be practised, whatever may be the seat 
and volume of the tumor, this being always 
accessible by the proceedings above or be- 
low which we have just indicated. 
4, The section of the thyroid may be 
necessary, if the tumor is situated in the 
ventricle of Morgagni, but in this case 
alone. This section ought to be avoided 
under all other circumstances : 
a. Because the penetrating wounds of 
the thyroid produce, necessarily, lesion 
of the vocal cords, however exactly in 
the median line of the cartilage the 
operation may be performed. 
b. Because the wounds of the cartilages- 
of the larynx (and what we say here 
has reference, also, to the cricoid) may 
produce perichondritis and consecu- 
tive caries. 
c. Because these cartilages are quite of- 
ten ossified; because this ossification 
is ordinarily premature in individuals 
afflicted by diseases of the larynx, and 
because it is necessarily a cause of 
more difficult cicatrization. 
d. And because, in fact, all the surface 
of the cavity of the larynx is accessi- 
ble to the sight and to the touch, with- 
out the section of any of the cartilages 
of the larynx. 
M. Planchon then introduces, in detail, 
the cases which have come to his know- 
ledge where laryngotomy has been perform- 
ed according to one or another of these 
methods, either for removal of a neoplasm 
or a foreign body, and from a consideration 
of these cases draws the following con- 
clusions : 
“1. The artificial opening of the larynx 
has been made by two different proceed- 
ings : 
a. Laryngotomy, direct: section of the 
thyroid cartilage. 
b. Laryngotomy, indirect: section of the 
thyro-hyoid, crico-thyroid, or tracheo- 
cricoid membranes, 
2. These operations ought to be practis- 
ed independently, except in case of lesions 
extraordinarily extensive. 
5. In cases where asphyxia is imminent, 
tracheotomy will find its immediate in- 
dication, and the safety of the patient 
once reestablished by this operation, the 
surgeon will consider the consecutive 
proceedings which he should employ 
following the indications that we have 
developed in detail.” 
3. Tracheotomy will only be performed 
with laryngotomy when there are special 
indications. 
4. The section of the cricoid cartilage 
ought always to be avoided. 
5. The choice of the operation will be 
established by the exact diagnosis of the 
lesion. 
Dr. Charles Planchon (Fails Gliniques de 
Laryngofomie, Paris, 1869) adopts M. Krish- 
aber’s classification of operations with some 
extension as follows : 
6. The section of the thyroid cartilage is 
not serious as regards life; practised me- 
thodically, it is not serious for phonation. 
The ossification of this cartilage is not a 
contra-indication. The healing will only 
be slower. This operation may be made 
every time there is need of access into the 
cavity, proper, of the larynx. The new 
artificial passage can be augmented at will 
by the section of the conoid ligament and 
“I. Laryngotomy direct, comprising : 
a. Section of the thyroid cartilage alone. 
b. Section of the thyroid cartilage and 
of the thyro-hyoid membrane. 
c. Section 0f the thyroid cartilage and of 
the crico-thyroid membrane. 3 
of the crico-thyroid membrane, practised 
transversely perhaps to the right, perhaps 
to the left of the median line, perhaps on 
two sides at once. In certain cases of se- 
rious fracture of the larynx, thyroid laryn- 
gotomy should be made in preference to 
tracheotomy. It might be very useful in 
some cases of obliteration of the larynx 
consecutive to wounds of the respiratory 
tube, or certain grave affections of the 
organ. 
sufficient to open the larynx at this exact 
seat. 
“5. Of all the methods employed up to 
this time for the extraction of polyps, the 
operation, of which I have just given the 
history, is that in which the incision of 
the larynx is the least extensive. It is 
to this proceeding that I attribute the cure 
of the patient. I propose to call the ope- 
ration I have just described restricted thy- 
rotomy (thyrotomie restreinte).” 
7. Indirect laryngotomy should only be 
employed in very special cases. The pro- 
ceeding employed by Follin—section of 
the thyro-hyoid membrane immediately 
above the thyroid cartilage—is preferable 
to the proceeding of Malgaigne, section 
below the hyoid bone. 
It will be observed that M. Krishaber has 
very materially modified his opinion pre- 
viously expressed in regard to the necessity 
of injuring the vocal cords, in making section 
of the thyroid cartilage. 
M. Krishaber’s paper is supplemented by 
a report by Dr. F. Guyon, to whom the 
subject seems to have been referred, which 
approves of Krishaber’s method of operat- 
ing in the case reported, and says that thy- 
rotomy alone gives direct and complete 
access to the larynx, particularly to the 
ventricular cavities. It says that sub-hyoid 
laryngotomy practised according to the in- 
structions of Malgaigne only gives access 
to the vestibule of the larynx, that is, to 
parts accessible per vias naturales, and that 
furthermore this operation requires exten- 
sive incision, and that it is only at the bot- 
tom of a very deep wound that the surgeon 
perceives, with difficulty, the ary-epiglottic 
folds and the ventricular bands. When 
the incision is made nearer the thyroid car- 
tilage, as was performed by Follin, an 
easier access is gained to the larynx, par- 
ticularly to the posterior part. 
8. Section of the crico-thyroid membrane, 
and that of the tracheo-cricoid membrane, 
are very simple operations, but still more 
rarely applicable than the preceding.7’ 
M. Krishaber (La Thyrotomie Restreinte 
appliquee au polype du ventricule du la- 
rynx, Paris, 1869) gives a resume of a paper 
presented to the “ Societe Imperiale de Chi- 
rurgie,” in which he recommends section 
of the thyroid cartilage without section of 
any of the membranes, and containing the 
details of a case and the following conclu- 
sions derived from his farther experience : 
"1. There are cases of polyp of the 
larynx, in which destruction and extirpa- 
tion per vias naturales are impossible; in 
these cases, one can open the larynx direct- 
ly, obtain its complete cicatrization and the 
cure of the patient. 
“2. The choice of the mode of operation 
will depend upon the tumor and its struc- 
ture ; the opening of the larynx can be 
performed on the membranes of the larynx 
or on one of its cartilages. 
To reach the larynx by the course fol- 
lowed by Follin, it is necessai’y to divide a 
bursa and a cushion of fat often quite ex- 
tensive, to detach the epiglottis from its 
inferior attachment and to raise it. Section 
of the crico-thyroid membrane gives suffi- 
cient space to introduce a canula or instru- 
ments, but it does not permit one to see 
into the laryngeal cavity, it does not ne- 
cessitate a deep incision, but it exposes to 
injury the little crico-thyroid artery, hemor- 
rhage from which is not without gravity, 
on account of the liability of the blood to 
run into the air passages. 
“3. In cases where the polyp is implant- 
ed in the ventricule of Morgagni, section of 
the thyroid cartilage must be made. The 
separation thus obtained is sufficient for 
the extraction of even a voluminous polyp, 
without section of the thyro-hyoid and 
crico-thyroid membranes. The section of 
this cartilage can be made so as to spare 
the vocal cords, and then the voice remains 
intact. The presumed ossification of the 
cartilage is not a contra-indication although 
it retards cicatrization. 
Notwithstanding the fortunate results 
with regard to the voice which have been 
obtained by M. Krishaber and others, after 
section of the thyroid, considering the un- 
fortunate results obtained by other opera- 
tors and the results of experiments upon 
the cadaver, the report does not regard the 
operation to be without serious danger to 
the voice, but does not consider this a 
“ 4. Laryngotomy which consists in the 
section of the entire larynx, membranes 
and cartilages, such as has been performed 
a number of times, ought to be rejected. 
When, by means of the larynscope the 
exact seat of the tumor is established, it is 4 
contra-indication in cases where thyrotomy 
is indicated. In regard to the restriction 
of the operation proposed by M. Krishaber, 
the report considers that oftentimes in 
case of multiple sessile polypi, section of 
the thyroid cartilage alone might not give 
sufficient room for operation. In all these 
cases, there is always time, as M. Krisha- 
ber thinks, to enlarge the incision by divid- 
ing the membranes longitudinally. Balassa 
has twice incised the crico-thyroid mem- 
brane transversely, in order to separate 
more freely the two parts of the thyroid. 
This resource could be employed if the 
separation allowed by the longitudinal in- 
cision were not sufficient. 
moval of polypi (Wiener Med. Wochenschr., 
28 Juni und Juli, 1865. British Medical 
Journal, Sept,, 1865), (Planchon). The 
operation has been done twice since that 
time by Balassa, and once by Krishaber, 
whose case, an abstract of which was pub- 
lished in the Medical Times and Gazette, 
Nov. 20th, 1869, was remarkable from the 
fact that the patient spoke with a perfectly 
normal voice immediately after the operation. 
Schwebel (These de la Laryngotomie 
Thyroidienne et de ses Indications, Stras- 
bourg, 1866, p. 17), sajm the operation of la- 
ryngotomy being decided upon, if the patient 
is afflicted with intense dyspnoea, if suffoca- 
tion appears imminent, one should com- 
mence by practising tracheotomy and in- 
troducing a canula in order to -make sure 
of respiration, or rather should make laryn- 
go-tracheotomy by an incision of two rings 
of the trachea and of the cricoid cartilage. 
When, on the contrary, it has been decided 
to operate on a polyp which has not caused 
very serious trouble in respiration, and 
when asphyxia is not imminent, one can 
proceed to thyroid-laryngotomy without 
preliminary tracheotomy. 
It has been sufficiently demonstrated that 
simple thyrotomy gives sufficient space for 
operation within the larynx, for operators 
to impose upon themselves the rule only to 
pass the limits of the cartilage, when, in 
the course of the operation, necessity com- 
pels them to do so. 
Dr. Cutter, in a monograph entitled, 
Thyrotomy for the Removal of Laryngeal 
Growths, Modified (Boston, 1871), recom- 
mends, “ In the operation for the removal 
of growths in the larynx by section of the 
thyroid cartilage to hold the use of trache- 
otomy and the tracheotomy tube as a re- 
serve measure.’7 Dr. Cutter is certainly 
entitled to all the merit of originality in 
this method of operating, for he seems not 
to have been aware of the operations of 
pure thyrotomy which preceded this ; but 
we cannot call it the “ American method,” 
as it was done by others before he did it, 
and has been performed about an equal 
number of times in this country and in 
Europe, for the removal of growths, not 
taking into account the numerous opera- 
tions of this kind for the removal of foreign 
bodies. The first operation of simple thy- 
rotomy of which we have any record was 
performed by Brauers de Louvain, in 1833 
(Krishaber, Diction. Encyc., p. 162). Deb- 
ron reported a case to the Societe de Chirur- 
gie de Paris, March 30th, 1864 ( Gazette des 
Hopitaux, 1864, Nos. 76, 87, 88), (Krisha- 
ber), in which he attempted sub-hyoid 
laryngotomy, was obliged, on account of 
threatened asphyxia, to perform thyrotomy 
and finally to perform tracheotomy, the 
cricoid cartilage having been left intact. 
Koeberle (Gazette des Hopitaux, Jane 7th, 
1866j, reports a case in which he performed 
“ Laryngotomie d’emblee sans Tracheoto- 
mie,” for the removal of a growth, June 
19th, 1865. In Dec., 1864, Gilewski made 
a section of the thyroid cartilage and of 
the crico-thyroid membrane for the re- 
Laryngotomia Thyreoidea Lateralis. 
Luschka (Der Kehlkoph des Menschen, 
Tubingen, 1871, p. 19) suggests this ope- 
ration which has thus far only been per- 
fox-med on the cadaver. It is recommended, 
in case of neoplasm in the ventricle of 
Morgagni, when, from any cause, median 
thyrotomy does not seem advisable, or in 
case of any affection of the wall of the ven- 
tricle, removable by operative procedure. 
By this operation, it is proposed to open 
the ventricle of Morgagni without expos- 
ing the vocal cord or its muscle to any 
danger of injury. 
This suggestion is founded on the well 
known fact, that the ventricles of the larynx 
extend upward on each side to the neigh- 
borhood of the upper border of the lateral 
wings of the thyroid cartilage. 
The long axis of the ventricle runs nearly 
in the direction of a vertical line, drawn 
between the first and second quarter of the 
horizontal distance, between the incisura 
thyreoidea superior and the posterior bor- 
der of the thyroid cartilage. This vertical 
line indicates the direction of the incision 
for lateral thyrotomy, in the execution of 
which it is necessary to divide the skin, 
the muse, sub-cut. colli, the muse, sterno- 
hyoideus, as well as the thyroid cartilage 
from top to bottom. After the edges of 
the cartilage have been drawn asunder by 
blunt hooks, the upper end of the ven- 
tricle of Morgagni comes into view in such 5 
a manner that there is no difficulty in con- 
tinuing the incision through its lateral wall 
as far as the level of the upper surface of 
the vocal cords. 
sion of the Vocal Cords.—Dr. M. J. Ross- 
bach ( Virchow’s Archiv, April 11th, 1872) 
reports two cases of special interest with 
reference to the physiology of the voice, 
in which, during partial paralysis of one 
vocal cord, there were produced two tones 
instead of one, clearly distinguishable from 
each other. One tone had always the cha- 
racter of a chest-tone, the other that of a 
falsetto, Thq affected cord was seen to be 
stretched somewhat, but was not rendered 
so tense as that on the sound side. On at- 
tempted phonation, the arytenoid cartilages 
were not brought up quite to the median 
line ; hence there was not a complete clo- 
sure of the glottis. Dr. R. says that this 
formation at the same time of two tones 
by two unequally stretched cords, which, 
of course, were much weaker and less clear 
than a normal tone, admits probably of 
no other interpretation than that they 
have been formed by the vibrations of the 
vocal cords themselves. For, during the 
process of phonation the chink of the glot- 
tis was several millimetres wide and the 
processus vocales of the arytenoid carti- 
lages did not even touch each other, so that 
there could be no interrupted currents of 
air. Then, again, it is hard to think that 
one and the same current of air, set into un- 
equal vibrations by not equally rapid move- 
ment, should be divided into two tones. 
Dr. Mackenzie, in a letter {Lancet, Dec. 
2, 1871), replying to certain remarks of 
Mr. Durham in the Royal Medico-Chirurgi- 
cal Society, reiterates the opinion expressed 
in his Essay on Growths in the Larynx, 
considering it “a cardinal law that an extra 
laryngeal method ought never to he attempted 
(even when laryngoscopic treatment cannot 
be pursued), unless there be danger to life 
from suffocation or dysphagia.” 
Perichondritis Laryngea.—A case is re- 
ported in the British Medical Journal, July 
13th, 1812, which seems to have been one 
of perichondritis laryngea; it occurred at 
the Hull Infirmary under the care of Dr. 
G. F. Elliot. The case is remarkable from 
its having occurred in a robust man with- 
out any history of syphilis or other consti- 
tutional disease, and from its having re- 
covered without any necrosis. Ten weeks 
before admission, and shortly after the ces- 
sation of what seemed a slight cold, the 
patient noticed a difficulty in swallowing, 
and also that respiration was somewhat ob- 
structed, especially on making any exertion. 
When these symptoms had existed for about 
a month, he observed that his neck was 
harder and larger than natural, and this 
continued gradually to increase. On his 
admission, the most noticeable feature was 
the great increase in the antero-posterior 
diameter of the neck ; the swelling was 
evidently situated in the thyroid cartilage ; 
it was hard, painless on pressure, and pre- 
sented no indication of suppuration. He 
was ordered an iodide of potassium mix- 
ture, and the local application of iodide of 
ammonium ointment. On the 28th of Feb- 
ruary, he was suddenly seized with a com- 
plete obstruction to respiration. Mr. Plax- 
ton, the house-surgeon, having been imme- 
diately summoned, with great promptitude 
opened the trachea, and respiration (all at- 
tempts at which had ceased) was happily 
restored by intermittent pressure on the 
thorax. The necessary incision gave vent 
to a quantity of somewhat glaiz-y-looking 
pus. From this time, the man’s improve- 
ment was uninterrupted, the swelling of 
the neck gradually subsided, and the thick- 
ened thyroid cartilage became nearly re- 
duced to its natural dimensions. The tube 
was removed on the 7th of May, rather 
more than two months after its incision ; 
the opening rapidly closed, and on the Ilth 
of May, he was discharged, well. 
Cases have been reported by Merkel and 
Tiirck in which a double tone was produced 
by a collection of mucus between the vo- 
cal cords and ventricular bands, and by 
growths and polyps on the vocal cords, 
dividing the glottis into unequal parts, but 
the above are the first cases reported in 
which a double tone was produced by une- 
qual tension of the vocal cords. 
Papilloma of the Larynx; Warts on the 
Hands.—Dr. Paluce de Marmon (iV. Y. 
Med. Record, Oct. Ist, 1872) reports the 
case of a patient 51 years of age, who had 
had whooping cough at 4, lasting four or 
five months. This was followed by hoarse- 
ness and aphonia. A homoeopathist had 
told the parents that the child “ would out- 
grow it.” Instead of this, however, it 
died suddenly of asphyxia. On post-mor- 
tem examination, a large papillomatous 
growth was found in the larynx. There 
were also half a dozen warts on the backs 
of the hands. Dr. M. is inclined to think 
that there was a connection between the 
two growths. 
Primitive Cancer of the Larynx.—Dr. 
Emile Blanc (Etude sur le Cancer primitif 
da Larynx, Paris, 18V2), at the end of his 
Double Tone of the Voice in unequal Ten- 6 
monograph, draws the following conclu- 
sions : 
fulfils its mission, which is to soothe if not 
to cure.” 
“1. Primitive cancer of the larynx is a 
rare affection ; the number of observations 
of laryngeal tumors in general, hitherto 
published, is very considerable ; that of 
cancer of this region is limited to less than 
thirty. 
The Electrolytic Treatment of Naso-Pha- 
ryngeal Polypi.—Dr. Paul Bruns, assistant in 
the surgical clinique at Tubingen, in an arti- 
cle on this subject (Berliner Klin. Woch- 
ensch., July 1,1872), reports a case* treated 
in the clinique of his father, a short notice of 
which has already appeared in the latter’s 
work on “ Galvano-Chirurgie.” A young 
man nineteen years of age, with a large 
nasb-pharyngeal polypus, appeared at the 
clinique in November, 1865. Treatment by 
means of Electrolysis was attempted, but 
given up after six applications on account 
of want of noticeable improvement and of 
the proper apparatus. In December, 1866, 
the tumor was extirpated by means of a 
wire sling, but there remained a small part, 
which could not be immediately removed 
on account of profuse bleeding and faint- 
ness. The patient appeared again at the 
clinique towards the end of the year 1868. 
The tumor had grown to a much greater 
size than before the extraction. 
“2. The point of origin and the seat of 
election of cancer of the larynx, is espe- 
cially the mucous membrane of the ventri- 
cle of Morgagni. 
“ 3. The principal varieties of cancer of 
the larynx are medullary cancer and epithe- 
lioma. 
“ 4. Left to itself, cancer of the larynx 
invades the neighboring tissues, contract- 
ing the respiratory passages and those of 
deglutition. The cartilages of the larynx 
oppose for a long time the progress of the 
disease, but they end by being involved in 
their turn, and then the progress of the 
tumor is arrested only by the death of the 
patient. 
“5. At the beginning of the affection, in 
spite of the most careful laryngoscopic ex- 
amination, it is very difficult to recognize 
the cancerous nature of a laryngeal tumor. 
Later, the rapid extension and the peculiar 
aspect of the neoplasm, the ganglionic en- 
gorgement and the final cachexy make the 
diagnosis certain. 
It now caused a very considerable dis- 
figurement of the face, which was notice- 
able at the first glance. Nearly the whole of 
the left half of the face appeared pushed 
up, the left half of the nose was noticeably 
broadened, the left nostril much dilated and 
filled up by a pale-red smooth swelling. 
The fossa canina and temporalis of the 
same side were filled up, the whole cheek 
pushed forward. The globe of the left eye 
stood several lines farther forward, and was 
at the same time displaced outwards and 
downwards. In consequence of this, there 
existed diplopia, incomplete closure of the 
lid and impaired action of the internal rec- 
tus muscle. 
“ 6. The treatment recognizes two prin- 
cipal indications : 
a. To remove the disease. 
b. To palliate the most urgent symptoms 
and especially the threatening of asphyxia. 
This last indication is fulfilled by tracheoto- 
my, the first by the extirpation of the tu- 
mor. According to the case, this removal 
is practised by the mouth or by different 
procedures of laryngotomy. 
The pharyngeal cavity was nearly com- 
pletely filled up with a very resistent tumor, 
which pushed forward between the edges 
of the artificial slit in the soft palate, which 
was made previously to the first operation, 
into the mouth and downwards as far as the 
lower end of the uvula. 
“ Laryngotomy is always indicated when 
the tumor is not accessible by the natural 
passages, or when by this latter means we 
do not succeed in the total destruction of 
the neoplasm. In conclusion, however 
well practised and however radical it may 
be, extirpation is constantly followed, some- 
times by local recurrence, sometimes by 
secondary generalization, and finally by 
death by cancerous cachexy. Always, if 
one does not succeed in saving the life of 
the patient, at least he mitigates and pro- 
longs it. It was thus that in the case ob- 
served by M. Desormeaux laryngotomy 
permitted the subject to survive for three 
years. Here, then, as in other analogous 
circumstances, surgical art by interfering 
Both nostrils were impervious to the air, 
the left in consequence of complete stop- 
page by the nasal part of the polypus, the 
right in consequence of the pushing of the 
septum towards this side, and the closure 
of its posterior opening by the growth. 
Respiration and deglutition were rendered 
* An allusion to this article has been already made in 
the report on Electro-Therapeutics, Oct. 31, 1872, but 
the great importance of any aid in treating this most 
troublesome affection leads me to give the details of Dr. 
Bruns’s case, and some particulars not given by Dr. Lin- 
coln. 7 
difficult. Hearing on the left side and the 
sense of smell were entirely lost. There 
existed also a condition of great general 
debility and frequent somnolency. From 
the above appearances the diagnosis of a 
so called retro-maxillary tumor (Langen- 
beck) was made, the extirpation of which 
it was thought could only be made by 
means of a temporary (osteoplastic) resec- 
tion of the upper jaw. Instead of this, the 
attempt to destroy the tumor by electro- 
puncture was repeated, and this treatment 
was commenced May 2d, 1869. The elec- 
trolytic treatment was continued to the end 
of March, 1810, and during these eleven 
months there were made one hundred and 
thirty applications, sometimes daily and 
sometimes at the interval of one or several 
days. The duration of one application was 
ten to fifteen minutes. After the first sit- 
ting, the left nostril was a little pervious 
to the air; after the tenth sitting, there was 
an evident diminution in the size of the 
pharyngeal part of the polyp. It continued 
gradually to diminish in size, and after forty 
sittings the anterior end of the nasal part 
was three centimetres removed from the 
edge of the nostril. There was notable im- 
provement in breathing through the nose, 
the globe of the left eye was less promi- 
nent, its movement less hindered, and there 
was no diplopia. After sixty sittings no 
exophthalmos existed; the nasal part of 
the tumor was four centimetres from the 
nasal opening. After eighty sittings the 
polyp was five centimetres from the nasal 
opening; the pharyngeal part was no longer 
visible in the cleft of the palate, and could 
only be reached by means of a curved 
needle. After one hundred sittings, by 
rhinoscopic examination there was seen in 
the remainder of the tumor, which was of 
the size of a walnut, a deeg ulcerating hole 
covered with purulent secretion which was 
soft to the touch, friable, and surrounded 
by resisting edges. After one hundred and 
thirty sittings, at the conclusion of the 
treatment, the outward deformity of the 
face, the prominence of the whole left upper 
half of the face, and the dislocation of the 
globe of the eye had disappeared. Both 
nostrils were pervious to the air, the nasal 
part of the polyp had entirely disappeared, 
the pharyngeal part was no longer visible 
in the cleft of the palate, and only a hard 
knot of the size of a bean remained on the 
posterior edge of the vomer. .Respiration 
and deglutition were unimpeded; hearing 
in the left ear was nearly normal. Up to 
March, 1872, there had been no sign of a 
recurrence of the growth in this patient; 
he had remained in the hospital as an atten- 
dant. 
Dr. Bruns then gives abstracts of eight 
other cases of naso-pharyngeal polypi, 
which had been successfully treated by 
electrolysis. Five had been observed by 
Nelaton, two by Ciniselli, and one by 
Fischer. 
In six of these, there was a complete 
cure, and in the remaining two the cure was 
incomplete ; in the first in consequence of 
intercurrent typhus fever, which proved 
fatal, and in the second because the report 
was made before the conclusion of the treat- 
ment. In none of these cases had a recur- 
rence occurred. The duration of the treat- 
ment in those cases where it is stated, is 
reported to have been as follows : six sit- 
tings, nine sittings at long intervals, six sit- 
tings within six weeks, and six sittings 
within about three months. In these cases, 
where the application was made at such 
long intervals, the current employed was of 
much greater intensity than in the case of 
Professor Bruns. In one of Nelaton’s cases 
an operation had been previously performed 
by means of re-section of the hard palate, 
and there was a recurrence of the growth 
after three months. Eight months after 
the cure by electrolysis, there had been no 
recurrence. 
Dr. Bruns does not claim that this method 
of treatment can be employed with success 
in all cases, and, indeed, mentions a case 
already reported by himself [Berliner Klin. 
Wochenschr. 12 u. 13, 1812), in which, after 
unsuccessful employment of electrolysis, 
extirpation was performed. 
The histological character of the tumors 
successfully operated upon by electrolysis 
seems to have been fibrous ; in the one un- 
successful case the tumor is described as 
being composed of a tissue in part purely 
fibrous, and in part very rich in cells ap- 
proaching the sarcoma. Contrary to the 
custom in the treatment of tumors situated 
in other parts of the body, experience 
seems to show that it is better to employ 
a weak current, frequently repeated, than a 
strong one at longer intervals ; the close 
proximity of the brain and the serious local 
disturbance which might be set up by the 
strong current, would indicate caution in 
this respect. 
Dr. Bruns does not consider that in any 
base a diminution of the tumor was due to 
catalytic or escharotic action alone, but to 
both combined. In conclusion, Dr. Bruns 
says that there is inducement enough in pre- 
vious experience to warrant the employment 
of electrolysis in other cases, even if we 8 
cannot share the enthusiasm of Dolbeau, 
who characterizes its employment as “ une 
methode qui parait destinee a faire dispa- 
raitre toutes celles qui I’ont precedee.” 
nodular varieties. The treatment which 
has been found most successful in this va- 
riety by Dr, M., is the introduction of a 
twine seton passed transversely through 
the whole substance of the gland.' 
On the Differential Diagnosis and Treat- 
ment of Bronchocele.—Dr. Morell Macken- 
zie (Lancet, May 4th and 11th, 1872) 
gives an interesting paper on this sub- 
ject, which he had read before the Hunteri- 
an Society. 
Counter-irritation, or applications of 
tincture of iodine or iodine ointment, or 
the injection of a solution of iodine, have 
proved quite unavailing. Out of one hun- 
dred and one cases of the fibrous varie- 
ty which came under notice, in thirty-one 
the tumor was so small and the inconve- 
nience so slight that treatment was not 
recommended; and nine patients, who were 
told that the disease was not dangerous to 
life, declined treatment. Of the remaining 
sixty-one, in forty-two the result was com- 
pletely successful. In eleven, there was 
considerable improvement ; in five, no 
change, and in three the parties ceased to 
attend before the result could be ascer- 
tained. In the two illustrative cases intro- 
duced by Dr. M., the dyspnoea was relieved 
within a day or two after the introduction 
of the seton. 
He says that since Coindet discovered 
the medicinal value of iodine, the therapeu- 
tics of goitre have - remained almost sta- 
tionary. Whilst, however, iodine exercises 
such a beneficial influence over some forms 
of goitre, in others it is quite inoperative, 
and hence it becomes important to differ- 
entiate the varieties of the disease which 
are met with in practice. Dr. Mackenzie 
divides bronchocele into seven varieties, 
viz. : (1) simple or adenoid, (2) fibrous, 
(3) cystic, (4) fibro-cystic, (5) fibro-nodu- 
lar, (6) colloid, and (7) vascular. 
The disease may present the characteris- 
tic features of any one of the types referred 
to, or many of the different varieties may 
be associated together in varying degrees. 
The internal administration of iodine is a 
specific for the endemic variety of simple 
or adenoid bronchocele; and, though it 
likewise often cures sporadic cases, it is fre- 
quently unavailing. 
The treatment of cystic goitre which Dr. 
M. likes best, is the conversion of the cyst 
into a chronic abscess. The treatment 
which most rapidly produces suppuration 
also most effectually arrests the haemor- 
rhage. The method of procedure is as fol- 
lows: Ist. Empty the cyst; when prac- 
ticable, make the puncture as near as possi- 
ble to the median line in the most dependent 
portion of the tumor. As soon as the 
trocar is felt to pierce the cystic wall, it 
should be withdrawn and the canula passed 
further in by means of a blunt pointed key. 
The fluid having been withdrawn, a solution 
of per-chloride of iron (two drachms to the 
ounce), is injected through the canula by 
means of a syringe, the plug is inserted, 
and the canula secured in position by a strip 
of plaster. Tl*e injection of iron is repeated 
at intervals of two or three days until sup- 
puration is established. When this point 
is reached, the tube is withdrawn, poultices 
are applied, and the case treated as a 
chronic abscess. When there is more than 
one cyst, the others can frequently be 
opened through the cyst originally punc- 
tured, and in this way some scars may be 
avoided. Of thirty-nine cases of cystic 
goitre, thirty-eight underwent treatment; 
all of these were completely cured. 
Simple hypertrophy occurring in weak 
anremic girls, is most effectually treated by 
iron and proper hygienic measures. Cases 
not yielding to internal treatment may al- 
most invariably be cured by counter-irrita- 
tion, or the internal and external treatment 
maybe combined. The liquor epispasticus 
of the British Pharmacopoeia, applied about 
twice a week on alternate sides of the 
throat, is the remedy which Dr. M. usually 
employs. Electrolysis had also proved of 
great service in some cases. Of the fifty- 
four cases of simple goitre of which notes 
were taken, forty-seven underwent treat- 
ment. In thirty-five the enlargement en- 
tirely disappeared, five were lost sight of 
after a few visits, and in seven no appreci- 
able alteration took place. 
Fibrous Bronchocele may. attack either 
lobe, the isthmus, or the whole gland, but 
it is comparatively rare that the isthmus 
alone is affected. To the touch fibrous 
goitre is smooth, hard, and unyielding. It 
does not, as a rule, cause any disturbance of 
function, but in some cases it presses on 
the trachea and produces dyspnoea. When 
once established it never disappears spon- 
taneously, though it may occasionally be 
developed into the fibro-cystic or fibro- 
The treatment of a case of fibro-cystic 
goitre consisted in the evacuation of the 
cysts and the injection of iron, and after 
the obliteration of the cysts, the introduc- 
tion of a drainage-tube, from left to right, 
through the entire mass. 9 
Great induration remaining, two caustic 
darts were introduced. By this treatment 
the circumference of the throat was reduced 
five inches and a half. 
least, causes no dyspnoea, but complete 
loss of voice, difficult expectoration and 
impossibility of forcible cough. There is 
the same want of dyspnoea in complete pa- 
ralysis of the recurrent on one side. This 
is easily explained from the position of one 
or both vocal cords in these cases. With 
reference to this point, the views of differ- 
ent authors seem to differ considerably. 
Many pathologists have spoken of paraly- 
sis of the recurrent when the paralyzed vo- 
cal cord is displaced nearly or quite up to 
the median line. Such a conception seems 
to Riegel to be erroneous. Complete pa- 
ralysis of the recurrent can never result in 
a position of the vocal cord exactly on the 
median line. He does not deny that such 
a median position can be the consequence 
of an affection of the recurrent, as a neuro- 
pathic paralysis; but in the peculiar me- 
dian position of the vocal cord there is 
never a paralysis of all the muscles of the 
larynx.* 
In fibro-nodular bronchocele, treatment 
has seldom any beneficial effect. 
Of two reported cases of colloid bron- 
chocele, one was treated by electrolysis, and 
the other by a seton, both unsuccessfully. 
Dr. M. thinks that with his increased expe- 
rience both of these cases might have been 
successfully ti’eated by irritating setons 
or caustic darts. 
No case of the vascular form of bron- 
chocele occurred. The rule which Dr. 
Mackenzie has adopted with reference to 
the advisability of surgical interference in 
cases of goitre is, not to •recommend patients 
to undergo treatment unless there is serious 
embarrassment of function or continuous 
increase of the tumor ; but, as none of the 
various methods of treatment employed by 
him have hitherto been attended by fatal 
results in his practice, he has always been 
willing to carry out treatment when the 
patient desired it, on account of disfigure- 
ment. 
From this position of the glottis in com- 
plete paralysis of the recurrent, the want 
of dyspnoea, at least under ordinary cir- 
cumstances, is easily explained. The me- 
dian position, however, pre-supposes an 
activity of the vocal cord ; it can only oc- 
cur through action of the adductors, and, 
therefore, can never he observed in com- 
plete paralysis of the cord. Neither is 
much dyspnoea possible in this form of pa- 
ralysis, as there is still sufficient room for 
inspiration and expiration, as the glottis 
now in a manner assumes a mean position, 
the resultant of those two positions, which 
correspond to the two functions of vocali- 
zation and respiration. The same thing 
must naturally hold good for complete pa- 
ralysis of the recurrent on one side. Here, 
the conditions for the production of dysp- 
noea are still more unfavorable. If we ask, 
on the contrary, which form of paralysis of 
the vocal cords produces dyspnoea, it is 
evidently the paralysis of the adductors. 
This form, also, of paralysis, like the com- 
plete paralysis of the recurrent, can occur 
on one or both sides. Paralysis of the abduc- 
tors, while the adductors remain intact, is 
not followed by a mean position of the vocal 
cords and arytenoid cartilages. One would 
here, indeed, expect the same position as 
on the cadaver, with the possibility of ap- 
proximation to the median line on intona- 
tion. Observation shows, however, that 
this does not occur, or at least such a con- 
dition has not been seen in those cases 
which have been considered paralysis of 
the abductors. The picture of paralysis of 
Paralysis of the Abductors of the Vocal 
Cords.—Dr. Franz Riegel, Privat-Docent 
and First Assistant in the Medical Clinique 
at Wurzburg (Berliner Klin. Woch., May 
18th and 20th, 1812), says that paralysis of 
one or a few muscles of the larynx is sel- 
dom met with; but when it does occur, it 
is generally myopathic ; much more rarely 
does it happen that only a single muscle or 
a small group of muscles is paralyzed in 
consequence of a central lesion, or one af- 
fecting the vagus and recurrent. He be- 
lieves the opinion of Gerhardt, that, in case 
of an affection of the recurrent only, a sin- 
gle group of muscles may be paralyzed, 
namely, the adductors and tensors, to be 
correct, notwithstanding the opposition of 
Navratil; and refers to a case reported by 
himself* in which paralysis and change in 
the voice came on immediately after an op- 
eration in a case of struma, evidently from 
injury to the recurrent nerve. The paraly- 
sis affected only a part of the muscles of 
the vocal cord on the side of the injury ; 
the widening of the glottis was completely 
unimpeded. Those cases in which the pa- 
ralysis is incomplete must not be consi- 
dered as myopathic ; for in an affection of 
the recurrent the paralysis may be incom- 
plete at first, and afterwards become com- 
plete. It seldom happens that paralysis of 
the vocal cords, under ordinary conditions, 
leads to disturbance of the respiration. 
Complete paralysis of the recurrent on both 
sides, under ordinary circumstances, at 
* Deutsches Archiv far Klin. Med., Band 6. 
* Complete paralysis of all the muscles of the larynx 
will produce only the post-mortem position of the vocal 
cord, and the ary tenoid cartilage. 10 
the abductor is characterized as follows : 
The vocal cord and arytenoid cartilage of 
the affected side stand near the median line 
immovable ; on deep inspiration, the cord 
does not move outward, but sometimes a 
little inward; its capacity for tension and 
vibration is not materially limited ; the 
voice, therefore, shows no essential change. 
It may be easily conceived how, on rela- 
tively little exertion, dyspnoea can arise 
from this median position of the paralyzed 
vocal cord. As the glottis-chink is dimin- 
ished by one-half, the increased demand for 
air during any marked bodily exertion can- 
not be satisfied, and dyspnoea is the result. 
The only abductor of the vocal cord is the 
crico-arytenoideus posticus. Paralysis of 
the abductor, therefore, is paralysis of 
this muscle. Paralysis of the abductors 
on both sides occurs very rarely. 
muscles, the limb is drawn gradually to 
one side. But in the larynx. Dr. Riegel 
thinks a negative factor is more important. 
When the vocal cord, in case of paralysis 
of the abductor, is brought into a state of 
adduction by intonation, cough, expectora- 
tion, &c., the power to widen the glottis 
again is wanting ; the cord retains the po- 
sition into which it has been brought, with 
the exception of what change may be due 
to a relaxation of tension. In case of 
total paralysis of an extremity, the flexors 
overcome the extensors. In the larynx, on 
the contrary, respiration being a more im- 
portant function than vocalization, we see 
the abductors overcome the adductors in 
case of complete paralysis. Hence the 
considerable drawing outward of the cords. 
If, on the contrary, only the abductor is 
paralyzed, the adductors obtain the prepon- 
derance, and hence a position results near 
the median line. This last position may 
only be arrived at gradually. Dr. Riegel 
alludes to the great rarity of bi-lateral pa- 
ralysis of the abductors, and says that 
Gerhardt’s case is the only other true one 
which has been published ; one or more 
cases, however, have been published by 
Mackenzie, and two by the writer.* 
After citing the cases of Gerhardt, Tiirck 
and JBiermer, Riegel introduces one of his 
own, in which there was paralysis of the 
crico-arytenoideus posticus on each side. 
The patient, a child 4 years old, was said 
by his parents frequently to throw hjs head 
strongly backwards and stretch his throat. 
On increase of dyspnoea, this position was 
particularly noticed by his parents. A sim- 
ilar condition obtained in Gerhardt’s case, 
who explained this by the power of the 
hyo-thyroideus, as antagonist of the 
crico-thyroideus, to approximate the thy- 
roid cartilage to the arytenoids with relaxa- 
tion of the vocal cords, and so to diminish 
the contraction of the glottis caused by 
tension of the same. The question remains 
how the position of the vocal cords, which 
has been mentioned as occurring in case of 
paralysis of the abductors, is produced. 
According to theory, paralysis of the ab- 
ductor, like complete paralysis of the re- 
current, would manifest itself by the ordi- 
nary post-mortem position of the vocal 
cord. It would then be distinguished from 
complete paralysis of the vocal cord by the 
existence of the power of adduction, and 
from paralysis of the adductor from the 
want of ability to move outward from the 
post-mortem position. Instead of the post- 
mortem position, however, we find the 
vocal cords much nearer.the median line. 
We see, therefore, an increased activity of 
the antagonistic muscles, as we see a pre- 
ponderating contraction of the flexors in 
paralysis of the extensors. So we can 
designate this appearance as paralytic con- 
traction of the vocal cord in the same way 
as we notice the secondary contractions in 
paralysis of the extremities. The occur- 
rence of such contractions in case of paraly- 
sis has been accounted for by the so-called 
antagonistic theory, whereby, in conse- 
quence of the tonicity of the non-paralyzed 
Successful Tracheotomy performed on 
a Child of Ten Months (Union Medicate, 
1812, No. 18); (Centralblatt fur die Med. 
Wissenschft, Aug. 23, 1812). Dujardin re- 
ports a case of croup in a child ten months 
old, in which tracheotomy was performed. 
It was necessary to wear the canula eight 
months. Now, after four years, a small, 
tracheal fistula exists. The reporter in the 
Centralblatt says this is the sixth success- 
ful case of tracheotomy in children under 
eighteen months reported in France. 
A Eemedy for Coryza.—E. Brandt (Ber- 
liner Wochenschrift. No. 12 and 18) ; ( Gen- 
tralb. fur die Med. Wissensch., No, 29, 1812) 
reports that for many years he had suffered 
every autumn with intense coryza,_lastiug 
several weeks, and that he has obtained a 
very favorable effect from the “ Olfactorium 
Anti-catarrh-oicum;; of Dr, Hager (acid 
carbol. 5 parts, spir. vini rectif. 15, liq. 
ammonim fort. 5, aq. dest. 10) inasmuch as 
the coryza was cured after one day’s ex- 
istence in the first stage, and without, as 
formerly, invading the trachea. 
A few drops of the mixture should be 
poured on blotting paper and inhaled, care 
being taken to protect the eyes.f 
* Boston Medical and Surgical Journal, Feb. 25th. 
and Sept. 30th, 1869. 
f Writers of papers on the Diseases of the Throat and 
Chest will contribute much assistance in the preparation 
of the semi-annual reports in this department if they 
will forward copies of their papers, addressed to this 
Journal.—Eds.